Eventus WholeHealth

Remote Teletriage Nurse Practitioner Nights and Weekends- NC

Posted on:

January 13, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

NP/APP

State License:

North Carolina

Eventus WholeHealth was founded in 2014 to provide physician-led healthcare services for residents and patients of skilled nursing and assisted living facilities. With our highly-trained team of physicians, psychiatrists, nurse practitioners, physician assistants, psychotherapists, podiatrists, optometrists, audiologists, and support staff, our comprehensive, evidence-based model provides collaborative interdisciplinary care with the seamless and vital integration of a wide range of specialties. Our differentiated approach not only empowers the facilities to reach their own goals and objectives but also ensures better patient outcomes. For more information, please visit www.eventuswholehealth.com.

Eventus WholeHealth delivers an integrated model of care to adults who reside in a variety of settings including but not limited to skilled nursing facilities, assisted living facilities, independent living and in personal homes. These services are provided through a network of Eventus WholeHealth providers who include Physicians, Nurse Practitioners, Physician Assistants, Care Team Advocates, and in-house Support Staff.    Telemedicine uses videoconferencing equipment to send and receive patient medical information and pictures. Eventus WholeHealth telemedicine providers deliver medical services to patients at assigned contract sites according to site-specific protocols. Telemedicine providers also render medical consultations with family, facility staff and specialty providers when necessary. Medical services are provided via telemedicine. Shift: 7p-7a with Rotating weekends Must have NC License

Knowledge: Knowledge of theory, practice, and regulations to give and evaluate patient care. Knowledge of rules and regulations of bodies governing health care. Knowledge of Eventus WholeHealth policies and procedures. Knowledge of common safety hazards and precautions to establish/maintain a safe work environment. Skills Required: Skill in gathering and analyzing physiological, socioeconomic, and emotional patient data. Skill in accurately evaluating patient problems and providing appropriate advice, intervention, or referral. Skill in documenting clinical services Skill in using computer technology Skill in exercising a high degree of self-direction, judgment, and discretion. Abilities: Ability to communicate clearly and establish/maintain effective working relationships with patients, medical staff, and the public. Ability to react calmly and effectively in emergency situations. Ability to interpret, adapt and apply guidelines and procedures. Ability to work collaboratively with all members of the health care team. Ability to make responsible decisions within the scope of the provider’s license Ability to evaluate and make recommendations for continuous quality improvement. Ability to handle confidential and sensitive information. Physical/Mental Demands: Sedentary physical demands. Ability to lift equipment and small items which is generally not more than 10 pounds needed. Flexibility of schedule at times may be required. Work may be busy and demand multi-tasking. Qualifications/Education: Master’s degree in Nursing from an accredited educational institution and a current and valid license to practice advanced practice nursing issued by the state where you are providing tele triage. All certifications necessary to perform one’s responsibilities must be current and valid. Specialization in geriatric, family, or internal medicine desired. OR Have graduated from a physician assistant educational program that is accredited by a National Commission on Accreditation of Allied Education Programs. Have passed the national certification examination of the National Commission on Accreditation of Certification of Physician Assistants. Licensed by the state of where you are providing tele triage as a Physician Assistant. Specialization in geriatric, family, or internal medicine desired.

Provide primary-care telemedicine services in accordance with Eventus site-specific protocols and consistent with the standard of care for the specialty of family medicine, geriatric medicine, and/or internal medicine. Perform other duties and activities as appropriate and/or assigned by Eventus Management as pertains to providing quality or timely medical care and or administrative responsibilities. Manage facility and other partners relationships, organization, patient consents, CCM and billing. Provide on call tele triage per established protocol policy. Confirm treatment and telehealth consents are signed prior to telemedicine visit. Follow Eventus telehealth visit etiquette protocols. Include family members in the visit, as appropriate. Be familiar with telemedicine equipment, delivery platform and software. Ensure the patient has the proper equipment available. If a patient, family, or site staff report faulty or lack of equipment, the provider is to notify the director of tele triage. Providers are to complete documentation and sign all orders specific for the telemedicine visit immediately after completing the visit. All narcotic prescriptions are to be managed per Eventus RX Policy. Notify patient’s regular provider of visit and triage treatment plan via EMR. On-call telehealth scheduling may be modified as needed. Providers are expected to adhere to the newest agreed upon triage schedule. Establish and maintain open and positive communications with facility staff and administration. Provide verbal and/or written instruction or feedback regarding medications and other pertinent caregiver information. Give time for questions to be asked by patient, family, or staff members. Establish when the patient should be seen next. All required data to be collected and documented same day. Be knowledgeable of and adhere to Eventus standards, policies, and procedures. Be aware of and adhere to all legal and regulatory agencies' rules, guidelines, and professional ethical standards. Comply with all regulatory agencies governing health care delivery. Always conduct self in a professional manner, this includes avoiding gossip, avoiding negative comments about other staff or competitors, maintaining appropriate interpersonal boundaries, and avoiding dual relationships (this includes refraining from offering medical or psychotherapy services to facility staff or family members, avoiding accepting gifts from patients, etc.), and observing appropriate professional attire when on call. Perform other duties and activities as appropriate and/or assigned by Eventus Management. Always maintain patient confidentiality including appropriate use of Cell phone, emails text messaging, patient charts and EMR. Agrees to abide by and be knowledgeable of HIPAA rules and regulations Maintain multiple practice licenses and comply with each state’s practice regulations, as requested by Eventus.

Wellbox Virtual Care Solutions

LPN - Remote Chronic Care Management

Posted on:

January 13, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

LPN/LVN

State License:

Compact / Multi-State

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

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

Active Compact LPN License. Minimum two years of clinical experience; care coordination experience preferred. Proficient with Electronic Medical Records and Microsoft Office. Excellent communication and problem-solving skills. Candidates who reside in Mountain Standard Time (MST) 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.

SPECTRAFORCE

LPN Medical Reviewer I (Remote)

Posted on:

January 13, 2025

Job Type:

Contract

Role Type:

Clinical Operations

License:

LPN/LVN

State License:

Compact / Multi-State

What we offer: Remote work opportunity (after a week of onsite training). Supportive team environment. Opportunity to make a difference in member health.

Job Title: LPN Medical Reviewer I Location: Columbia, SC, 29229 (1 to 2 week onsite training then remote) Duration: 3 months assignment with possible conversion Shift: M - F, 8:30 am - 5 pm Pay Rate: $23/hr In this role, you'll review medical records, ensure accurate coverage decisions based on medical necessity, and sometimes interact with providers and members.

You're a great fit if you have: Active Licensed Practical Nurse (LPN) license for SC or compact. 2+ years of clinical experience.

Analyze medical records using established guidelines. Determine coverage and precertification for medical services. Collaborate with healthcare professionals to obtain additional information (if needed). Educate members and providers on coverage determinations.

Centene Corporation

TeleHealth Registered Nurse (Registry)

Posted on:

January 13, 2025

Job Type:

Part-Time

Role Type:

Telehealth

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. Compact RN License Required PRN - At Least 29 Hours Per Month - Nights 6 - 4 hr On-Call Shifts Per Month Must be able to pass DFPS Background Check for Texas

Education/Experience: Graduate certificate from an accredited nursing program. 3+ years combined experience in critical care, pediatric, obstetrics, home health, school nursing, or emergency nursing. 5 years experience strongly preferred. Licenses/Certifications: Current RN license without restriction in state of residence

Position Purpose: Triage inbound calls, gather information, select appropriate triage guidelines, and disposition and care advice based on database protocols and department policies and procedures for a 24 hour per day/7 day a week operation. Provide clinical information and education for inbound and outbound calls providing oversight and support to the non-clinical staff. Conduct assessments of callers’ presenting symptoms. Develop, implement, and evaluate a plan of care for each caller presenting symptoms. Answer all calls in a timely manner. Maintain confidentiality of all caller and personnel issues. Document all call inquiries according to department policies and procedures. Participate in the collection of data for department quality projects. Promote recovery concepts and inspire hope. Possess and maintain a thorough grasp of clinical knowledge pertaining to various disease states, medications, treatments, etc. Comply with Federal and respective state’s laws regulating health management organizations and telephone information centers and all department standards and policies and procedures. Apply primary nursing knowledge while performing all aspects of assigned tasks.

TEEMA

Virtual Registered Nurse

Posted on:

January 13, 2025

Job Type:

Contract

Role Type:

Behavioral Health

License:

RN

State License:

California

We are seeking Remote RN's who will be responsible for conducting phone-based health assessments for patients awaiting placement with a Family Care Practitioner. This role focuses on performing comprehensive health intakes to collect patient information, identify health needs, and facilitate a smooth transition into appropriate healthcare services.

Bachelor’s degree in nursing or an equivalent qualification. Minimum 1 year of clinical experience in acute care (ER or ICU), oncology, non-acute care (medical/surgical), or mental health. Active provincial nursing license in good standing in the respective province of residence. Proficient in office productivity software (Microsoft Office Suite, soft phone tools) and experienced with EMR applications for data entry and information retrieval. Outstanding communication skills across verbal, written, telephone, email, and chat channels. Flexibility to accommodate variable schedules, including occasional evening hours when necessary. This is a full time- 6 month contract( Could extend and possible perm employment at end of contract)

Act as the primary clinical contact for patients on the waitlist for rostering to a Family Care Team. Conduct comprehensive health intakes and accurately document relevant medical information. Efficiently utilize multiple software platforms and Electronic Medical Record (EMR) systems to ensure accurate and timely documentation. Collaborate with team members and administrative staff to provide a seamless patient experience. Ensure compliance with regulatory requirements, professional standards, and organizational policies related to patient care and data privacy.

US Tech Solutions

RN Level 2

Posted on:

January 13, 2025

Job Type:

Contract

Role Type:

Clinical Operations

License:

RN

State License:

New Jersey

US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit www.ustechsolutions.com.

This position is responsible for the medical policy determination of claims/cases consistent with Plan Medical Policy to ensure appropriate and efficient utilization of benefits. Additionally, the position is responsible for the research and analysis of medical techniques, procedures and products and for recommendations in the formulation of draft medical policy.

Experience: Requires a minimum of two (2) years clinical experience. Requires minimum of three (3) years' experience in the health care delivery system/industry. Active Unrestricted RN License Required; NJ License Preferred Prefer Certified Professional Coder credentials. Knowledge - Must be proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint) and Lotus Notes; Should be knowledgeable in the use of intranet and internet applications. Skills: Must have effective verbal and written communication skills and demonstrate the ability to work well within a team. Demonstrated ability to deliver highly technical information to less technical individuals. Must demonstrate professional and ethical business practices, adherence to company standards, and a commitment to personal and professional development. Proven time management skills are necessary. Must demonstrate the ability to manage multiple priorities [or tasks], deliver timely and accurate work products with a customer service focus, and respond with a sense of urgency as required. Demonstrated ability to work in a production focused environment. Proven ability to exercise sound judgment and strong problem-solving skills. Proven ability to ask probing questions and obtain thorough and relevant information. Must be client service focused with effective ability to empathize. Education: Requires an associate or bachelor's degree (or higher) in nursing and/or a health-related field OR accredited diploma nursing school.

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

US Tech Solutions

Nursing - RN Level 1 RN Level 1

Posted on:

January 13, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

New Jersey

US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit www.ustechsolutions.com.

This position is responsible for performing RN duties using established guidelines to ensure appropriate level of care as well as planning for the transition to the continuum of care. Performs duties and types of care management as assigned by management.

Requires a minimum of two (2) years clinical experience. Additional licensing, certifications, registrations: Requires an active New Jersey Registered Nurse License. Knowledge: Prefers proficiency in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint) and Lotus Notes; prefers knowledge in the use of intranet and internet applications. Prefers working knowledge of case/care management principles. Prefers working knowledge of principles of utilization management. Prefers basic knowledge of health care contracts and benefit eligibility requirements. Prefers knowledge of hospital structures and payment systems. Skills: Analytical Compassion Interpersonal & Client Relationship Skills Judgment Listening Planning/Priority Setting Problem Solving Team Player Time Management Written/Oral Communication & Organizational Skills Education: Requires an associate’s or bachelor’s degree (or higher) in nursing and/or a health related field OR accredited diploma nursing school.

Assesses patient's clinical need against established guidelines and/or standards to ensure that the level of care and length of stay of the patient are medically appropriate for inpatient stay. Evaluates the necessity, appropriateness and efficiency of medical services and procedures provided. Coordinates and assists in implementation of plan for members. Monitors and coordinates services rendered outside of the network, as well as outside the local area, and negotiate fees for such services as appropriate. Coordinates with patient, family, physician, hospital and other external customers with respect to the appropriateness of care from diagnosis to outcome. Coordinates the delivery of high quality, cost-effective care supported by clinical practice guidelines established by the plan addressing the entire continuum of care. Monitors patient's medical care activities, regardless of the site of service, and outcomes for appropriateness and effectiveness. Advocates for the member/family among various sites to coordinate resource utilization and evaluation of services provided. Encourages member participation and compliance in the case/disease management program efforts. Documents accurately and comprehensively based on the standards of practice and current organization policies. Interacts and communicates with multidisciplinary teams either telephonically and/or in person striving for continuity and efficiency as the member is managed along the continuum of care. Understands fiscal accountability and its impact on the utilization of resources, proceeding to self-care outcomes. Evaluates care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes. Completes other assigned functions as requested by management.

UnityPoint Health

Registered Nurse Transition Care - Remote

Posted on:

January 13, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

Compact / Multi-State

The UnityPoint IntelliCenter nurse is an RN who provides care over the telephone by thoroughly assessing symptoms to identify acuity to disposition caller or patient appropriately utilizing best-practice updated protocols. Protocols are embedded within the eMR to support guidance in appropriate care delivery. Nursing services are provided telephonically and, in some cases, virtually. May include triage, care management, referral management and telehealth support. Must have proficient keyboarding/typing skills and have a technical aptitude to learn new computer software systems quickly. Ability to handle a “call center” environment: work quickly and multi-task, utilizing clinical critical skill thinking while navigating computer software to meet the required turnaround time to support key performance indicators which support patient care delivery and operational costs. We are a 24/7 operation with the bulk of our services provided in the evenings and weekends.

RN Call Center Monday - Friday, 8:30a-5p, Rotating Weekends, 3 of 6 holiday required Ability to sit remote in certain regions Full Time Benefits - 40 hours a week **remote - must have compact RN nursing license**

Requires active and unrestricted license to practice nursing in the states of Iowa and Illinois. Requires a minimum of 1-2 years of clinical nursing experience providing direct patient care or equivalent work experience - 2-3 years preferred Strong time management and organizational skills Possesses excellent written and verbal communications. Proficiency in use of computer applications such as Microsoft Office and electronic health systems. Requires knowledge of federal healthcare laws and regulations. Requires highly developed communication skills to effectively work with all levels of management throughout the UnityPoint Health, its subsidiaries and affiliates. Excellent academic credentials with a track record of professional accomplishments, which demonstrate superior performance, leadership and vision. Ability to work as a team member, creating and maintaining effective working relationships. Ability to understand and apply guidelines, policies and procedures. Education: Graduate from an accredited nursing program. Bachelors of Science (BSN) preferred Compliance with Mandatory Child/Adult Abuse Reporting

Primary Function and Relationship to the Total Organization: My UnityPoint Nurse Call Center offers a free health information service for the public, sponsored by UnityPoint Health and staffed by registered nurses 24-hours a day, 7 days a week. The nurses at My UnityPoint Nurse provide medical assessment and triage, up-to-date health information and physician and clinic referral service. My UnityPoint Nurse Call Center is a centralized function of UnityPoint Health providing clinical support to UnityPoint Health and affiliates. Operations: Performs symptom assessment triage utilizing protocols to guide best practice care delivery and disposition. Documents call criteria in eMR within a timely manner. Promotes and educates appropriate callers regarding second level triage and virtual care visits with NP and MDs when appropriate. Serves as a resource to customers seeking physician referral and community-based resource information. Provides health information to customers via UnityPoint Health’s approved resources Maintains strict confidentiality of all employee and customer information Adhere to all UnityPoint Clinic personnel Policies and Procedures and safety guidelines. Supports change transformation initiatives Identifies with shift change requirements as call volume dictates in order to support staffing needs appropriately Perform other duties as assigned. Support team efforts in patient care delivery objectives. Provides assistance with other reasonable related duties as assigned by supervisor or manager. Ability to handle confidential and sensitive information. Ability to communicate effectively on the telephone. Ability to relate to persons with diverse educational, socioeconomic and ethnic backgrounds. Ability to handle a “call Center” environment: work quickly and multi-task. Ability to demonstrate good customer service. Exhibits discretion and sound judgment in all aspects of the job. Strategic Planning and Clinical Leadership Participates and takes personal responsibility to support key strategic initiatives in order to achieve organizational success. Participates and takes personal responsibility to ensure appropriate clinical delivery of programs, keeping within RN scope of practice. Is proactive in bringing ideas forward to support a continuous process improvement environment. Strive for clinical excellence through professional development activities Represents UnityPoint Clinics in a professional manner. Promotes positive interpersonal relations and serves as a role model within the department and with UnityPoint Clinic personnel. Displays creativity and innovation when making recommendations for improvement in the delivery of services to the customer Works collaboratively and professionally with all staff and supports others development

Humana

Pre-Authorization RN

Posted on:

January 13, 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 Pre-Authorization Nurse 2 reviews prior authorization requests for appropriate care and setting, following guidelines and policies, and approves services or forward requests to the appropriate stakeholder.

Required Qualifications: Licensed Registered Nurse (RN) in either Florida or a compact state with no disciplinary action. Live in NC, SC, FL or GA Experience working with CMS Guidelines, MCG and/or Interqual guidelines 2 or more years of Utilization Management (UM), Pre-Auth, and/or other managed care review experience 1 or more years of acute and/or critical care clinical experience Proficient with MS Office Word, Excel (ie filter) and Outlook Work Tuesday – Saturday 8am-5pm EST, Overtime and Holidays based on business needs Preferred Qualifications: BSN Bilingual English/ Spanish. Must be able to speak, read and write in both languages without limitations or assistance. See Additional Information on testing Health Plan experience working with large carriers. Medicare/ Medicaid experience. OneNote

Completes medical necessity and level of care reviews for requested services using clinical judgment Refers to internal stakeholders for review depending on case findings. Educates providers on utilization and medical management processes. Enters and maintains pertinent clinical information in various medical management systems. Communicate with providers or members

Prime Home Health and Pacific Hospice & Palliative Care

Registered Nurse RN - In Home Hospice PRN

Posted on:

January 13, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Texas

We are seeking a dedicated and compassionate Registered Nurse to join Pacific Hospice and Palliative Care on a W2 PRN basis. As an RN on our team, you will play a vital role in coordinating and providing holistic care to patients and their families during the end-of-life journey in the comfort of their San Antonio area homes. Your expertise in palliative care, strong assessment skills, and ability to provide emotional support will contribute to enhancing the quality of life for our patients. The ideal candidate will possess excellent clinical knowledge, exceptional communication skills, and a deep commitment to providing compassionate care.

Hospice Experience: Minimum of 2 years of clinical experience with in-home hospice and palliative care Registered Nurse: Current and unrestricted RN license in the State of Texas; Proficient with computers and EHR systems: Axxess EHR or other hospice EHR; email; Slack and other platforms; You MUST live in the San Antonio area. Case Management Skills: Strong case management skills, including assessment, care planning, coordination, and documentation. Compassion and Empathy: Ability to provide compassionate and empathetic care to patients and families during the end-of-life journey, demonstrating sensitivity to their physical, emotional, and spiritual needs. Communication Skills: Excellent verbal and written communication skills, with the ability to effectively communicate with patients, families, and interdisciplinary team members. Critical Thinking: Strong critical thinking and problem-solving abilities to assess complex patient situations, make sound clinical judgments, and provide appropriate interventions. Time Management: Efficient time management skills to prioritize tasks, meet deadlines, and provide timely care while ensuring attention to detail and accuracy in documentation. Emotional Resilience: Ability to cope with emotional and challenging situations while maintaining professionalism and providing support to patients and families. Team Player: Demonstrated ability to work collaboratively in an interdisciplinary team, fostering a positive and supportive work environment. Regulatory Knowledge: Familiarity with hospice regulations, including Medicare Conditions of Participation and Joint Commission standards.

Patient Care: Provide comprehensive and compassionate nursing care to patients in their homes, ensuring their physical, emotional, and spiritual needs are met. Care Planning and Coordination: Develop and implement individualized care plans in collaboration with the interdisciplinary team, patients, and their families, considering their unique needs, goals, and preferences. Assessment and Evaluation: Conduct thorough assessments of patients' physical and psychological status, including pain management, symptom control, and psychosocial support, ensuring ongoing evaluation of their condition. Medication Management: Administer medications, including pain management and symptom control medications, according to physician orders, and educate patients and families on medication management and potential side effects. Patient and Family Education: Provide education and support to patients and their families regarding the disease process, treatment options, pain management techniques, and end-of-life care, promoting understanding and involvement in the care plan. Emotional Support: Offer emotional support and counseling to patients and families, addressing their fears, concerns, and coping mechanisms during the end-of-life journey. Interdisciplinary Collaboration: Collaborate with the interdisciplinary team, including physicians, social workers, spiritual care providers, and volunteers, to ensure continuity of care, effective communication, and holistic support. Documentation and Compliance: Maintain accurate and up-to-date patient records, ensuring compliance with regulatory requirements, hospice policies, and best practices. Bereavement Support: Provide bereavement support to families and caregivers following the loss of a loved one, offering resources, counseling, and referrals as needed. Continuous Education: Stay informed about current trends, best practices, and advancements in hospice and palliative care through participation in continuing education opportunities and professional development activities.

ACI Federal Inc., Staffing Division

Registered Nurse Disease Manager REMOTE

Posted on:

January 13, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Compact / Multi-State

ACI Federal specializes in top-notch healthcare transformation solutions for the public and private sectors, including hospitals, LTC facilities, and healthcare groups. Our experienced team of Talent Acquisition Specialists and clinicians excels in medical staff augmentation for almost any healthcare setting. Engage the Tried and True ACI Federal Staff Augmentation team for unparalleled solutions in healthcare transformation.

We are seeking a dedicated and experienced Registered Nurse Manager to lead our nursing team in providing exceptional patient care. The ideal candidate will possess strong leadership skills and a comprehensive understanding of nursing practices, particularly in acute care settings. This role involves overseeing nursing staff, ensuring compliance with healthcare regulations, and enhancing the quality of care provided to patients.

Current Registered Nurse (RN) license in the state of practice. Proven experience in a managerial or supervisory role within a healthcare setting. Strong clinical skills with experience in dementia care, pediatrics, vital signs monitoring, and acute care. Proficiency in coding practices related to ICD-10. Experience administering injections and managing tube feeding procedures is preferred. Excellent communication skills with the ability to lead a team effectively. Strong organizational skills with attention to detail in patient documentation and compliance. Ability to work collaboratively within an interdisciplinary team environment. We invite qualified candidates who are passionate about improving patient outcomes through effective leadership to apply for this rewarding opportunity. Be licensed and/or certified in the Commonwealth of Virginia or have multistate licensure privilege to practice in the Commonwealth of Virginia. Have current County Health Department approved CPR certification from any of the following organizations: American Red Cross, National Safety Council, American Heart Association, American Safety and Health Institute, community colleges, hospitals, rescue squads and/or fire departments. CPR certifications from other sources must receive prior written approval from the County. Have knowledge and experience in child and adolescent health including working with mildly to profoundly developmentally and/or emotionally disabled clients. Nurses assigned to a public school setting must have the ability to work independently with other staff members in a school environment. (If assigned as a Continuous Duty Nurse)

Supervise and manage nursing staff, providing guidance and support to ensure high standards of patient care. Develop and implement nursing policies and procedures that comply with healthcare regulations. Conduct regular evaluations of patient care practices and outcomes, making necessary adjustments to improve quality. Collaborate with interdisciplinary teams to coordinate patient care plans, ensuring all aspects of patient health are addressed. Monitor and maintain accurate patient records, including vital signs, medication administration, and treatment plans. Provide training and mentorship to nursing staff on best practices in areas such as dementia care, pediatrics, and acute care. Administer injections, perform spinal taps, and manage tube feeding as required by patient needs. Ensure proper coding practices are followed for documentation using ICD-10 standards.

HireOps Staffing, LLC

Registered Nurse-Case Manager-Remote $52/hr

Posted on:

January 13, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

The position is work from home with field visits.

Registered Nurse (RN), with 3 years direct clinical care to the consumer in a clinical setting or Licensed Professional Counselor (LPC), or Licensed Master Social Worker (LMSW), which includes 2 years of clinical practice to obtain their LPC or LMSW license. Current, valid, unrestricted license in the state of operations (or reciprocity). For compact licensee changing permanent residence to state of operations, you must obtain active, unrestricted RN licensure in the state of operations within 90 days of hire. Plus 3 years wellness or managed care experience presenting clinical issues with members/physicians. Knowledge of the health and wellness marketplace and employer trends. Verbal and written communication skills including discussing medical needs with members and interfacing with internal staff/management and external vendors and community resources. Analytical experience including medical data analysis. Ability and willingness to travel within assigned territory. PC proficiency to include Word, Excel, and PowerPoint, database experience and Web based applications. PREFERRED JOB QUALIFICATIONS: 3 years clinical experience. Patient education experience. Condition Management experience. Bilingual in English and Spanish. Transition of Care experience. Experience in managing complex or catastrophic cases. Certification in Case Management, Training, Project Management or nationally recognized health care certification.

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

CVS Health

Appeal Nurse Associate - MUST live in WV

Posted on:

January 13, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

LPN/LVN

State License:

West Virginia

Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver. Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.

This is a full-time telework position. Position Summary: Facilitate the delivery of appropriate benefits and/or healthcare information which determines eligibility for benefits while promoting wellness activities. Supports Health Strategies, tactics, policies and programs that ensure the delivery of benefits and to establish overall member wellness and successful and timely return to work. Services and strategies, policies and programs are comprised of network management, clinical coverage, and policies.

Required Qualifications: 2+ years of clinical experience LPN/LVN with current unrestricted state licensure in the state of West Virginia Must reside in the state of West Virginia Preferred Qualifications: Managed Care experience preferred Education: LPN/LVN with current unrestricted state licensure required

Responsible for the review and resolution of clinical complaints/grievances and appeals. Interprets data obtained from clinical records to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and provider issues. Independently coordinates the clinical resolution with internal/external clinician support as required. Requires LPN/LVN with unrestricted active license. Assists with reviewing clinical complaint/grievance and appeal requests of all clinical determinations/clinical policies. Considers all previous information as well as any additional records/data presented to prepare a recommendation. Assists with data gathering that requires navigation through multiple system applications. Contacts the provider of record, vendors, or internal Aetna departments to obtain additional information Accurately applies review requirements to assure case is reviewed by a practitioner with clinical expertise for the appeal issue at hand (e.g. Specialty Match Review (SMR), RN, MD, etc.). Commands a comprehensive knowledge of complex delegation arrangements, coding logic, contracts (member and provider), clinical criteria, benefit plan structure, regulatory requirements, and ERO eligibility which are required to support the clinical complaints/grievances and appeals determinations. Pro-actively and consistently applies the regulatory and accreditation standards to assure that appeals and ERO requests are processed within requirements. Assists with condensing information from multiple sources (i.e., contract, coding, regulatory, etc.) into a clear and precise clinical picture for presentation to an appropriate clinician for determination. Seeks guidance from other healthcare professionals in the coordination and administration of the appeal and grievance process.

Community Health Network

Registered Nurse Ambulatory Triage (RN) - CPN Primary Care – Evenings

Posted on:

January 13, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Indiana

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). Three years or more of nursing experience required. One to two years of ambulatory and/or triage experience preferred. Adult Cardiac/ICU/ED experience preferred. Excellent communication skills. Excellent team skills. Compassionate and caring. Accountable and self-directed. EPIC experience a plus. Bachelor of Science in Nursing preferred.

The Ambulatory Triage RN is responsible for assessing patient's condition/symptoms, giving appropriate clinical direction, education, and recommendation(s) for disposition. Responds to incoming calls in a timely, professional manner and triages (as appropriate) to address and/or support the needs of the caller. Coordinates and collaborates with providers, medical directors, social workers, pharmacists, and other healthcare professionals to evaluate and address patient needs. Assesses needs using standard evidenced based protocols for triage, offers clinical recommendations, as well as, referrals to health care providers, services and community resources using telephone and information system technologies. Utilizes standardized protocols for medication management, prescription refills, and prior authorizations. Schedules appointments. Provides coordination of care to patient/family/facility as determined by plan of care across the continuum of care (POC). Other duties and responsibilities as assigned. The RN will primarily work remotely from home, however training will be held onsite and continuing education will be held onsite as needed. The RN will support primary care and some specialty care areas. *Must reside in the Indianapolis area or surrounding counties*

Prime Healthcare Home Care and Hospice

Home Care Triage RN

Posted on:

January 12, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Illinois

Company is an equal employment opportunity employer. Company prohibits discrimination against any applicant or employee based on race, color, sex, sexual orientation, gender identity, religion, national origin, age (subject to applicable law), disability, military status, genetic information or any other basis protected by applicable federal, state, or local laws. The Company also prohibits harassment of applicants or employees based on any of these protected categories. Know Your Rights: https://www.eeoc.gov/sites/default/files/2022-10/EEOC_KnowYourRights_screen_reader_10_20.pdf

EDUCATION, EXPERIENCE, TRAINING: One to two years recent clinical experience. Home Care experience preferred. Graduate from an accredited school of nursing. BSN preferred. Current and valid state license as a Registered Nurse. Strong verbal and written communication skills. Strong interpersonal skills. Strong problem solving skills. Strong time management skills. Ability to work independently.

The Triage RN provides remote care to established patients. This position is a Registered Nurse who practices nursing remotely, utilizing the nursing process, input from physicians, and the organizationally approved nursing guidelines and protocols. Maintains competency in meeting patient safety goals.

Aware Recovery Care, Inc

Intake Coordinator

Posted on:

January 12, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Conneticut

Typical Work Week: This position is per-diem with changes to be made with appropriate notice to meet agency needs. Hours may include nights and/or weekends. Position Summary: The Intake Coordinator is responsible for administering and scoring Intake Assessments for prospective and incoming Aware Recovery Care (ARC) Clients. Intake Coordinators will work in the admissions department and collaborate with the appropriate Integrated Healthcare Services personnel across ARC agencies to ensure assessments have been completed and clients are properly set up to enter the program. Reports To: Admission Manager/ VP Medical Service Position Highlights: RN or LPN, with a preference for RN One year in professional clinical social work experience or at least one year of professional nursing experience within the past three years Experience in Substance Use Disorder (SUD) or Mental Health preferred Willingness to become licensed in all states that Aware provides services Preferred candidate will have multi-state nursing license already in place Salary range is $36- $42 hourly contingent on experience and licensure This role is 100% remote but candidate must reside in one of the following states: CT, FL, GA, IN, KY, ME, MA, NH, OH, RI, VA, NJ, NY, AR, MN, PA, TX, MI Candidate will report to corporate office out of Wallingford, CT We’re proud to be a Great Place to Work-Certified™ company! **Aware Recovery Care is an equal opportunity employer**

Required Qualifications: RN/LPN One year of professional clinical social work experience or at least one year of professional nursing experience within the past three years Experience in Substance Use Disorder (SUD) or Mental Health preferred License to be in good standing Willingness to become licensed in all states that Aware provides services. Preferred candidate will have multi-state nursing license already in place Key Competencies: Strong assessment skills and holistic health knowledge regarding addiction Exemplary motivational interviewing and deep listening skills Strong interpersonal and group communication skills Ability to collaborate Clinical excellence and excellent internal and external customer service skills Resolution-focused with the ability to think critically and creatively Pay: $36.00 - $42.00 per hour Schedule: Monday to Friday Weekends as needed People with a criminal record are encouraged to apply Experience: Addiction Recovery: 1 year (Preferred) Medical terminology: 1 year (Preferred) Experience: Addiction Recovery: 1 year (Preferred) Medical terminology: 1 year (Preferred)

Complete assessments and screenings including Biopsychosocial, ASAM, CIIWA, COWS, PHQ-9, and CSSRS Determine level of care needs including whether there are needs for Virtual Ambulatory Detox, detoxification, psychiatric stabilization, etc. Responsible for the initial screening to determine whether appropriate for In-Home Addiction Treatment (IHAT), Medication assisted treatment (MAT) and Virtual Ambulatory Detox. Assessing and determining appropriate recommendations to support clients within IHAT including MATs, Internal Psychiatric evaluation, admission team support, and referral to external provider needs. Providing clinical support to Admissions for client needs. Reviewing Higher Level of Care (HLOC) documentation to ensure clinical appropriateness for IHAT LOC. After completing initial assessments, notifying the admission nurse practitioner or appropriate personnel to ensure proper final review and signature.

Aware Recovery Care, Inc

Ambulatory Detox & MAT Care Coordinator

Posted on:

January 12, 2025

Job Type:

Part-Time

Role Type:

Telehealth

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 be actively licensed in both CT and MA. Candidate must reside in one of the following states: CT, FL, GA, IN, KY, ME, MA, NH, OH, RI, VA, NJ, NY, AR, MN, PA, TX 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 be licensed in at least CT and MA. Must also hold a compact license and resides in a compact state 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

ACI Federal™

Registered Nurse Disease Manager

Posted on:

January 12, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Compact / Multi-State

ACI Federal specializes in top-notch healthcare transformation solutions for the public and private sectors, including hospitals, LTC facilities, and healthcare groups. Our experienced team of Talent Acquisition Specialists and clinicians excels in medical staff augmentation for almost any healthcare setting. Engage the Tried and True ACI Federal Staff Augmentation team for unparalleled solutions in healthcare transformation.

We are seeking a dedicated and experienced Registered Nurse Manager to lead our nursing team in providing exceptional patient care. The ideal candidate will possess strong leadership skills and a comprehensive understanding of nursing practices, particularly in acute care settings. This role involves overseeing nursing staff, ensuring compliance with healthcare regulations, and enhancing the quality of care provided to patients.

Current Registered Nurse (RN) license in the state of practice. Proven experience in a managerial or supervisory role within a healthcare setting. Strong clinical skills with experience in dementia care, pediatrics, vital signs monitoring, and acute care. Proficiency in coding practices related to ICD-10. Experience administering injections and managing tube feeding procedures is preferred. Excellent communication skills with the ability to lead a team effectively. Strong organizational skills with attention to detail in patient documentation and compliance. Ability to work collaboratively within an interdisciplinary team environment. We invite qualified candidates who are passionate about improving patient outcomes through effective leadership to apply for this rewarding opportunity. Be licensed and/or certified in the Commonwealth of Virginia or have multistate licensure privilege to practice in the Commonwealth of Virginia. Have current County Health Department approved CPR certification from any of the following organizations: American Red Cross, National Safety Council, American Heart Association, American Safety and Health Institute, community colleges, hospitals, rescue squads and/or fire departments. CPR certifications from other sources must receive prior written approval from the County. Have knowledge and experience in child and adolescent health including working with mildly to profoundly developmentally and/or emotionally disabled clients. Nurses assigned to a public school setting must have the ability to work independently with other staff members in a school environment. (If assigned as a Continuous Duty Nurse)

Supervise and manage nursing staff, providing guidance and support to ensure high standards of patient care. Develop and implement nursing policies and procedures that comply with healthcare regulations. Conduct regular evaluations of patient care practices and outcomes, making necessary adjustments to improve quality. Collaborate with interdisciplinary teams to coordinate patient care plans, ensuring all aspects of patient health are addressed. Monitor and maintain accurate patient records, including vital signs, medication administration, and treatment plans. Provide training and mentorship to nursing staff on best practices in areas such as dementia care, pediatrics, and acute care. Administer injections, perform spinal taps, and manage tube feeding as required by patient needs. Ensure proper coding practices are followed for documentation using ICD-10 standards.

Stepping Stone Advocacy Services

Nurse Patient Advocate

Posted on:

January 12, 2025

Job Type:

Contract

Role Type:

Case Management

License:

RN

State License:

Maryland

We are seeking a dedicated and compassionate Nurse to join our Nurse Patient Advocate team. The Nurse Patient Advocate serves as a trusted liaison between patients and the healthcare system. They assist clients in navigating complex medical decisions, ensuring they receive personalized, high-quality care. This role combines clinical expertise with compassionate advocacy to help clients understand their options, communicate effectively with providers, and make informed decisions. This is mostly a remote position with some local travel. Willing to provide training for this position for Nurses interested in pivoting to this role as a Nurse Patient Advocate. This is an as-needed position and part-time with flexibility. Perfect for those that do not need full time or salaried position.

Qualifications: Registered Nurse (RN) license in good standing. Minimum 7 years of clinical nursing experience in a hospital, outpatient, or community setting. Experience in case management, care coordination, or patient advocacy preferred. Skills and Competencies: Strong communication and interpersonal skills to connect with clients and healthcare teams. Critical thinking and problem-solving abilities to navigate complex medical and administrative systems. Empathy and compassion, with a client-centered mindset. Organizational and time management skills for handling multiple cases. Proficiency in medical terminology and understanding of healthcare systems and insurance processes.

Assist clients in understanding diagnoses, treatment options, and care plans. Advocate for clients’ needs during medical appointments, hospitalizations, or other care settings. Educate clients and families about healthcare rights and available resources. Facilitate communication between clients, families, and healthcare providers. Coordinate referrals, second opinions, or specialist appointments. Ensure continuity of care across different healthcare settings. Provide clients with evidence-based information to support informed decision-making. Educate clients about managing chronic conditions, medications, and preventive care. Resolve billing or insurance issues, including appeals and denials. Identify and connect clients to community resources, support groups, or financial assistance programs. Help clients develop personalized healthcare plans tailored to their needs and goals. Maintain confidentiality and adhere to ethical guidelines, including patient-centered advocacy principles. Stay current with developments in healthcare policies, treatments, and advocacy best practices. Marketing and networking experience a plus

Wellbox

LPN Telehealth - Remote Chronic Care

Posted on:

January 12, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

LPN/LVN

State License:

Compact / Multi-State

Wellbox is a growing healthcare company dedicated to helping people live healthier, happier lives. We do this by providing comprehensive and preventative virtual care solutions delivered by an elite team of experienced LPN nurses. Their ability to create positive healthcare experiences and empower people in their health journeys allows us to improve clinical outcomes. Without these incredible LPN team members, we wouldn’t be able to make the positive impact we do. Their consistent efforts in supporting, encouraging, and caring for our patients, especially during these uncertain times, while giving them personalized care truly make a difference. If this mission resonates with you, we invite you to join us.

We are seeking an LPN Patient Care Coordinator to develop personalized care plans and perform telephonic encounters with patients on behalf of our partners. Patient Care Coordinators are assigned a specific panel of patients to whom they are responsible for reaching out to monthly and following up as necessary. We are proud to partner with a great team of LPN nurses who guide our patients to better health and help them achieve a greater quality of life. With every interaction, Patient Care Coordinators help close the gap between people needing care and not being able to receive it.

Work Environment: This opportunity allows you to care for patients virtually from the comfort of your home. We will provide you with the equipment and software needed such as a desktop computer and headset for internet-based calls. Since we’re dedicated to offering our patients the best care experience possible, a wired, high-speed internet connection is needed, a private space free from outside noise and distraction, including noise and distractions from pets or children, and that complies with HIPAA privacy laws. Physical Demands: This is a virtual position that requires you to sit or stand at a computer for 36-40 hours weekly and be able to make phone calls. Some equipment setup is required. Position Type and Expected Hours of Work We are seeking full-time LPN team members who can work 36-40 hours per week, between the hours of 8 am – 6 pm in your time zone, Monday - Friday Pay Structure: Orientation (First eight weeks): $19.44 hourly, plus incentive Post-Orientation: $22 hourly, plus incentive Required Education and Experience: Must have a Compact Nursing License that is clear and active Must reside and work in the continental US Must have a minimum of two years of clinical experience Experience in care coordination or care management, health coaching, and motivational interviewing a plus Hands-on experience and comfort with Electronic Medical Records Experience using Microsoft Office products such as Teams, Outlook, and Excel Competencies Required to Perform the LPN Patient Care Coordinator Position and Key Success Factors; Comfortability using new technology and software while demonstrating proficient computer skills The ability to stay flexible and quickly adapt to new processes, software changes, and priorities Understand healthcare goals provided by the practice while monitoring, assessing, and recording patient progress against a care plan Successfully execute motivational coaching to prevent and intervene in multiple diseases Exercise initiative, judgment, organization, problem-solving, and decision-making The ability to be productive in a virtual work environment Collaborate well with medical staff, partners, and organizations Facilitate patient access to community resources Excellent verbal and written communication skills are required Perform care management and patient assessments Awareness of resource, utilization, and care management best practices A true passion for caring for patients and guiding them in their health journeys

Manage and support patients’ healthcare needs via virtual phone conversations Conduct and document visits by using several technology platforms and EHRs Develop personalized care plans to address patients’ physical, mental, and preventative health needs Coach patients virtually to reach their care goals by following medical treatment plans that include healthy eating, physical activity, stress reduction, etc. Connect patients with resources such as nutritionists, nurses, and doctors who can also assist them in meeting their care needs Prepare patients for appointments and procedures, and provide follow-up as needed Coordinate some administrative aspects of medical record recovery, appointment management, and insurance claims Review insurance plans and suggest tips to get the most from their benefits Proactively suggest services or preventive screenings relevant to each patient

Prime Healthcare Home Care and Hospice

Hospice Triage RN

Posted on:

January 12, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Illinois

Company is an equal employment opportunity employer. Company prohibits discrimination against any applicant or employee based on race, color, sex, sexual orientation, gender identity, religion, national origin, age (subject to applicable law), disability, military status, genetic information or any other basis protected by applicable federal, state, or local laws. The Company also prohibits harassment of applicants or employees based on any of these protected categories. Know Your Rights: https://www.eeoc.gov/sites/default/files/2022-10/EEOC_KnowYourRights_screen_reader_10_20.pdf

EDUCATION, EXPERIENCE, TRAINING: One to two years recent clinical experience. Home Care experience preferred. Graduate from an accredited school of nursing. BSN preferred. Current and valid state license as a Registered Nurse. Strong verbal and written communication skills. Strong interpersonal skills. Strong problem solving skills. Strong time management skills. Ability to work independently.

The Triage RN provides remote care to established patients. This position is a Registered Nurse who practices nursing remotely, utilizing the nursing process, input from physicians, and the organizationally approved nursing guidelines and protocols. Maintains competency in meeting patient safety goals.

Planned Parenthood of the Rocky Mtns

Virtual Care Center Clinician

Posted on:

January 11, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

Colorado

Planned Parenthood is committed to creating a dynamic work environment that values diversity, equity, inclusion, respect, integrity, customer focus, and innovation. We are committed to creating a welcoming space for all people on our staff, in our health centers, and in our community. We do this by tending to the team, respecting and honoring all people, jumping in, trying and learning, caring for our business, and returning to our mission.

Supervisor: Virtual Care Center Manager, Telehealth Percent On-Site vs Remote: 90% Remote/ 10% onsite (You may be required to be in the office occasionally for administrative duties, training, or team building) Schedule: Full Time ∼37.5 hours Benefits Eligible Monday - Friday 9am - 5pm with occasional Saturday and Sunday coverage Virtual Care Center Hours: Monday- Friday: 8 am-7 pm Saturday: 8am-3 pm (when assigned) Sunday: Closed-However, rotating assignment to cover the PPDirect App and respond to patients asynchronously 3 times a day. Position Salary Range: $47.67 / hour - $60.39 / hour Starting Pay: Although our full pay range is included above, the budgeted hiring range for this position is $47.67 / hour- $54.03 / hour Non-Exempt The Objective: To provide educational, supportive, and empathetic patient care and quality assurance in collaboration with PPRM protocols, the medical director, and state and federal regulations. Success: You will know you are successful when all patients who receive follow-up care or telehealth services through the Virtual Care Center (VCC) have their needs met in a patient-centered manner and in accordance with PPRM medical policies. Snapshot: Much of your time will be spent on the computer in a virtual environment providing care to diagnose and treat issues and conditions related to reproductive, sexual health, abortion, and gender-affirming care. Much of your time will be spent using Electronic Health Records and the Electronic Practice Management system, documenting patient interactions, and running reports. Some of your time will be spent interacting with team members and collaborating with other departments. You may work from home or the office. You may be required to be in the office occasionally for administrative duties, training, or team building.

Certified Nurse Practitioner (NP) by a national certification organization. Must reside in and be able to obtain an RN license in the states of Colorado, New Mexico, Nevada, and Wyoming. Have worked one or more years in sexual, reproductive health, or gender-affirming care. You must have active licensure in Colorado, New Mexico, Nevada or Wyoming and must have, or be willing to obtain, controlled substance prescriptive authority in Colorado, New Mexico, Nevada, and Wyoming. You are experienced in providing empathetic, patient-centered care. You are detail-oriented and experienced in multitasking, meeting deadlines, and prioritizing work independently with little supervision. You have strong computer skills and the ability to navigate all Microsoft Suite applications. You must be willing to apply for and maintain licensure in other states. You have no restrictions on your ability to be credentialed with Medicaid or other payors. Please complete this APC Pre-Hire Skills Self-Assessment Checklist along with this application. Key Approaches to the Work: Strong communication Strong Operator Flexible Equity and Inclusion Champion

Provide Outstanding Patient Care: At its core, your work is about providing care to patients who need you and doing so with the highest degree of competence and quality. To do this you will: Triage medical questions and concerns from patients, including providing daytime Call for Abortion patients in accordance with PPRM’s Medical Standards and Guidelines (MS&Gs). Provide asynchronous care for patients seeking birth control, emergency contraception, and/or UTI treatment by the PPDirect app, which is available for patients 7 days a week. Conduct patient visits via phone or video to diagnose and treat issues and conditions related to reproductive, sexual health, abortion, and gender-affirming care. Perform and order diagnostic studies as indicated and provide appropriate treatment and follow-up as necessary. Answer patient questions received via the Patient Portal. Provide excellent customer service to both internal and external customers by working towards a positive outcome with any problems encountered. Run reports, and document accurately, appropriately, and efficiently all phone interactions with patients in their medical chart in Electronic Health Records (EHR) and Electronic Plan Management (EPM) systems. Assist with scheduling patient appointments as needed. Perform mandatory STI reporting to Colorado, Nevada, New Mexico, and Wyoming State Departments of Health, when indicated. Support Capacity-Building Efforts Internally: You will work to build capacity in others who see patients, serving as a leader with expertise and knowledge that can support others. You also contribute to efforts to grow and shore up the foundation for others who join the team as the virtual care program expands, etc. To do this you will: Provide relevant education and collaborate with the health center team and other community agencies in providing comprehensive care. Support unlicensed staff with medical questions or concerns. Work with the Quality Management team when necessary to collaborate on difficult cases. Interface with the leadership team to prioritize and identify how to improve the provider. Abortion Care: We all work in abortion care, whether it is referrals, information, education, counseling, performing, scheduling, etc. In this role, you will be caring for patients who have or may be seeking abortion care with PPRM

Capital Blue Cross

Medical Record Reviewer-LPN/RN

Posted on:

January 11, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

LPN/LVN

State License:

Pennsylvania

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a diverse and caring team of supportive colleagues, and be encouraged to volunteer in your community. We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career.

At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.” The position will complete review and abstraction of medical records utilized for annual HEDIS submission. The reviewer will be required to track data submission and inform management of any trends, barriers, or backlog. The position requires interpretation of clinical data submissions in order to accurately submit records for processing or return the records to the submitter in a timely manner with detailed return reasons. Other responsibilities may include medical record retrieval either onsite or via remote access throughout the year, participation in annual HEDIS hybrid record processes, involvement in Health Outcomes Improvement Team initiatives, training temporary staff as applicable to assist in chart abstraction process, and meet departmental goals of timely and accurate review of medical records.

Skills: Ability to communicate effectively and professionally, both verbally and in writing with various audiences. Ability to plan, organize and coordinate multiple tasks and priorities. Ability to perform duties with minimal supervision. Includes the ability to act both independently and as part of a team while adapting to changing priorities. Analytical skills Knowledge: Knowledge of Facets, Excel and various software used for medical record abstraction documentation. Medical Terminology Experience: Varied clinical experience, 1-2 years of medical record review experience. Education, Certification, and Licenses: LPN required Physical Demands: While performing the duties of the job, the employee is frequently required to sit, use hands to finger, handle and feel, and talk, hear, and see. The employee must occasionally lift and/or move up to 5 pounds. Key Interfaces: Internal departments and external providers

Review medical records and abstractions from various modes of submission. Communicate with providers and internal staff to improve processes and submissions accuracy. Attend appropriate trainings related to HEDIS and medical record review/abstraction. Other duties as assigned

Community Health Network

Telephone Registered Nurse (RN) Outpatient Case Manager - Remote

Posted on:

January 11, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

Indiana

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.

4 year / Bachelor's Degree Graduate of National League for Nursing (NLN), Commission on Collegiate Nursing Education (CCNE), or Accreditation Commission for Education in Nursing (ACEN) accredited school of nursing or in lieu of accredited schools listed above, three years of related professional nursing experience. Bachelor’s degree in nursing is required. 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) Two years of clinical or nurse case management experience. (Required)

The Telephone Registered Nurse Case Manager is responsible for coordinating the care continuum for discharged patients through follow-up phone calls and functions as part of the multidisciplinary team to support the patient/family in their time of transitioning to home. This is done via a discharge telephone call to the patient/family to follow-up and assess for needs once the patient has returned home from a hospital stay and Emergency Department visits. This is a remote/ work-from-home position. Collaborates with other care team members throughout the continuum of care, including but not limited to physicians, directors, managers, case managers, risk managers, home health team, and CPI offices. Ensures quality patient transitions to home via telephonic interview and provides necessary supports to ensure a safe transfer to home by enlisting a multitude of interventions.

Trinity Health

(REMOTE) Epic Application Coordinator Resolute- Hospital Billing Claims Admin or Professional Billing Claims Admin

Posted on:

January 11, 2025

Job Type:

Full-Time

Role Type:

Informatics

License:

None Required

State License:

Michigan

Hospital Billing Claims Certified Application Coordinator or Professional Billing Claims Certified Application Coordinator REMOTE: position allows for work remote opportunity Resolute Hospital Billing Certified Application Coordinator or Resolute Professional Billing Certified Application Coordinator experience highly preferred POSITION PURPOSE: Responsible for providing primary support and contact for each application. Coordinates all issues that arise during the project for assigned application areas and provides subject matter expertise and comprehensive knowledgeable in Trinity Health's policies, procedures, and business operations. Works directly with the customer and develops best practice workflows based on decisions from different system decision making groups and translates the information into the application build. Works hand-in-hand with other Epic Application Coordinators, Project Managers, Trainers, and respective Application Managers.

Ability to work independently in a remote environment. Bachelor's degree in healthcare, IT or related field or an equivalent combination of education and experience. Must have progressively responsible experience serving as a subject matter expert, specialist or a consultant. Three (3) to five (5) years knowledge and leading performance/business process improvement activities, including analyzing workflow processes utilizing PDCA, Lean, Six Sigma or other continuous process improvement methodologies or direct experience building IT systems Ability to interface with multiple technical and business teams. Familiarity with information systems, clinical software and other computer applications. Ability to serve as primary support contact for application and to coordinate all issues that arise. Ability to understand choices involved in application configuration and to perform in-depth analysis of workflows, data collection, report details, and other technical issues associated with Epic software. Ability to analyze business operations relative to build decisions, investigate end users' preferences when making build decisions, and working directly with system decision groups. Ability to prioritize and implement requested changes to the system and to effectively analyze functionality in new releases in order to determine utilization. Ability to populate databases during the initial system build with assistance from Epic and to collect information regarding potential system enhancement needs. Ability to ensure data coming across an interface into an Epic application meets the business needs. Ability to set standards for naming and numbering conventions and security classifications using the Epic Style Guide Master File Naming and Numbering Conventions. Ability to serving as a liaison between end users, third parties, and Epic implementation staff. Strong communication skills with the ability to communicate information clearly and concisely with project leadership and team members. Strong analytical abilities and the ability to assess and match team member skills to team responsibilities and match organizational needs to the system's functionality. Ability to motivate team members and show appreciation for the overall team efforts. Ability to participate in training and work with end users. Ability to troubleshoot problems and questions from end users and provide resolution and requested information. Ability to research, evaluates, and analyzes alternatives to reach issue resolution. Ability to manage project from organizational perspective and to never lose sight of detailed tasks. Ability to work with report writers to ensure that the application has the necessary reports. Ability to commit to established timetables and deadlines in order to ensure successful project outcomes Must be an effective consensus builder and collaborator, have excellent written and verbal interpersonal and communication skills, and operate effectively in a highly collaborative environment. Must be able to operate effectively in a collaborative, shared leadership environment. Must possess a personal presence that is characterized by a sense of honesty, integrity and caring with the ability to inspire and motivate others to promote the philosophy, mission, vision, goals and values of Trinity Health.

Knows, understands, incorporates and demonstrates the Trinity Health Mission, Vision and Values in behaviors, practices and decisions. Establishes priorities that align with organizational initiatives. Manages multiple projects simultaneously and adapts to frequent changes in priority. Manages teams to consensus decisions that support organizational objectives Consults with providers, clinicians, executives and management at all levels in order to provide support for decisions, workflows, new initiatives and other assignments. Provides critical analysis of data to support assigned program, project and/or engagement and articulates same to colleagues, customers, business owners and all levels of management. Provides specialized guidance for integration, architectures, system selection, strategy, electronic health and/or financial records, clinical systems implementations and clinical process transformation as needed. Researches and contributes to recommendations into timing of introduction of new functionality. Supports upgrade design process and decision-making. Recommends innovative application solutions to product workflow, patient safety, productivity and financial problems. Provides leadership direction for application integration decisions with impacts across applications and clinical / business units. Assists product teams in development of design and required documentation. Analyzes business processes and reengineers those processes to improve business and/or clinical needs. Prepares or participates in the preparation of detailed project work plans and project status reports. Assists and collaborates with system decision making groups in determining best practice evidence-based workflows, order sets, forms, decision support and other tools that are consistently applied throughout Trinity Health. Utilizes performance improvement methodologies (e.g., PDCA, Lean, Six Sigma, etc.) and change management strategies to address gaps in performance, changing technology, regulations, standards and evidence. Participates in interdisciplinary functional groups that make design, implementation, enhancement and outcome reporting decisions. Models teamwork within the System Office and with RHMs. Demonstrates the ability to operate in a collaborative, shared leadership environment. Assists in the handling of multiple projects/assignments simultaneously and adapts to frequent changes in priorities. Actively pursues professional growth opportunities. Utilizes support staff appropriately and adopts new tools to manage projects and documents. Maintains a working knowledge of applicable Federal, State and local laws and regulations, the Trinity Health Integrity and Compliance Program and Code of Conduct, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical and professional behavior.

Trinity Health

Clinical Quality Review Specialist - RN License Required

Posted on:

January 11, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Michigan

Trinity Health At Home, a national home care, palliative care and hospice organization serving communities in twelve states. We are is a comprehensive, trusted provider of home care and end-of-life care in the sacred place that people call home. A Catholic-based, non-profit organization, we serve patients and their loved ones with home care (skilled nursing, physical/occupational and speech therapy and medical social work), hospice and bereavement services. Our legacy continues with a pioneering, future-thinking care model. We blend clinical expertise with our exclusive Home Care Connect™ virtual care program to help patients achieve their health goals. We have energizing new vision and strategy. Join us and shape the future of healthcare!

Trinity Health at Home is seeking an experienced RN remote Clinical Quality Review Specialist with ICD10 HCS-D certification which is Required. OASIS COS-C certification required within 6 months of hire Trinity Health at Home is seeking an experienced RN Clinical Quality Review Specialist for a remote position ICD10 HCS-D certification which is Required to interview OASIS COS-C certification required within 6 months of hire HCHB experience required

Registered Nurse with current license from the state in which practicing. May be required to obtain additional state licenses. Degree: Bachelor's preferred. Associate nursing degree considered if successfully demonstrated career progression and meets and exceeds performance expectations. ICD10 HCS-D certification Required. OASIS COS-C certification strongly preferred. Home Care Home Base software experience a plus! EPIC software experience a plus! Strong computer and technology skills required. Well-developed interpersonal and communication skills necessary for effective interaction with a wide range of customers, professional clinical staff and other related team members. Ability to consistently demonstrate alignment to the Mission, Vision and Values, Organizational Code of Ethics and adhere to the Compliance Program.

The Clinical Quality Review Specialist is a remote position, responsible for processing and completing assigned quality and clinical workflows, identifying errors and omissions in clinical assessments, OASIS, coding, plans of care and other clinical documentation. Collaborates with clinicians to achieve accurate documentation and plan of care development including visit utilization targets and identification of hospitalization risk to produce strong clinical outcomes. Provides clinician specific education regarding quality, outcomes improvement, documentation standards, and actions to improve clinical processes. Participates in department quality improvement initiatives. Collaborates with agency on focused quality improvement initiatives to achieve organization's strategic aims and top clinical outcomes.

Trinity Health

Supervisor, Clinical Documentation Integrity (CDI) (Remote)

Posted on:

January 11, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Michigan

At the direction of the Regional Manager, Clinical Documentation Integrity (CDI), this position supervises daily operations of the CDI program for the Health Ministries (HMs) within their region. Provides direct oversight of the Clinical Documentation Specialist and Clinical Documentation Integrity Coordinator. Working with the Regional Manager, Clinical Documentation Integrity, is directly responsible for the daily assessments of current Clinical Documentation Specialist staffing levels and processes. Ensures that defined goals are accomplished utilizing timely and compliant processes within the region and in concert with the Trinity Health System Office CDI program standards, policies, procedures and workflows. Assists with policy and education development on the use of guidelines and proper documentation requirements as it relates to reimbursement and other clinical data quality management for colleague training. Provides quality and productivity monitoring; coordinates and participates in performance improvement initiatives. Provides training and education to clinical documentation specialists (CDS) to enhance clinical and coding skill sets and optimal utilization of the 3M CDI software. Responsible for scheduling and work assignments for colleagues. Works closely with Clinicians, Coding, Quality and Denials teams to facilitate documentation within the medical record and supports the patient’s severity of illness, risk of mortality, clinical validity and proper DRG assignment.

Bachelor’s Degree in Health Information Management, Healthcare related field or Nursing or equivalent in experience. Must possess one of the below: Current Registered Nurse (RN) License Registered Health Information Administrator (RHIA) Registered Health Information Technician (RHIT) Certified Coding Specialists (CCS) Certified Clinical Documentation Specialists (CCDS) or Certified Documentation Improvement Professional (CDIP) preferred Minimum of five (5) years of current hospital clinical documentation integrity program experience is required. At least one (1) to three (3) years of experience in a supervisory/lead role for a hospital/inpatient clinical documentation integrity program is required. Must have thorough knowledge of CMS regulations, coding guidelines and DRG reimbursement. Demonstrated knowledge of state and federal Hospital Acquired Conditions (HAC) and other applicable quality indicator codes (i.e. PSI, PPI, etc.). Demonstrated, current expertise with 3M CDI Software. Working knowledge of Epic EMR preferred. Must possess strong analytical and critical thinking skills in order to detect and resolve problems related to clinical documentation integrity. Demonstrated ability to effectively supervise diverse and geographically dispersed teams both onsite and remote. Excellent interpersonal skills with ability to build collaborative working relationships with clinical staff, finance and compliance. Must possess strong written and verbal communication skills to effectively supervise clinical documentation integrity activities and communicate with a wide-ranging audience. Intermediate computer skills required, including working knowledge of and experience using MS Word, Excel, Outlook and PowerPoint. Must be able to spend majority of work time utilizing a computer, monitor and keyboard. Maintains professional attitude and ability to relate well with leadership, physicians, other care providers, colleagues and patients and others within the scope of the position. Strong understanding of the Catholic health ministry in an evolving health care delivery system and changing reimbursement market. Personal presence that is characterized by a sense of honesty, integrity, and caring as well as the ability to inspire and to motivate others to promote the philosophy, mission, vision, goals, and values of the Ministry. PHYSICAL AND MENTAL REQUIREMENTS AND WORKING CONDITIONS Ability to work in a fast-paced, multi-customer environment, with conflicting needs. May warrant varied and/or extended hours, with changes in workload and priorities to keep pace with the industry and advanced strategic priorities. Must possess the ability to comply with enterprise policies and procedures. Must be able to spend majority of work time utilizing a computer, monitor and keyboard.

Knows, understands, incorporates, and demonstrates the mission, vision, and values of the Ministry in leadership behaviors, practices, and decisions. Directly supervises the daily operations for the CDI team who work onsite and remotely. Communicates effectively with staff to ensure defined regional and/or system goals are met. Maintains current knowledge of the MS-DRG system, CCs/MCCs, impact on quality, risk of mortality, severity of illness and CMI as well as ICD-10 coding systems and the guidelines related to Clinical Documentation Integrity. Facilitates appropriate clinical documentation to ensure that the severity of illness, risk of mortality and level of services provided are accurately reflected in the health record. Assists in overall quality, timeliness and completeness of the quality health record to ensure appropriate data, provider communication and quality outcomes. Serves as a resource for appropriate clinical documentation. Responsible for scheduling and staffing assignments for the Clinical Documentation Specialist and Clinical Documentation Integrity Coordinator positions, facilitating management of personal time off and schedule change requests, assuring adequate staffing is in place. Monitors time and attendance system along with maintaining attendance records. Coordinates the work of external resources when used. Along with the Clinical Documentation Integrity Coordinator, facilitates training of all new CDS hires. Assists the Regional Manager, Clinical Documentation Integrity, in the recruitment, retention and supervision of CDI staff. Participates in the development of staff, including fostering teamwork, providing performance feedback, mentoring CDS and scheduling education. Collaborates with the Regional Manager, Clinical Documentation Integrity, on competency assessments, performance evaluations, counseling and/or conflict resolution. Communicates with and educates physicians and all other members of the healthcare team regarding clinical documentation and monitors provider participation. Identifies learning opportunities for healthcare providers. Ensures that direct reports communicate, educate and engage with physicians and other members of the healthcare team regarding clinical documentation. Collaborates with coding staff to assure documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient’s clinical status and care. Ensures appropriate and accurate DRG assignment. Resolves all discrepancies in a courteous manner. Demonstrates a thorough understanding of the MS-DRG system, CCs/MCCs, impact on quality and CMI as well as ICD-10 coding systems and the guidelines related to Clinical Documentation Improvement. Serves as a resource for the CDS team for any of the above. Provides input for policy and procedure maintenance and development. Assists with the collection, aggregation and analysis of data. Collaborates in development and monitoring of performance to measure process outcomes, quality and productivity, and to ensure continual process improvements. Ensures that direct reports remain current in coding guidelines and other regulatory directives that impact CDI performance. Ensures all compliance and regulatory standards are met. Ensures that direct reports perform clinical validation as part of the review process and remain current on CDI strategies. Maintains superuser level skill set in the use of 3M/360 and leverages technology and system reporting to improve CDI team efficiency and effectiveness. Monitors the CDI Dashboard and reporting to identify opportunities for improvement and areas of focus. May perform CDI reviews to support program during high volume, short staffing periods. Maintains a working knowledge of applicable Federal, State, and local laws and regulations, Trinity Health Corporate Integrity Program, Code of Ethics, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical, and professional behavior.

Centurion Consulting Group

Clinical Abstractor

Posted on:

January 11, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Virginia

Centurion Consulting is looking for a Clinical Abstractor for a REMOTE tole for one of our federal clients.

Required Skills: 5+ years of ORYX and CMS abstraction experience is required. Deep understanding of clinical quality measures (NCQA, HEDIS, etc.), analysis, audits, education, etc. and experience developing relevant reports. Education: Associate’s Degree or higher Preferred Skills: Experience with Cerner abstraction tools. RHIA, RHIT, or RN preferred. Prior government experience / prior clearance preferred.

Review Medical Charts and records to pull out key information to support calculation of clinical quality measures. Expected Deliverables: CMS and ORYX reports, HEDIS Compliance Audits, Annual ORYX Measure Selection, Leapfrog Reports & Training Material Updates, Global Trigger Tool, etc.

TMF Health Quality Institute

Field Reviewer (PRN)

Posted on:

January 11, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Texas

**Please make sure your application is complete, including your education, employment history, and any other applicable sections. Initial screening is based on the minimum requirements as defined in the job posting, such as education, experience, licenses, and certifications. Your experience should also address the knowledge, skills and abilities needed for the role. Incomplete applications will not be considered.** *This position is located Remote, Texas* *This position is Part Time (PRN)* Position Purpose: Performs moderately complex (journey-level) quality assurance work. Plans and facilitates projects and ensures required deadlines and deliverables are met. Travels across Texas and completes Vaccines for Children site visits in a timely manner before their due date. Works under general supervision, with moderate latitude for the use of initiative and independent judgement.

Education: High School Diploma or equivalent Experience: Four (4) years reviewing medical records College education or technical training in social services, public health, or related areas may be substituted for experience on a year per year basis. (Education requirements may be satisfied by full-time education or the prorated part-time equivalent.) Ability to travel daily, with up to 80% of the time being overnight travel Ability to work during core business hours (Monday-Friday, 8am to 5pm)

Completes Vaccines for Children and Adult Safety Net visits as assigned, in provider offices during core business hours (Monday-Friday, 8am-5pm). Enters documentation of visits into appropriate databases by deadlines established. Educates providers on key areas where they are deficient to assist in compliance with program requirements. Travels (drives) to various areas of Texas as assigned to complete site visits, including both day and overnight travel (up to a week at a time). Maintains communication and feedback necessary for program performance.

TMF Health Quality Institute

DRR III (Healthcare Professional)

Posted on:

January 11, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

None Required

State License:

Texas

Please make sure your application is complete, including your education, employment history, and any other applicable sections. Initial screening is based on the minimum requirements as defined in the job posting, such as education, experience, licenses, and certifications. Your experience should also address the knowledge, skills and abilities needed for the role. Incomplete applications will not be considered. *This position is located Remote Anywhere US* Position Purpose: Performs complex (senior-level) work. Provides dissatisfied patients/beneficiaries and/or providers the opportunity to present documentation to demonstrate why an appeal/dispute should be allowed. Provides an independent second level determination/dispute resolution based on the documentation, facts, laws, regulations, and guidelines. Works under general supervision, with moderate latitude for the use of initiative and independent judgment.

Education: Associate's degree or 60 or more credit hours towards a Bachelor’s degree from an accredited college or university in healthcare or related discipline Additional experience in Medicare appeals, medical review, clinical, or other related experience in a healthcare setting may be substituted for Associate’s degree on a year per year basis. (Experience requirements may be satisfied by full-time experience or the prorated part-time equivalent.) Experience: Three (3) years of medical dispute resolution or Medicare appeals, medical review, clinical, or related experience in a healthcare setting Healthcare Professional with demonstrated experience writing or making medical necessity decisions Nursing, Physical Therapy, Respiratory Therapy or Occupational Therapy experience Medical billing, medical appeals or clinical Patient- Provider Dispute Resolution, preferred Independent Dispute Resolution, preferred Coding certificate, preferred

Reviews medical records/case file, writes a reconsideration/dispute resolution decision that is clear, concise, and impartial and supports the determination made, and documents review. Makes sound, independent decisions based on medical evidence in accordance with statutes, regulation, rulings, and policy. Responds to and ensures that all appeal/dispute issues raised by the beneficiary/patient, representative, and provider/supplier have been addressed. Provides a fair and impartial decision based on current evidence, regulations, policies, and procedures.

Lightship

Travel Per Diem Clinical Research Nurse

Posted on:

January 11, 2025

Job Type:

Role Type:

Clinical Operations

License:

RN

State License:

California

Lightship is the virtual-first provider that is perfecting the way clinical trials get executed. Because clinical research plays such a vital role in bringing life-enhancing and lifesaving innovations to market, Lightship pursues operational excellence in clinical studies. Our end-to-end hybrid delivery model, our diversity of skillsets, and in-house patient care team ensure sponsor success and the best possible patient experience. With a problem-solving mindset, we strive to make every clinical trial better than the last. Operational excellence is not a goal, but a way of doing things at Lightship.

The Lightship Travel Per Diem Clinical Research Nurse is an energetic, independent, and compassionate individual that delivers quality nursing care to patients in their homes, Mobile Research Unites (MRUs), and brick and mortal facilities. This is a specialized role in clinical research that works directly with patients in our studies under oversight of study investigators and clinical study lead to perform delegated clinical research activities. A successful candidate will possess a willingness and desire to work independently without significant supervision. Additionally, this position will require considerable travel (approximately 90%).

Required knowledge, skills, and abilities Strong skills in venipuncture and starting/managing intravenous lines in adult patients required, adult and pediatric venous access skills preferred Strong skills in processing, centrifuging, and aliquoting biosamples required, preferably within a clinical research setting Strong communication skills, including verbal, written, and presentational Proactively identify and solve problems to completion Strong ability to form long-term positive relationships with patients, caregivers, and their families is required Ability to maintain a calm and collected manner when working with patients, physicians, and other research professionals Ability to independently navigate logistics as needed Exceptional ability to work as part of a team and to multitask effectively Willingness to maintain clinical compliance and submit all required health documentation on time, including verification of immunity via titer testing Willingness to receive annual influenza vaccine and additional “boosters” for COVID-19 at the frequency recommended by the CDC Education and experience Associate's degree in nursing required, Bachelor of Science in Nursing (BSN) preferred Current Basic Life Support (BLS) Certification through the American Heart Association Current valid RN license required Full and current vaccination record inclusive of COVID-19 (full vaccination) required Two (2) years of recent clinical nursing experience in a hospital, clinic, or similar health care setting At least two (2) years of sponsored clinical research experience in Pharma & Biotech Knowledge of nursing competency skills per scope of practice (i.e., performing vital signs, nursing assessments, performing ECG / EKG, administering injections, venipuncture, etc.) Knowledge of medical terminology, drug calculation skills, and clinical medicine Previous experience with dry ice required, previous or current certification for Shipping Category B Biological Substances preferred Direct experience with drug accountability calculations preferred Physical ability to perform nursing tasks and lift equipment up to 15 kg in weight Valid driver’s license Access to a reliable vehicle to perform study participant visits Ability to drive to local and/or remote locations to perform study participant visits and complete study activities Bilingual fluency in English and Spanish preferred

Assisting investigators, sub-investigators, and other Lightship personnel in successful implementation and conduct of research studies Providing nursing care to study patients, which includes: Participating and providing research nurse services to qualified study participants at home and, in some instances, in clinic or other settings per protocol requirements Ensuring strict compliance with each study’s protocol and internal operational guidelines by providing thorough review and documentation at each patient visit Performing protocol defined procedures and assessments, including, but not limited to, collection of vital signs, performing assisted physical examinations, conducting electrocardiograms, and collection and processing of biospecimen samples Preparing, coordinating, and executing on-time shipment of ambient, refrigerated, and frozen biospecimen samples using dry ice as necessary Administering investigational medications or providing patient education regarding administration as necessary. Administration routes include, but are not limited to, topical, oral, IM injection, IV injection, and IV infusion Notifying Principal Investigator of findings / issues / possible adverse events identified during the study visits Educating patients on study procedures; responding to patients’ questions in a compassionate and cultural / age-appropriate manner; triaging patients’ questions to the appropriate study personnel Documenting study data in patient records (paper and electronic, as applicable) Coordinating / conducting study activities with patients and serving as the primary point of contact for patients, investigators, and study personnel, including: Coordinating research procedures and assessments; keeping track of all planned and completed study visits Organizing patients’, investigators’, home health personnel, and any relevant vendors’ (e.g., drug management vendor) schedules to complete study visits within protocol windows Shipping materials to patients or other locations in preparation for study visits; collecting study materials after visits are completed Assisting investigator / sub-investigator / designated personnel in the informed consent process as requested and delegated Coordinating general study activities, including: Assisting with study start-up and close out activities as needed Ordering study supplies, materials, and equipment Assisting patients, investigators, and study personnel in troubleshooting problems with supplies, equipment, or vendors Successfully completing all Lightship and study-specific training by assigned due dates; training peers as requested Participating in site initiation and monitoring visits as requested; assisting with external and internal audits, as requested Accurately managing business-related expenses and submitting expense reports and required documentation on time Other study-related activities as assigned

CHI Health Immanuel

Virtual Care RN

Posted on:

January 11, 2025

Job Type:

Part-Time

Role Type:

Clinical Operations

License:

RN

State License:

Nebraska

CommonSpirit Health was formed by the alignment of Catholic Health Initiatives (CHI) and Dignity Health. With more than 700 care sites across the U.S. from clinics and hospitals to home-based care and virtual care services CommonSpirit is accessible to nearly one out of every four U.S. residents. Our world needs compassion like never before. Our communities need caring and our families need protection. With our combined resources CommonSpirit is committed to building healthy communities advocating for those who are poor and vulnerable and innovating how and where healing can happen both inside our hospitals and out in the community.

This Virtual Nurse role is an exciting new position! You will be involved in changing the nursing scope of practice and development of change within the nursing field. You will be able to interact with staff, patients, and families on a new level and help support the bedside staff. Virtual Nursing is on the rise and you will be on the forefront of the change.

Graduate of an RN nursing program and active RN license Minimum 3-5 years in clinical focus required, preferably in PCU or ICU. One year leadership experience required (e.g. Charge RN or related experience). BLS (Basic Life Support) is required upon hire. ACLS (Advanced Cardiovascular Life Support) certification required within 5 months of hire.

Supporting our Progressive Care Unit. The Virtually Integrated CareSM (VICSM) is a transformational model of care delivery offered by CommonSpirit Health that provides 24/7 virtual access to highly experienced RNs for patients and the bedside care team. With the VICSM program, the patient experience is enhanced and the interprofessional care providers are supported with time-consuming care activities such as charting, discharges, admissions, care coordination, and patient education (just to provide a few examples) leading to a reduction in nurse turnover, enhanced operational efficiency and unparalleled quality in patient care delivery. This is realized through a care delivery model that seamlessly integrates the virtual nurse as part of the interprofessional team. The virtually integrated careSM nurse is integral in facilitating the care delivery model. As a Virtually Integrated CareSM RN at CommonSpirit Health, you will advance professional practice by providing vital support in a proactive manner to the interprofessional bedside team and the patient/family using virtual technology. You will significantly enhance the patient experience and ensure each patient receives the highest level of care. You will also positively impact the staff experience and improve morale by assisting with essential nursing functions to unburden the workload of the frontline care teams allowing more time with patients and families. You'll collaborate with interdisciplinary patient care teams, provide guidance and mentorship, and lead the plan of care to deliver exceptional outcomes for patients. Your exceptional communication skills, positive attitude, and knowledge of various diagnoses and situations ranging from minor to critical will be crucial to your success as a highly skilled resource for on-site patient care teams. If you're looking to deliver exceptional patient care and provide expert support to the bedside care team, this could be your next step to elevate your professional practice and your nursing career!

Vaya Health

Transition Coordination Manager (Remote NC)

Posted on:

January 11, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

North Carolina

LOCATION: Remote – must live in North Carolina or within 40 miles from the NC border, preferably near Vaya’s catchment area. Vaya operates within the hours of 8:30am-5:00pm EST. GENERAL STATEMENT OF JOB: The Transition Coordination Manager is responsible for overseeing proactive intervention and clinical coordination of services of Transition Coordination Supervisors and Transition Coordinators (TCs) for persons residing in or being diverted from institutionalized settings prior to their transition to home and community-based services as part of Transitions to Community Living. These services prepare members/recipients for discharge and assist during adjustment period immediately following discharge from an institution. This is a mobile position with work done in a variety of locations. The Transition Coordination Manager will supervise Transition Coordination Supervisors.

KNOWLEDGE, SKILL & ABILITIES: Knowledge of the MH/SU/IDD service array provided through the network of Vaya providers. Knowledge in Vaya Medicaid B and C waivers and accreditation is essential. Maintain advanced knowledge of the laws, regulations, and policies which govern human services, and Vaya Health. Knowledgeable about Medicaid and Special Assistance benefits, available clinical services, community supports, supportive housing, supported employment, and other social determinants of person-centered healthcare. Extensive understanding of the Diagnostic and Statistical Manual of Mental Disorders (current version), if performing clinical duties. A high level of diplomacy and discretion is required to effectively negotiate and resolve issues with minimal assistance. Exceptional interpersonal skills, highly effective communication ability, and the propensity to make prompt independent decisions based upon relevant facts. Problem solving, negotiation, arbitration and conflict resolution skills are essential to balance the needs of both internal and external customers. Highly skilled at shifting between macro and micro level planning, maintaining both the big picture and seeing that the details are covered. Detail oriented, able to organize multiple tasks and priorities, and to effectively manage projects from start to finish. Ability to change focus to meet changing priorities, change according to mandated changes, and priorities within the department. Proficiency in Microsoft Office products (such as Word, Excel, Outlook, PowerPoint, etc.) and Vaya information system is required. QUALIFICATIONS & EDUCATION REQUIREMENTS: Bachelor's degree in Human Services and 3 years of experience providing care management, case management, or care coordination to the population being served OR Bachelor’s degree in a field other than Human Services or in Nursing and 5 years of experience providing care management, case management, or care coordination to the population being served Must meet the criteria of being a North Carolina Qualified professional in 10A NCAC 27G .0104 Licensure/Certification Required: Incumbents with a Bachelor’s Degree in Nursing must also hold licensure as a Registered Nurse (RN) in North Carolina PHYSICAL REQUIREMENTS: Close visual acuity to perform activities such as preparation and analysis of documents; viewing a computer terminal; and extensive reading. Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive motion of hands, wrists and fingers. Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time. Mental concentration is required in all aspects of work. RESIDENCY REQUIREMENT: The person in this position is required to reside in North Carolina or within 40 miles of the North Carolina border.

Transition Coordination Oversight and Planning: Ensure the Transition Coordination Supervisors are addressing the needs of the TCs to support members/recipients who wish to move to a more inclusive setting and are provided with necessary services and supports. Develop program guidelines and unit trainings in conjunction with leadership. Participate in meetings and may involve periodic standing participation in Vaya Health projects or committees. Assist in Vaya Health policy and participate in external statewide workgroups and trainings. Provide data, reports or other documentation needed to meet transition planning and other requirements. Recruit for vacancies within the unit and is responsible for screening applications, interviewing candidates, selecting the best-qualified candidate and documenting the selection process. Timesheet approval and requests for time off and overtime, if applicable, as well as travel/training requests. Address performance issues through the disciplinary process, with the assistance of Human Resources and is responsible for documenting performance. Assignment of tasks to Transition Coordinators, and outlining the tasks, specifications, completion timelines, and task assignment deliverables. Face-to-face, in-field, and other means of supervision to Transition Supervisors. Collaboration: Communication with all members/recipients involved in the transition process. Work closely with TC Supervisors, TCs, In Reach staff, care management, and other Vaya departments necessary to create, implement and fulfill successful transition planning with members and recipients. Participate in education with members/recipients, families, providers, and stakeholders associated with the Transition to Community Living. Development of training resources locally and statewide. Communication regarding micro and macro level issues with NC Division of Mental Health/Substance Abuse/Developmental Disabilities.

CVS Health

Appeal Nurse Associate - MUST reside in Kentucky

Posted on:

January 10, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

LPN/LVN

State License:

Kentucky

Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver. Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.

This is a full-time telework position. Kentucky residency is required. Hours for this role are Monday-Friday 8:00a-5:00p EST.

Required Qualifications: 2+ years of clinical experience LPN/LVN with current unrestricted state licensure in the state of Kentucky Must reside in the state of Kentucky Preferred Qualifications: Managed Care experience Prior Appeals experience Education: LPN/LVN with current unrestricted state licensure required

Facilitate the delivery of appropriate benefits and/or healthcare information which determines eligibility for benefits while promoting wellness activities. Supports Health Strategies, tactics, policies and programs that ensure the delivery of benefits and to establish overall member wellness and successful and timely return to work. Services and strategies, policies and programs are comprised of network management, clinical coverage, and policies. Responsible for the review and resolution of clinical complaints/grievances and appeals. Interprets data obtained from clinical records to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and provider issues. Independently coordinates the clinical resolution with internal/external clinician support as required. Requires LPN/LVN with unrestricted active license. Assists with reviewing clinical complaint/grievance and appeal requests of all clinical determinations/clinical policies. Considers all previous information as well as any additional records/data presented to prepare a recommendation. Assists with data gathering that requires navigation through multiple system applications. Contacts the provider of record, vendors, or internal Aetna departments to obtain additional information Accurately applies review requirements to assure case is reviewed by a practitioner with clinical expertise for the appeal issue at hand (e.g. Specialty Match Review (SMR), RN, MD, etc.). Commands a comprehensive knowledge of complex delegation arrangements, coding logic, contracts (member and provider), clinical criteria, benefit plan structure, regulatory requirements, and ERO eligibility which are required to support the clinical complaints/grievances and appeals determinations. Pro-actively and consistently applies the regulatory and accreditation standards to assure that appeals and ERO requests are processed within requirements. Assists with condensing information from multiple sources (i.e., contract, coding, regulatory, etc.) into a clear and precise clinical picture for presentation to an appropriate clinician for determination. Seeks guidance from other healthcare professionals in the coordination and administration of the appeal and grievance process.

CVS Health

Case Manager RN- Pennsylvania

Posted on:

January 10, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Pennsylvania

Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver. Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.

The Case Manager RN role is 100% remote work from home and candidates must live in the state of Pennsylvania and be licensed in the state of Pennsylvania. Normal Working Hours: Monday through Friday 9:00am – 5:30pm EST be willing and able to work 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, current and unrestricted RN licensure in the state of Pennsylvania and live in the state of Pennsylvania. Must be willing and able to obtain multiple state RN licensure after hire (expenses paid for by company) 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. Must be willing and able to work Monday through Friday 9:00am – 5:30pm EST zone Must be willing and able to work occasional evening, weekend, and holiday shifts per the needs of the team. 3+ years’ experience with Microsoft Office Suite Preferred Qualifications: Certified Case Manager (CCM) certification Case Management in an integrated model Discharge Planning experience Managed care experience Education: Associates Degree required

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.

Sagility

LPN/LVN Utilization Management Coordinator

Posted on:

January 10, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

LPN/LVN

State License:

Massachusetts

Sagility combines industry-leading technology and transformation-driven BPM services with decades of healthcare domain expertise to help clients draw closer to their members. The company optimizes the entire member/patient experience through service offerings for clinical, case management, member engagement, provider solutions, payment integrity, claims cost containment, and analytics. Sagility has more than 25,000 employees across 5 countries.

We are currently hiring a LPN/LVN Utilization Management Coordinator. This role is primarily responsible for the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of client?s benefits plan. The Utilization Management (UM) Coordinator is responsible for day-to-day timely clinical and service authorization review for medical necessity and decision-making. The Utilization Management Coordinator has a key role in ensuring the client meets CMS compliance standards in the area of service decisions and organizational determinations. Successful candidates must have a current, valid Massachusetts clinical license in good standing.

Education: Associate degree MA clinical license in good standing. Experience: Required: 3+ years combined clinical and utilization management experience Strong plus: 3+ years? experience working in a health plan and/or experience with a care management platform Skills: Ability to apply predetermined criteria (e.g., InterQual) to service decision requests to assess medical necessity Flexibility and understanding of individualized care plans Ability to influence decision making Strong interpersonal, verbal and written communication skills Ability to work independently Comfort working in a team-based environment Will be required to pass credentialing process. This is a fully remote work at home role. You must have a secure, private wok at home area with a hardwired internet connection with speeds greater than 5MB upload and 10MB download.

Conducts timely clinical decision review for services requiring prior authorization in a variety of clinical areas, including but not limited to Durable Medical Equipment/Services, Long Term Services and Supports (LTSS), and Home Health (HH) Applies established criteria (e.g., InterQual and other available guidelines) and employs clinical expertise to interpret clinical criteria to determine medical necessity of services Communicates results of reviews verbally, in the medical record, and through official written notification to the primary care team, specialty providers, vendors and members in adherence with regulatory and contractual requirements Provides decision-making guidance to clinical teams on service planning as needed Works closely with Clinicians, Medical Staff and Peer Reviewers to facilitate escalated reviews in accordance with Standard Operating Procedures Ensures accurate documentation of clinical decisions and works with UM Manager to ensure consistency in applying policy Works with UM Manager and other clinical leadership to ensure that departmental and organizational policies and procedures as well as regulatory and contractual requirements are met Creates and maintains database of denied service requests Additional duties as requested by supervisor Standard office conditions. Some travel to clinical practices may be required.

Sagility

Care Manager

Posted on:

January 10, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

None Required

State License:

Colorado

Sagility combines industry-leading technology and transformation-driven BPM services with decades of healthcare domain expertise to help clients draw closer to their members. The company optimizes the entire member/patient experience through service offerings for clinical, case management, member engagement, provider solutions, payment integrity, claims cost containment, and analytics. Sagility has more than 25,000 employees across 5 countries.

The Sagility team is currently hiring for the role of Care Manager. The Care manager works closely with members and their caregivers to promote habits to improve quality of life and attainment of health goals using a Whole Person Care approach. The Care Manager creates a customized plan to meet the clients? key risks through a collaborative approach with the clients and their caregivers. The Care Manager is responsible for developing a health coaching relationship with members and assisting the members through the process of actively working towards better health by providing support, encouragement, follow-up, and education on chronic conditions. The Care Manager supports coordination of care and condition management activities with members, caregivers, and providers. This is a fully remote work at home role, you must have a quiet, private workspace and hard-wired internet with speeds greater than 5MB upload and 10MB download.

Education: College degree in a health-related field preferred Professional Qualification: Current and unrestricted PTA license/certification will be required Experience: Minimum 1-3 years? clinical experience with patient assessments. Experience utilizing Motivational Interviewing techniques and behavioral change theory to facilitate member adoption of positive changes and improve health. Experience working with the Medicare population. Functional/Technical Knowledge, Skills and Abilities Required: Excellent interpersonal skills Ability to understand and interpret policy provisions. Product knowledge Typing Skills Problem Solving Skills Proficient computer skills Demonstrates empathy Strong organizational skills Strong member advocate: willing to go above and beyond normal responsibilities to provide the best service possible Ability to assist member in navigating the healthcare system and community-based resources Culturally sensitive and competent for assigned membership Strong organizational skills; ability to multi-task and be nimble Ability to work remotely Ability to determine when to escalate issues appropriately and in a timely manner

Develop a trusting relationship with members to support the member through the process of changing behavior and improving management of their health by utilizing motivational interviewing techniques and change management concepts. Assist in coordinating members? relationships with multiple service systems. This may include activities such as: Educational resources Recommendations for functional adaptations, durable medical equipment, and care coordination for other skilled interventions and preventive services. Recommendations for follow up care with physicians and specialists as clinically indicated. Present health education in a culturally appropriate format. For example, teaching a member how to prepare traditional foods using less fat Provide social support to improve members? adherence to medical treatment plans Encourage the member in adoption of habits that are conducive to improved management of their chronic condition Develop an individualized plan including goals and plan of action Serve as a resource to Care Management team members

Sagility

RN Utilization Management Reviewer

Posted on:

January 10, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Massachusetts

Sagility combines industry-leading technology and transformation-driven BPM services with decades of healthcare domain expertise to help clients draw closer to their members. The company optimizes the entire member/patient experience through service offerings for clinical, case management, member engagement, provider solutions, payment integrity, claims cost containment, and analytics. Sagility has more than 25,000 employees across 5 countries.

We are currently hiring a talented RN, Utilization Management Reviewer.? This role will be responsible in day-to-day timely clinical and service authorization review for medical necessity and decision-making. The Nurse Utilization Management Reviewer has a key role in ensuring the client meets CMS compliance standards in the area of service decisions and organizational determinations. Successful candidates must hold a valid, current license issued by the Massachusetts Board of Registration in Nursing.

Education Requirements: RN - Associate?s Degree required, Bachelor?s Degree preferred RN, current license issued by the Massachusetts Board of Registration in Nursing CCM (Certified Case Manager) a plus Required Experience (must have): 1 to 2 years Utilization Management experience. 2 or more years working in a clinical setting Desired Experience (nice to have): 2 or more years of Home Health Care experience 2 or more years working in a Medicare Advantage health Plan Required Knowledge, Skills & Abilities (must have): Ability to complete assigned work in a timely and accurate manner Knowledge of the Utilization management process Ability to work independently Desired Knowledge, Skills, Abilities & Language (nice to have): Ability to apply predetermined criteria (e.g., Medical Necessity Guidelines, InterQual) to service decision requests to assess medical necessity Flexibility and understanding of individualized care plans Ability to influence decision making Strong collaboration and negotiation skills Strong interpersonal, verbal, and written communication skills Comfort working in a team-based environment Knowledge of Medicare and Mass health services and benefits This is a fully remote work at home role. You must have a secure, private wok at home area with a hardwired internet connection with speeds greater than 5MB upload and 10MB download.

Conducts timely clinical decision review for services requiring prior authorization in a variety of clinical areas, including but not limited to surgical procedures, Medicare Part B medications, Long Term Services and Supports (LTSS), and Home Health (HH) Applies established criteria (e.g., InterQual and other available guidelines) and employs clinical expertise to interpret clinical criteria to determine medical necessity of services Communicates results of reviews verbally, in the medical record, and through official written notification to the primary care team, specialty providers, vendors and members in adherence with regulatory and contractual requirements Provides decision-making guidance to clinical teams on service planning as needed Works closely with Clinicians, Medical Staff and Peer Reviewers to facilitate escalated reviews in accordance with Standard Operating Procedures Ensures accurate documentation of clinical decisions and works with UM Manager to ensure consistency in applying policy Works with UM Manager and other clinical leadership to ensure that departmental and organizational policies and procedures as well as regulatory and contractual requirements are met Additional duties as requested by supervisor Maintains knowledge of CMS, State and NCQA regulatory requirements

CVS Health

Prior Authorization - LPN - LVN - Remote

Posted on:

January 10, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

LPN/LVN

State License:

Texas

Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver. Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.

Candidates MUST HAVE AT LEAST TWO YEARS OF prior authorization experience. Schedule: For training there is a set schedule 8am-430pm CST Monday-Friday. Following training, you will have a permanent schedule. Shift range varies and is subject to change. Will work 5 days concurrently to include either a Saturday or Sunday. Shift range: Sunday – Saturday 8:00 AM – 6:00 PM. New hires will be expected to work a weekend shift ongoing as part of their permanent schedule rotation (Sunday-Thursday or Tuesday-Saturday).

Required Qualifications• Hold and maintain an active, unencumbered LPN/LVN license in the state of practice. Position requires proficiency with computer skills which include multitasking, navigating multiple systems, and keyboarding. Experience using MS Office, other Windows-based computer applications, web based processing and telephony programs. Minimum 2 years’ recent experience reviewing and processing prior authorizations against health plan criteria for a determination in a specialty/skilled clinical setting i.e., specialty medical office or Pharmacy Benefits Manager (PBM). Preferred Qualifications: 3+ years prior work experience as an LPN/LVN in a specialty medical office and/or skilled clinical setting. Education: The Licensed Practical Nurse is a graduate of a school of Practical, approved by the State Agency and/or accredited by the National League for Nursing (Accrediting Commission (NLNAC)) at the time the program was completed by the applicant. The LPN must have a full, active, and unrestricted license as a Licensed Practical in a State, Territory or Commonwealth of the United States or District of Columbia.

Collection of appropriate clinical/medical data needed to perform clinical assessments and/or reviews as per the health plan/employer agreed criteria, including inbound from the coordinator as needed as well as outreach calls to physician offices. Conducts prospective, concurrent, and/or retrospective review of cases using health plan/employer agreed upon Documentation of required clinical/ medical data that support case decision as required – electronically and/or in written format. Coordinates timely communication of case decision to physician, health plan/employer, patient and other healthcare professionals, and internal departments within CVS\Caremark following agreed upon approval & denial management processes. Generate, review, and validate reporting related of program results Participate in implementation of new Specialty Pharmacy Programs with employers and health plans as needed. Documentation and validation of client specific processes including communication procedures plan demographics, criteria selection, denial management procedures, and reporting requirements. Facilitation of documentation of program agreement with client. Review complex clinical criteria-based prior authorizations in accordance with CVS/Caremark policies and procedures. Refer prior authorization cases not meeting clinical criteria for upper-level review when appropriate. Must possess excellent communication skills, both written and verbal. Shift priorities while exhibiting a high level of urgency and responsiveness with all calls, prior authorization requests, and ADHOC assignments. Follow all prior authorization procedures to meet business quality standards and ensuring the operational unit is complying with regulatory requirements and accreditation standards. Participates in quality assurance activities on ongoing bases, including but not limited to reviewing work instructions and job aids regularly. Collaborate with representatives on the prior authorization team, pharmacists, clinical colleagues, healthcare professionals, clients, leaders, and team members. Complete other prior authorization assignments as delegated by the leadership team. Working hours will vary. Shift range include Sunday – Saturday 8:00 AM – 6:00 PM CST. New hires will be expected to work a weekend shift ongoing as part of their permanent schedule rotation (Sunday-Thursday or Tuesday-Saturday). Utilization of clinical and problem-solving skills to support the research of documentation, communication of medical services, and prior authorization determinations. Ability to multitask, prioritize, and effectively adapt to a fast-paced changing environment. This position involves sedentary work with extended periods of sitting, talking on the telephone, using multiple computer screens, and keyboarding. Must have regular and predictable attendance. Colleague will be required to work business required overtime/ work weekends when business requires, making outreach, and processing prior authorization requests.

CHS Corporate

UR Clinical Specialist (Remote)

Posted on:

January 10, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Compact / Multi-State

Utilization management is the analysis of the necessity, appropriateness, and efficiency of medical services and procedures in the hospital setting. Utilization review is the assessment for medical necessity, both for admission to the hospital as well as continued stay. The Utilization Review Clinical Specialist supports and coordinates the various aspects of the hospital's utilization management program, denials and appeals activities, and readmission reduction initiatives. The nurse specialist will use technology resources to support and monitor authorizations for hospital admissions and extended hospital stays with portals, faxes and phone calls. The Utilization Review Clinical Specialist will monitor adherence to the hospital's utilization review plan to ensure the effective and efficient use of hospital services and monitor the appropriateness of hospital admissions and extended hospitals stays. The specialist will assist the manager in implementing process improvement plans and projects to maximize desired outcomes.

Qualifications: Associate Degree in Nursing required Bachelor's Degree in Nursing preferred At least 2 years of previous nursing experience required 1-3 years work experience in care management preferred Knowledge, Skills and Abilities: Strong analytical skills for reviewing medical records and treatment plans. In-depth knowledge of healthcare policies and regulations. Strong communication, organizational and customer service skills required. Proven ability to work successfully in a fast-paced environment while maintaining good relationships with co-workers and supervisors. Demonstrated proficiency in computer and web-based applications. Licenses and Certifications: RN - Registered Nurse - State Licensure and/or Compact State Licensure required or LPN - Licensed Practical Nurse - State Licensure required or LVN - Licensed Vocational Nurse required Holds active compact state license or active license in the state of support and review required

Performs admission and continued stay reviews by utilizing evidence-based criteria, medical experience-based problem-solving skills, and adhering to established policies and regulations governing this process in order to obtain authorization. Collaborates with physicians to obtain necessary documentation for medical necessity, discharge, and payer requirements. These discussions aim to help the UR Clinical Specialist understand the reason for admission and request appropriate additional documentation from the physician(s). Documents all actions and activities related to utilization review in the case management software system used by the hospital. This documentation includes but is not limited to, clinical reviews, escalations, avoidable days, payer contacts, authorization numbers, wDRG, etc. Documentation may also be made in other systems as required based on hospital and/or corporate policies and procedures. Works with insurance companies to ensure coverage and approvals. Mitigate concurrent denials by submitting a reconsideration or arranging a peer-to-peer. Communicates with the UR Coordinators and facility case manager(s) (i.e. licensed social workers, discharge planners, etc.) virtually, and/or through the case management software to ensure effective collaboration between all disciplines managing a patient’s care. Performs problem analysis and resolution as it pertains to the areas of job responsibility. Maintains performance metrics in line with Utilization Review Service Line Key Performance indicators (KPIs). May serve as a key contact for facility and insurance contacts. Maintains confidentiality as it pertains to all Human Resource and Payroll information. May support training within the department. Performs responsibilities that contribute towards meeting or exceeding team goals. Promptly escalate appropriate issues to manager. Provide suggestions and/or recommendations for changes to applicable processes or tools as recognized from functioning in the role on a daily basis. Provides prompt, courteous and accurate customer support. Performs other duties as assigned. Complies with all policies and standards.

Optum

RN Case Manager Telephone Advice Nurse - Remote in Nevada

Posted on:

January 10, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Nevada

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

Optum NV is seeking a RN Case Manager Telephone Advice Nurse to join our team in Nevada. Optum is a clinician-led care organization that is changing the way clinicians work and live. If you live in the state of Nevada, you will have the flexibility to work remotely* as you take on some tough challenges.

Required Qualifications: Current, unrestricted RN licensure 3+ years of Clinical RN experience, resulting in excellent clinical skills and critical thinking Proven solid inbound and outbound telephonic skills Proven intermediate or expert level of proficiency with being able to assess and identify needs and being able to influence and motivate Intermediate computer skills (Microsoft Word, Outlook and Internet) with the ability to navigate a Windows environment and the ability to create, edit, save and send documents utilizing Microsoft Word Preferred Qualifications: Bachelor’s degree in Nursing Coaching and/or decision support experience Managed care experience Proven conflict management skills Proven understanding of change and ability to move members along the continuum of change Proven ability to work under pressure and appropriately prioritize responsibilities

Provide health education and coaches consumers on treatment alternatives to assist them in best decision making Support consumers in selection of best physician and facility to maximize access, quality, and to manage heath care cost Coordinate services and referrals to health programs Prepare individuals for physician visits Assess and triage immediate health concerns Manage utilization through education Identify problems or gaps in care offering opportunity for intervention Assist members in sorting through their benefits and making choices Take in-bound calls and place out-bound calls as dictated by consumer and business needs Special projects, initiatives, and other job duties as assigned

Vanderbilt University Medical Center

Utilization Management Specialist (RN Required) - REMOTE

Posted on:

January 10, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Tennessee

Discover Vanderbilt University Medical Center: Located in Nashville, Tennessee, and operating at a global crossroads of teaching, discovery, and patient care, VUMC is a community of diverse individuals who come to work each day with the simple aim of changing the world. It is a place where your expertise will be valued, your knowledge expanded, and your abilities challenged. Vanderbilt Health recognizes that diversity is essential for excellence and innovation. We are committed to an inclusive environment where everyone has the chance to thrive and where your diversity of culture, thinking, learning, and leading is sought and celebrated. It is a place where employees know they are part of something that is bigger than themselves, take exceptional pride in their work and never settle for what was good enough yesterday. Vanderbilt’s mission is to advance health and wellness through preeminent programs in patient care, education, and research.

Facilitates optimal reimbursement through accurate certification and complete chart documentation ensuring that the appropriate admission status is ordered. Conducts initial admission based on utilization review medical necessity criteria. Refers cases for secondary review when appropriate. Refers and consult with the multidisciplinary team to promote appropriate communication in the absence of definitive documentation and/or review criteria to support hospital stay.

Certifications: LIC-Registered Nurse - Licensure-Others Work Experience: Relevant Work Experience Experience Level: 1 year Education: Bachelor's

KEY RESPONSIBILITIES: Facilitates optimal reimbursement through certification and denial processes. Facilitates throughput of patients admitted urgently or emergently through the emergency department. Participates as an active partner with multidisciplinary team members to ensure case is in the appropriate level of care setting. The responsibilities listed are a general overview of the position and additional duties may be assigned. TECHNICAL CAPABILITIES: Medical Terminology & Documentation (Novice): Possesses sufficient fundamental proficiency to successfully demonstrate medical terminology and documentation in practical applications of moderate difficulty. Clinical Applications Systems (Novice): Possesses fundamental proficiency in utilization review systems, clinical support systems and business support applications as needed Utilization Review (Intermediate): Demonstrates expertise of utilization review in practical applications of a difficult nature. Possesses sufficient knowledge, training, and experience to independently complete clinical review to obtain payor authorization. Demonstrates mastery in InterQual Level of Care Criteria and Milliam Care Guidelines. Able to train and educate by setting the example, giving technical instruction, providing leadership, and generally raising the level of performance of others while on the job. Interdisciplinary Education (Novice): Seeks to provide education by collaborating with providers and other members of the health care team to ensure that the patient is placed in the appropriate level of care setting. Core Accountabilities: Organizational Impact: Independently delivers on objectives with understanding of how they impact the results of own area/team and other related teams. Problem Solving/ Complexity of work: Utilizes multiple sources of data to analyze and resolve complex problems; may take a new perspective on existing solution. Breadth of Knowledge: Has advanced knowledge within a professional area and basic knowledge across related areas. Team Interaction: Acts as a "go-to" resource for colleagues with less experience; may lead small project teams. Core Capabilities : Supporting Colleagues: - Develops Self and Others: Invests time, energy, and enthusiasm in developing self/others to help improve performance e and gain knowledge in new areas. - Builds and Maintains Relationships: Maintains regular contact with key colleagues and stakeholders using formal and informal opportunities to expand and strengthen relationships. - Communicates Effectively: Recognizes group interactions and modifies one's own communication style to suit different situations and audiences. Delivering Excellent Services: - Serves Others with Compassion: Seeks to understand current and future needs of relevant stakeholders and customizes services to better address them. - Solves Complex Problems: Approaches problems from different angles; Identifies new possibilities to interpret opportunities and develop concrete solutions. - Offers Meaningful Advice and Support: Provides ongoing support and coaching in a constructive manner to increase employees' effectiveness. Ensuring High Quality: - Performs Excellent Work: Engages regularly in formal and informal dialogue about quality; directly addresses quality issues promptly. - Ensures Continuous Improvement: Applies various learning experiences by looking beyond symptoms to uncover underlying causes of problems and identifies ways to resolve them. - Fulfills Safety and Regulatory Requirements: Understands all aspects of providing a safe environment and performs routine safety checks to prevent safety hazards from occurring. Managing Resources Effectively: - Demonstrates Accountability: Demonstrates a sense of ownership, focusing on and driving critical issues to closure. - Stewards Organizational Resources: Applies understanding of the departmental work to effectively manage resources for a department/area. - Makes Data Driven Decisions: Demonstrates strong understanding of the information or data to identify and elevate opportunities. Fostering Innovation: - Generates New Ideas: Proactively identifies new ideas/opportunities from multiple sources or methods to improve processes beyond conventional approaches. - Applies Technology: Demonstrates an enthusiasm for learning new technologies, tools, and procedures to address short-term challenges. - Adapts to Change: Views difficult situations and/or problems as opportunities for improvement; actively embraces change instead of emphasizing negative elements.

Elevance Health

Nurse Case Manager Lead

Posted on:

January 10, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Nevada

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

Location: Alternate locations may be considered. This position will work in a virtual environment however, must reside within 50 miles of an Elevance PulsePoint. Preference will be given to candidates who reside within 50 miles of the following Nevada PulsePoint location(s). 9133 W Russel Road Las Vegas, NV or 3634 S Maryland Pkwy Las Vegas, NV The Nurse Case Manager Lead is responsible for care management within the scope of licensure for members with complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize member health care across the care continuum and ensuring member access to services appropriate to their health needs. Performs duties telephonically or on-site such as at hospitals for discharge planning.

Minimum Requirements: Requires a BA/BS in a health related field and 5 years of clinical experience; or any combination of education and experience, which would provide an equivalent background. Current, unrestricted RN license in the state of Nevada Preferred skills, qualifications and experiences: Must have Medicaid Case Management experience. Certification as a Case Manager is preferred.

Conducts assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment. Implements care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangements. Coordinates internal and external resources to meet identified needs. Monitors and evaluates effectiveness of the care management plan and modifies as necessary. Interfaces with Medical Directors and Physician Advisors on the development of care management treatment plans. Negotiates rates of reimbursement, as applicable. Assists in problem solving with providers, claims or service issues. Assists with development of utilization/care management policies and procedures, chairs and schedules meetings, as well as presents cases for discussion at Grand Rounds/Care Conferences and participates in interdepartmental and/or cross brand workgroups. May require the development of a focused skill set including comprehensive knowledge of specific disease process or traumatic injury and functions as preceptor for new care management staff. Participates in audit activities and assists supervisor with management of day-to-day activities, such as monitoring and prioritizing workflow, delivering constructive coaching and feedback, and developing associated corrective action plans at direction of the manager. Serves as first line contact for conflict resolution. Develops training materials, completes quality audits, performs process evaluations, and tests and monitors systems/process enhancements.

Elevance Health

Licensed Utilization Reviewer Sr.

Posted on:

January 10, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Florida

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

Office Location: This is a virtual role, but the selected candidate must reside within 50-mile radius and a 1-hour commute to the Tampa, FL Elevance Health major office (PulsePoint) location. Elevance Health supports a hybrid workplace model with PulsePoint sites used for collaboration, community, and connection. The Licensed Utilization Review Sr. is responsible for working with healthcare providers to help ensure appropriate and consistent administration of plan benefits through collecting clinical information required to preauthorize services, assess medical necessity, out of network services, and appropriateness of treatment setting and applying appropriate medical policies, clinical guidelines, plan benefits, and/or scripted algorithms within scope of licensure. This level works with the most complex elements and requires review of the most complex benefit plans. May also serve as mentor or preceptor for less experienced staff in addition to serving as department representative on various intradepartmental initiatives. May assist in formal training of associates and may be involved in process improvement initiatives within the utilization management function. Examples of such functions may include: review of claim edits, pre-noted inpatient admissions or, episodic outpatient therapy such as physical therapy that is not associated with a continuum of care, radiology review, or other such review processes that require an understanding of terminology and disease processes and the application of clinical guidelines.

Minimum Requirements: Requires a HS diploma or equivalent and a minimum of 2 years of clinical or utilization review experience and minimum of 2 years of managed care experience; or any combination of education and experience, which would provide an equivalent background. Current active unrestricted license or certification as a LPN, LVN, or RN to practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States required. Preferred Skills, Capabilities & Experiences: Knowledge of the medical management process strongly preferred. For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

Conducts pre-certification, inpatient, out of network and appropriateness of treatment setting reviews within scope of licensure by utilizing appropriate medical policies and clinical guidelines in compliance with department guidelines and consistent with the members eligibility, benefits and contract. Develops working partnerships with physicians, healthcare service providers, and internal and external customers to help improve health outcomes for members. Applies clinical knowledge to work with facilities and providers for care-coordination. May access and consult with peer clinical reviewers, Medical Directors and/or delegated clinical reviewers to help ensure medically appropriate, quality, cost effective care throughout the medical management process. Educates the member about plan benefits and contracted physicians, facilities and healthcare providers. Refers treatment plans/plan of care to peer clinical reviewers in accordance with established criteria/guidelines and does not issue medical necessity non-certifications. Facilitates accreditation by knowing, understanding, and accurately applying accrediting and regulatory requirements and standards.

Elevance Health

Nurse Medical Management I

Posted on:

January 10, 2025

Job Type:

Part-Time

Role Type:

Clinical Operations

License:

RN

State License:

Texas

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

Location: Remote- Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location. Shift: Part-time Days. Saturday-Sunday, Weekends only. 10 Hour shifts Build the Possibilities. Make an Extraordinary Impact. The Nurse Medical Management I is responsible to collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources. Ensures medically appropriate, high-quality, cost-effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards accurately interpreting benefits and managed care products and steering members to appropriate providers, programs or community resources. Works with medical directors in interpreting appropriateness of care and accurate claims payment. May also manage appeals for services denied.

Minimum Requirements: Requires a HS diploma or equivalent. Requires current active valid unrestricted RN license to practice as a health professional within the scope of practice in applicable state(s) or territory of the United States and minimum of 2 years acute care clinical experience. Preferred skills, qualifications and experiences: Prior experience in inpatient Utilization Management, preferred. 3-5 years of experience in a hospital setting. ER, ICU, MedSurg, preferred. Knowledge and/or experience of MCO, preferred. For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills. For associates working within Puerto Rico who are member or patient facing either in a clinical setting or in the Best Transportation unit, a current PR health certificate and a current PR Law 300 certificate are required for this position.

Conducts pre-certification, continued stay review, care coordination, or discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts. Ensures member access to medical necessary, quality healthcare in a cost-effective setting according to contract. Consult with clinical reviewers and/or medical directors to ensure medically appropriate, high-quality, cost-effective care throughout the medical management process. Collaborates with providers to assess member’s needs for early identification of and proactive planning for discharge planning. Facilitates member care transition through the healthcare continuum and refers treatment plans/plan of care to clinical reviewers as required and does not issue non-certifications. Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.

Elevance Health

Nurse Reviewer I (US)

Posted on:

January 10, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Texas

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

Location: This is a virtual position Shift: Monday-Friday, 8am-5pm PST or CST

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

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

Horizon Home Care & Hospice

RN Intake Care Coordinator - Work from home after 6 months

Posted on:

January 10, 2025

Job Type:

Part-Time

Role Type:

Care Management

License:

RN

State License:

Wisconsin

Our Intake Department has a Part-time opening for an RN Intake Care Coordinator to join our dynamic team at our Corporate Headquarters with the potential to work from home after 6 months. Intake is the hub of our Agency, and we need a nurse with organizational and interpersonal communication skills to join our dynamic team. The RN Intake Care Coordinator role includes assessing, developing care plans, and working with hospital case management in coordinating and admitting patients into home care and hospice services. This is your opportunity to create a positive experience for our patients and their families.

Degree from an Accredited School of Nursing (BSN preferred) Current Wisconsin RN license Minimum of 3-5 years of related experience Strongly prefer prior home care experience

Luminis Health

Utilization Management Nurse - PreBill & Denials

Posted on:

January 10, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Maryland

Utilization Management Nurse - PreBill & Denials (remote) Anne Arundel Medical Center, Annapolis, MD Full Time - Day shift (M-F, 8a-4:30p, rotating weekends) Status: Non-exempt/hourly Remote work is approved only for locations in the following states: Maryland, Pennsylvania, Washington D.C., West Virginia, Virginia, Tennessee, Texas, North Carolina, South Carolina, Georgia, Florida Position Objective: Conducts concurrent and retrospective chart review for clinical, financial, and resource utilization information. Provides intervention and coordination to decrease avoidable delays and denial of payment.

Educational/Experience Requirements: Bachelor's of Science in Nursing. Three years of clinical nursing in an acute care hospital setting. RequiredLicense/Certifications: Current RN license from Maryland Board of Nursing. Working Conditions, Equipment, Physical Demands: There is a reasonable expectation that employees in this position will be exposed to blood-borne pathogens. Physical Demands: Medium work. Exerting up to 50 pounds of force occasionally, and/or up to 30 pounds of force frequently, and/or up to 10 pounds of force constantly to move objects. The physical demands and work environment that have been described are representative of those an employee encounters while performing the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions in accordance with the Americans with Disabilities Act. The above job description is an overview of the functions and requirements for this position. This document is not intended to be an exhaustive list encompassing every duty and requirement of this position; your supervisor may assign other duties as deemed necessary.

Chart Review: Reviews the medical record by applying utilization review criteria, to assess clinical, financial, and resource utilization; enters clinical review in EPIC; maintains close communication with external reviews, care coordinators, and providers; reconciles and records days authorized in EPIC Denial Management: Monitors and identifies patterns or trends in utilization management; monitors potential and actual denials and collaborates with care coordinator for any follow up necessary; documents actions taken to avoid denial; assists Care Coordinator in communicating with the patient denied hospital days with work toward resolution and discharge. Care Coordination: Collaborates with the Care Coordinator to achieve optimal and efficient patient outcomes while decreasing length of stay, avoidable delays and denied days; utilizes Physician Advisor and administrative personnel for unresolved issues; identifies opportunities for expedited appeals and collaborates with the care coordinator and Physician Advisor to resolve payer issues. Process improvement initiatives: Participates in nursing unit and department clinical outcome projects as well as process improvement initiatives of care management.

Humana

RN - Remote Utilization Management Nurse - Medicare - SE Region (Compact license preferred)

Posted on:

January 10, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Compact / Multi-State

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

The Utilization Management Nurse 2 utilizes clinical nursing skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations. The Utilization Management Nurse 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. Creating Healthy Communities is good for the Soul. Join Us! 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.

Required Qualifications: Licensed Registered Nurse (RN) with compact license with no disciplinary action or in process of obtaining compact license 3 - 5 years of Clinical Nursing experience required; preferably Emergency room or critical care Prior clinical experience preferably in an acute care, skilled or rehabilitation clinical setting Comprehensive knowledge of Microsoft Word, Outlook and Excel Ability to work independently under general instructions and with a team. Must have the ability to provide a high-speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 10x1 (10mbs download x 1mbs upload) is required. Must be passionate about contributing to an organization focused on continuously improving consumer experiences. Preferred Qualifications: Education: BSN or Bachelor's degree in a related field Health Plan experience Experience in utilization management or related activities reviewing criteria to ensure appropriateness of care preferred Previous Medicare experience a plus Milliman MCG experience preferred Work-At-Home Requirements: 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

Coordinates and communicates with providers, members, or other parties to facilitate optimal care and treatment Coordinates and communicates with providers, members, or other parties to facilitate appropriate discharge planning including to assist with social determinants and closing gaps 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

CVS Health

Utilization Management Clinician Behavioral Health

Posted on:

January 9, 2025

Job Type:

Full-Time

Role Type:

Behavioral Health

License:

RN

State License:

Pennsylvania

Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver. Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.

Fully remote role. Monday-Friday 8:30-5pm EST. No weekends or holidays. Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. Applies critical thinking and is knowledgeable in clinically appropriate treatment, evidence based care an clinical practice guidelines for Behavioral Health and/or medical conditions based upon program focus.

Required Qualifications: Must have active current and unrestricted Master's Level Behavioral Health clinical license in the state of residence (LMSW, LCSW, LISW, LPC, or comparable) or Registered Nurse licensure with psychiatric specialty, certification, or experience in state of residence Must be able to work Monday through Friday 8:30-5pm EST. No weekends or holidays. 1+ years of utilization review/utilization management required Preferred Qualifications: 3+ years of behavioral health clinical experience in a hospital setting Experience working with geriatric population Crisis intervention skills preferred. Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding. Managed care preferred Education: Master's degree required if social worker, MSW, LCSW, Behavioral /mental health services or if Registered Nurse, Associates degree required, BSN preferred

Utilizes clinical experience and skills in a collaborative process to assess appropriateness of treatment plans across levels of care, apply evidence based standards and practice guideline to treatment where appropriate. Coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Provides triage and crisis report. Gathers clinical information and applies the appropriate clinical judgment to render coverage determination/recommendation along the continuum of care facilities including effective discharge planning. Coordinates with providers and other parties to facilitate optimal care/treatment. Identifies members at risk for poor outcomes and facilitates 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. Work requires sitting for extended periods, talking on the telephone and typing on the computer.

The Christ Hospital Health Network

TCHP Care Manager-RN - Full Time - Remote

Posted on:

January 9, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Ohio

For more than 130 years, The Christ Hospital been the beacon for exceptional healthcare in the Greater Cincinnati community. We're industry pioneers, always pushing the boundaries and reimagining the future of healthcare. Our culture promotes collaboration, diversity and innovation. Together, as a team, we work tirelessly to enhance healthcare quality, accessibility and safety.

This position will require working in Norwood for up to 6 weeks for training, along with making any required in-person meetings at either the main hospital or in Rookwood. The primary duties of this position involve facilitation of continuity of care across the healthcare continuum. This role acts as a navigator and advocate for better health outcomes for patients served by the primary care physician. The Care Manager is responsible for managing high risk patients with multiple comorbidities or at high risk for hospital admission or readmission. This will include developing and monitoring health promotion, disease management, care coordination and utilization management. The Care manager will develop care plans in conjunction with the care team to implement interventions that assist moving the patient toward optimal health. The Care manager will facilitate care transitions after a hospital admission to ensure the patient has a seamless experience and well coordinated care.

KNOWLEDGE AND SKILLS: Please describe any specialized knowledge or skills, which are REQUIRED to perform the position duties. Do not personalize the job description, credentials, or knowledge and skills based on the current associate. List any special education required for this position. EDUCATION: Registered Nurse YEARS OF EXPERIENCE: Minimum of 3 years experience REQUIRED SKILLS AND KNOWLEDGE: Autonomous Excellent problem solving and critical thinking skills Ability to prioritize work, and manage multiple demands Knowledge of basic computer functions Ability to communicate effectively with others, both written and verbally Ability to work both with and for the team Ability to show respect and sensitivity to cultural differences in both employees and patients Knowledge and support of organization’s goals and values LICENSES & CERTIFICATIONS: Must be current Registered Nurse Licensed in state of Ohio

Care Management - Work with all clinical teams as a resource on care management Identify targeted patient populations that would benefit from care management. Pre-visit planning workflow to ensure care completion prior to visit whenever possible Use of efficient, accurate point of care reminders for evidence based care Coordinates patient care services for selected patients across the continuum of care through collaboration with the patient and family and health care providers in achieving optimal patient outcomes Communicate with patients after hospitalizations to schedule appointments, assist with medication education, review after visit summary and provide the patient with a point of contact. Collaborate with the Care Team and follow up appropriately to ensure smooth transition of care for patients treated in a facility (inpatient or emergency department), by a specialty physicians, or by another health care provider Involve patients in activities to improve their health (patient engagement); Educates patients about self-management tasks they can undertake to gain greater control of their health status. Conducts health teaching and health counseling to patients and/or their families. Identify barriers preventing patients from achieving optimal health, problem solve and plan with the Care Team and outside resources to overcome. Clinical quality and performance: Works closely with providers as well as clinical staff to assure clinical quality is an ongoing priority in all phases of patient care. Participates in clinical quality activities and facilitate implementation of clinical best practices. Network/collaborate with professional colleagues and outside community agencies to develop best practices. Coordinate with physician leadership to develop strategies for the high risk patient population to coordinate patient care from office to hospital to home. Monitors utilization of resources and collaborates with the patient and care team to promote efficient and appropriate use. Provides leadership in the development of office workflows, collaborating with physicians on the development of care standards with preventative services and chronic disease management. Leads health care team by influence and role modeling integrated effective nursing practices, excellent customer service, innovation and providing outstanding support for the physician practice. Ensure safe practices and report any concerns Provide the highest level of customer service to achieve the goal of “putting patient’s first”. Promote excellence in healthcare delivery to the patient and/or patient family. Identify and facilitate implementation of clinical best practices. Engages co-workers and patients in a positive, respectful manner Shows respect and sensitivity for differences among co-workers and patients Facilitate seamless patient experience by coordinating care with the care team, patient and family. Information Technology: Ensure complete and accurate documentation in the medical record Effectively use all electronic tools to deliver evidenced based care Design effective workflows using population management software, the electronic medical record and registries Collect and monitor data related to outcomes. Participate in performance improvement projects to leverage the electronic medical record All other duties as assigned.

The Christ Hospital Health Network

Virtual Registered Nurse - Part Time - Days

Posted on:

January 9, 2025

Job Type:

Part-Time

Role Type:

Telehealth

License:

RN

State License:

Ohio

For more than 130 years, The Christ Hospital been the beacon for exceptional healthcare in the Greater Cincinnati community. We're industry pioneers, always pushing the boundaries and reimagining the future of healthcare. Our culture promotes collaboration, diversity and innovation. Together, as a team, we work tirelessly to enhance healthcare quality, accessibility and safety.

Virtual Nursing Unit: The virtual nursing unit is a new care delivery model which, through technology, allows the virtual nurse to provide care to the patient in collaboration with the bedside team. The virtual nurse will assume responsibilities for a list of patient care responsibilities including but not limited to collecting admission information, preparing patients for discharge, education, interacting with patients and their support, and patient care rounding. The virtual nurse will play a vital role providing additional support by mentoring newer nurses at the bedside. Virtual nurses will partner with units who provide care for a wide variety of general medical/surgical/orthopedic patients. The Virtual Nursing Unit will be located off-site. The team is committed to the remote delivery of quality care and to the expansion of the vision of virtual nursing.

KNOWLEDGE AND SKILL: Please describe any specialized knowledge or skills, which are REQUIRED to perform the position duties. Do not list personal credentials of the current jobholder that would not be required if the job were being filled. List any special education required for this position. EDUCATION: TCH does hire AD and Diploma nurses; however, all nurses hired after January 2010 must receive their BSN within 5 years of the date of hire. RN’s who were employed at TCH prior to January 2010 and have more than 20 years of experience as an RN are permitted to pursue their BSN on a voluntary basis. A MSN or DNP are not required but supersede the requirement for the BSN. YEARS OF EXPERIENCE: 3 years REQUIRED SKILLS AND KNOWLEDGE: The RN demonstrates the knowledge, abilities, and skills to provide age and culturally specific patient care and education. The RN effectively communicates with peers, utilizes appropriate channels of communication and maintains absolute confidentiality. The RN maintains competence and demonstrates evidence of continuing professional growth. The RN demonstrates the ability to accept and implement change and the ability to work in a culturally diverse setting. LICENSES & CERTIFICATIONS: The RN holds a current licensure to practice nursing in Ohio. Membership in professional organizations is desirable. BLS certification is required prior to patient contact. ACLS is required within 6 months of hire in step-down and ICU areas. Certification in area of clinical specialty is expected within five years of eligibility.

Assessment - Demonstrates the nursing skills to complete a holistic assessment of the patient’s physical, psychosocial, spiritual, and education needs utilizing The Christ Hospital Professional Practice Model. Understands signs and symptoms and data related to the patient’s presenting needs and actual or potential nursing diagnosis. Recognizes and appropriately reports to the physician and charge RN pertinent abnormal data and changes in the patient’s condition. Utilizes appropriate handoff methods to collaborate with other healthcare team members to communicate pertinent data regarding patient’s physiological and psychological data. Assesses patient, family, and environment for safety risks, proactively seeks out and performs safety initiatives. Diagnosis and Planning - Utilizes collected data to establish and prioritize a list of actual, and potential, individualized patient problems and needs. Prepares, coordinates, and revises multidisciplinary plan of care in collaboration with the patient and family to be supportive of the TCH model of care/Patient and Family Centered care. For each problem a measurable goal is set. Communicates the plan of care utilizing SBAR and handoff processes with all team members. Establish priorities of care, discusses plan of care during shift report, and participates in care conferences. Initiates discharge planning upon admission, makes appropriate referrals consistent with the anticipated length of stay. Implementation – The method of providing evidence based, quality care is based on assessed needs and standards of care while adhering to hospital policy and procedures to achieve set goals. Performs and delegates nursing actions based on appropriate orders demonstrates critical thinking and accountability for appropriate implementation. Provides ongoing, individualized holistic patient and family education based on needs and plan of care in collaboration with the multidisciplinary team. Demonstrates critical thinking upon review of physician orders, making appropriate referrals, & contacts other health team professionals. Responds to emergency situations that require an immediate, controlled precision in a skillful manner. Implements measures to prevent contamination and/or transmission of disease to include the use of appropriate protective devices and equipment to prevent injury and maintain a safe environment. Evaluation – Continuously evaluates nursing practice related to the plan of care in relation to the standards of care established through evidence-based literature and standards established by professional organization that have been built into order sets in the electronic medical record, the individual plan of care, and patient outcomes and goals. Evaluates effectiveness of nursing care interventions, adjusts or continues with plan of care based on patient and family response. Maintains continuity of care by continuous evaluation during ”handoff” report, rounding, and upon transfers to other specialty units and post care facilities. Documentation: Nursing process is accurately and concisely documented in the patient’s electronic medical record reflecting the plan of care as implemented by the patient, family, and multidisciplinary team. Documents information in a timely manner, according to hospital policy, to include the plan of care, accurate updates, teaching and the patients’ and family response to care. Leadership and Professional Development: Demonstrates leadership skills such as the ability to motivate, educate, delegate, and mentor peers and other members of the healthcare team while effectively managing the care of patients and family members. Assumes responsibility and accountability for professional growth and development. Contributes to the professional development of peers, colleagues, and others. Participates in 75% of staff meetings and 75% of council meetings as appropriate. Participates in unit based activities/initiatives for performance improvement, evidence based projects, and research as needed. Participates in council activities and task forces to improve competencies of self, co-workers, and staff members related to patient care. Supports self and peers in professional growth and development utilizing resources and opportunities within and outside of The Christ Hospital. Participates in self and peer review activities to include the positive recognition of peers and staff on a regular basis. Acts as a resource, educator and preceptor for multidisciplinary team members, staff and nursing students, continuously evaluating and documenting competency. . Maintains competency in POC (point of care) testing for unit specific nursing practice. The following are strongly encouraged: Participation in the professional advancement program. Certification specific to work area of professional practice when eligible. Participation in chosen professional organizations and conferences. Participation in development and maintenance of research activities. Participation in community service activities. Employee Responsibilities: Complies with organization and department policies and required training. Completes all educational requirements to maintain competency related to specific population of patient and/or regulatory agencies (Healthstream education 100% on-time completion and attendance for annual education day). Submits required tests and paperwork in a timely manner without management interventions. Attendance: Follows the time and attendance policy; reports to work on time, maintains a good attendance record, has badge and uses it to clock in and out, makes requests for tie off as far in advance as possible, etc.

Ipsen Biopharmaceuticals Inc.

Patient Education Liaison - REMOTE

Posted on:

January 9, 2025

Job Type:

Full-Time

Role Type:

Coaching

License:

RN

State License:

Missouri

The Patient Education Liaison, Rare Diseases, is part of the Patient Services organization and is a field-based role accountable for providing education to patients and their caregivers/families to ensure they have patient-relevant disease information as well as an appropriate understanding of the clinical profile and administration recommendations of Ipsen products. Their role may at times also include broadly educating on complex reimbursement issues and requirements necessary to initiate and maintain therapy. This team embodies Ipsen’s approach to working with patients for patients. This is a complex position requiring coordination with other Ipsen teams (Medical, Clinical, Communications and Patient Advocacy, Regulatory, Compliance, Marketing, Value and Access, Care Coordination Team, and other field-based colleagues) to facilitate alignment and to ensure patients are supported throughout their journey in a most appropriate, compassionate, ethical, and compliant way. This is an ideal role for an individual that is looking to join a small team that is devoted to growth and development of its team members and who wants to work for a mid-size biotech organization with a strong focus on patient centricity. Please Note: Eligible candidates may be located anywhere in the continental US within one hour access to a major airport.

Knowledge, abilities & experience: Bachelor’s degree in nursing or equivalent or certified genetic counselor required. Master’s degree and relevant certifications is a plus. Active RN license or certified genetic counselor required (note that this role does not involve the practice of direct patient care). 5+ years of prior Pharma/Biotech experience in specialty products, including interacting with providers, patients, and caregivers. 3+ years’ experience in designing and or delivering patient and/or consumer-oriented health education. Rare-disease experience a plus. Strong clinical acumen. Excellent understanding of patient-literacy concepts and ability to communicate complex scientific/medical information in patient-friendly language. Must be comfortable with domestic travel, 30-50%. Fluent in English. Fluent in Spanish is highly preferred. Key Technical Competencies Required Demonstrated passion for patients. Excellent communication and presentation skills and ability to navigate difficult conversations. Strong understanding and ability to lead within the life-sciences compliance environment. Demonstrated ability to solve problems, seek answers and drive to solutions. Proven track record for consistently meeting or exceeding quantitative and qualitative goals. Working location assignment: Remote

Provide, proactively and in response to requests, relevant, approved patient-oriented disease/product information to patients, caregivers, and patient communities in the assigned geography. Organize and/or participate in patient and patient group engagement in a variety of settings including one-on-one settings, meetings, and conferences of all sizes, and using a variety of communication media Facilitate and/or deliver educational services to patients, caregivers, patient organizations. Facilitate, attend and/or staff patient community events. Help patients and caregivers connect with Ipsen Patient Services resources to address complex reimbursement issues, insurance options and limitations, benefits, and requirements necessary to initiate and maintain therapy. Respect the privacy of patients and their caregivers/families and manage all personal information in accordance with all laws, regulations, and policies. Collaborate with other cross functional roles to coordinate patient disease and product education activities. Maintains disease-state and product expertise through continuing education and attendance at relevant symposia, conferences, and other educational opportunities. Maintain documentation requirements. This is not a promotional selling role and is not accountable for delivery of organization sales goals. Act in full compliance with all laws, regulations, and policies. Utilize only approved resources and messages to perform function responsibilities. It is the responsibility of all company employees who receive information pertaining to a possible adverse event (AE) or serious adverse event (SAE) to understand that the appropriate clinical and regulatory personal must be notified of the event promptly upon receipt regardless of severity.

R1 RCM, Inc.

Clinical Appeals & Denials Manager

Posted on:

January 9, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Illinois

R1 is the leading provider of technology-driven solutions that transform the patient experience and financial performance of hospitals, health systems and medical groups. We are the one company that combines the deep expertise of a global workforce of revenue cycle professionals with the industry’s most advanced technology platform, encompassing sophisticated analytics, AI, intelligent automation, and workflow orchestration.

As our Clinical Appeals and Denials Manager, you will serve as an expert on clinical appeals and denials management. Every day you will support client hospitals where claims were denied or underpaid by governmental contractors, third-party auditors, or other payers. You will oversee the Clinical Appeals staff, strategically manage the appeals inventory and workflow, and continuously refine efficiencies through process improvement. The Manager is responsible for ensuring client satisfaction and department goals are met and maintained. To thrive in this role, you must have prior leadership experience in a high-volume inventory management setting that includes medical record reviews or clinical denial management.

Preferred Skills: Active RN license preferred

Responsible for the oversight of department supervisor(s) and overall department vision. Mentors, supports, and coaches the team, providing feedback and education as needed. Ensures and helps establish alignment with division cash goals, adjusting account focus as needed. Coordinates efforts across all operational & support verticals to ensure optimization of workflow Review and analyze denial reports, identify trends and root causes, and implement corrective actions to prevent future denials. Manage the appeals process, ensure compliance with payer policies and regulations, and negotiate with insurance companies to resolve disputed claims. Collaborate with other departments, such as coding, clinical documentation, and patient access, to improve the quality and accuracy of billing and documentation. Develop and maintain policies and procedures for denials and appeals management, ensure adherence to best practices and industry standards, and update them as needed. Prepare and present monthly reports on denials and appeals metrics, such as denial rate, appeal success rate, aging AR, and revenue recovery. Identify opportunities for process improvement, cost reduction, and revenue enhancement, and implement solutions to optimize the revenue cycle.

R1 RCM, Inc.

Clinical Appeals Supervisor

Posted on:

January 9, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Illinois

R1 is the leading provider of technology-driven solutions that transform the patient experience and financial performance of hospitals, health systems, and medical groups. We are the one company that combines the deep expertise of a global workforce of revenue cycle professionals with the industry’s most advanced technology platform, encompassing sophisticated analytics, AI, intelligent automation, and workflow orchestration.

As our Clinical Appeals Supervisor, you will help support clinicians who conduct a comprehensive review of clinical denials and formulate appeals based on clinical documentation, evidence-based medical necessity criteria, physician documentation, and medical policies of the payor. Every day you will supervise the day-to-day clinical operations and functions within the department, ensuring productivity and quality metrics are met and regularly identify and communicate denial trends and patterns to leadership. To thrive in this role, you must have experience supervising in a clinical inpatient environment and the ability to use sound judgment in reviewing clinical documentation supporting patient care as well as conceptual knowledge of the denials landscape. Proficiency in basic computer skills is essential for excelling in this remote position.

Required Skills: Active Registered Nurse license

Track and monitor the workflow of the clinical team daily to ensure internal and external compliance deadlines are met. Track clinicians’ productivity and quality by performing regular audits of appeals. Evaluate and report on overturned appeals to continuously refine clinical practices and ensure optimal outcomes. Assess the viability of cases for external review or escalation, as well as make final determinations on clinical appeals that require no further action. Act as a liaison for non-clinical staff and attorneys to collaborate on appeals processing. Leverage employee engagement data to identify targeted areas for additional support and engagement.

R1 RCM, Inc.

Peer-to-Peer Nurse Author

Posted on:

January 9, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Illinois

R1 is the leading provider of technology-driven solutions that transform the patient experience and financial performance of hospitals, health systems, and medical groups. We are the one company that combines the deep expertise of a global workforce of revenue cycle professionals with the industry’s most advanced technology platform, encompassing sophisticated analytics, AI, intelligent automation, and workflow orchestration.

As our Peer-to-Peer Nurse Author, you will help our clients by reviewing cases for which the authorization has been denied and evaluating if the proper documentation was available to support the admission status, procedure, and care setting that was requested. Every day you will advise our clients regarding the appropriateness of the request based on available documentation to ensure proper billing and authorization level; thereby increasing clean claims submission and reducing accounts receivable days. To thrive in this role, you must have strong clinical knowledge across multiple areas and be capable of working independently with a high level of performance in a fast-paced production environment.

Required Skills: Active RN license 3+ years of recent acute, hospital-based clinical experience in a medical/surgical unit, emergency department, and/or ICU

Write clinical consultations evaluating the authorization requested, documentation support or lack of support for that authorization, evidence-based criteria for that support, and complex clinical evaluation of the request as a whole Evaluate and interpret multiple types of hospital documentation as it relates to the requested authorization Provide feedback regarding actionable root cause analysis of the specific case to the client hospitals regarding submitted cases Serve as a clinical resource to medical and case management staff by providing analysis of documentation issues and opportunities Provide written analysis of the case and perform case reviews across multiple specialties

CVS Health

Registered Nurse - RN - Member Health Coach

Posted on:

January 9, 2025

Job Type:

Full-Time

Role Type:

Coaching

License:

RN

State License:

Compact / Multi-State

Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver. Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.

Position Summary: This is a full-time telehealth role for a Registered Nurse with Virtual Group Coaching and Telehealth experience required. WORK SCHEDULE: Monday-Friday EST working 3 day shifts and 2 evening shifts a per week Evening hours end at 9:00 PM EST Rotating Saturdays will be required per business needs. When required, they are partial shifts. JOB DESCRIPTION: The Health Coach Consultant utilizes a collaborative process of assessment, planning, implementation and evaluation, to engage, educate, and promote and influence member's decisions related to achieving and maintaining optimal health status. Assesses members through the use of clinical tools and information/data review, conducts comprehensive evaluation of member's needs and benefit plan eligibility for available integrated internal and external programs/services Utilizes assessment techniques to determine member's level of health literacy, social determinants of health, technology capabilities, and/or readiness to change

Required Qualifications: Must be an Registered Nurse with Virtual Group Coaching Presentation experience for a audience of 20-50 members. Must have an unrestricted COMPACT RN license in the state of residence with ability to apply for, and obtain, additional licenses required per account needs 3+ years of ADULT MEDICAL SURGICAL ACUTE CARE EXPERIENCE IN A HOSPITAL OR CLINIC SETTING Must possess/be willing and able to obtain high speed internet access and be hardwired to Internet Experience with clinical documentation in Electronic Medical Records Preferred Qualifications: Previous telephonic or face to face health coaching experience Previous Managed care experience Experience with Microsoft Word, Outlook, Excel products, EPIC, EMR Experience using multiple digital applications simultaneously as you conduct assessment interviews and document member responses Education: Associate or Bachelor’s degree required

Enhancement of Medical Appropriateness & Quality of Care: Application and/or interpretation of applicable criteria and guidelines, health/wellness management plans, policies, procedures, regulatory standards while assessing benefits and/or member's needs to enable appropriate utilization of services and/or administration and integration with available internal/external programs Using holistic approach consults with supervisors, Medical Director, Social Worker, Pharmacist and/or others to overcome barriers to meeting goals and objectives Identifies and escalates quality of care issues through established channels Utilizes influencing/motivational interviewing skills to ensure maximum member engagement and promote lifestyle/behavior changes to achieve optimum level of health Provides coaching, information, and resources/support to empower the member to make ongoing independent medical and/or healthy lifestyle choices Interprets and utilizes clinical guidelines/criteria to positively impact members health Provides up-to-date healthcare information to help facilitate the member’s understanding of his/her health status Helps member actively and knowledgably participate with their provider in healthcare decision-making Monitoring, Evaluation and Documentation of Care: Develops and monitors established plans of care, in collaboration with the member and/or attending physician, to meet the member's goals Utilizes internal policy and procedure in compliance with regulatory and accreditation guidelines

Independence Blue Cross

Team Lead - Operations (Remote)

Posted on:

January 9, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

None Required

State License:

Pennsylvania

Serving more than 8 million people nationwide, including 2.5 million in southeastern Pennsylvania, Independence Health Group — together with its subsidiaries — is the leading health insurance organization in the Philadelphia region. Our mission to build healthier lives for you, your family, and your employees shapes our actions and decisions every day. At Independence, we see each of our members as an individual, with unique needs and concerns. We’re dedicated to harnessing the very latest ideas and technologies to deliver access to care that meets those needs and surpasses your expectations. For more information about Independence access our website at www.ibx.com. We’re revolutionizing health care, and our focus is on you!

Bring your drive for excellence, teamwork, and customer commitment to Independence. Join us as we renew and reimagine the future of health care. Together we will achieve our mission to enhance the health and well-being of the people and communities we serve. If this describes you, we want to speak with you.

Education: Minimum High School diploma or equivalent Two years of college education preferred. Experience: Schedule flexibility between the hours of 8 AM-9 PM during peak season. (Must be willing to occasionally support the 1 PM – 9 PM shift when coverage is needed) Excellent oral and written communication skills, as well as the ability to carry out assignments with minimal guidance. Mastery of call center customer service practices. Foundational understanding of the IBC family of companies, organization, and functions including BCBSA, Claims, Billing Appeals, Customer Service, Enrollment QA, Workforce Management, etc. Mastery of general health insurance products e.g., PPO, HMO, group and individual plans, assigned IBC products and services under Scope, Ancillary products, (e.g. Dental, Vision, Prescription), the Affordable Care Act, CMS requirements, HIPAA, relevant state laws and Departments of Insurance (DOI) regulations. Demonstrate listening, verbal, and written communication skills. Can do approach to work. Excellent communication skills Excellent interpersonal skills, including influencing others and negotiation. Excellent project management skills Experience in innovative problem-solving. Problem solver and self-starter Strong attention to detail Ability to lead multiple and varied initiatives and activities simultaneously. Analytical ability to identify and resolve staff and customer problems. Must be able to prioritize work in an environment that changes frequently. Must have the ability to manage organize, plan, and provide leadership to staff. Developing and motivating team members to facilitate professional growth. Leadership and relationship-building skills Demonstrated time management skills. Technical / Computer Skills Intermediate knowledge of Team Leader functions Exposure to an operations service’s environment is highly recommended. Ability to work from home, which includes high-speed wi-fi capability of at least 400 Mbps and a quiet, confidential workspace.

Call monitoring of agents Support the Escalation Line to handle supervisor calls, answer inquiries, research, and follow through with members. Side by Side coaching and monitoring to focus on: QA AHT issues Adherence MTM errors Short training sessions for selected topics – as needed. Run listening lounge sessions. Review and Approve/Process RX updates (if RX edit trained) Provide support for agent questions via floor support, phone, Teams chat, email, and video interactions. Communicates, implements, and interprets corporate and departmental policies and procedures. Provides team members with ongoing feedback on performance for achievement of all benchmarks. Provides technical expertise related to job unit function. Compiles and prepares required data for reporting information pertaining to the unit. Serves as the next level contact for problems/issues that staff cannot resolve. Identifies high-performing agents for future opportunities. Request form updates for follow-up time as needed. Inventory - as needed. Submit manager exceptions after all research has been completed. Respond to the WFM daily chat. Take phone calls as needed. Performs all other appropriate responsibilities and duties as assigned.

Independence Blue Cross

Health Coach RN - remote (PA/NJ/DE)

Posted on:

January 9, 2025

Job Type:

Full-Time

Role Type:

Coaching

License:

RN

State License:

Pennsylvania

Serving more than 8 million people nationwide, including 2.5 million in southeastern Pennsylvania, Independence Health Group — together with its subsidiaries — is the leading health insurance organization in the Philadelphia region. Our mission to build healthier lives for you, your family, and your employees shapes our actions and decisions every day. At Independence, we see each of our members as an individual, with unique needs and concerns. We’re dedicated to harnessing the very latest ideas and technologies to deliver access to care that meets those needs and surpasses your expectations. For more information about Independence access our website at www.ibx.com. We’re revolutionizing health care, and our focus is on you!

Under the direction of the Care Management Manager, the Health Coach functions as the primary nurse to provide both health coaching and case management services to members across the continuum of health ranging from health promotion to end-of-life. Health coaches collaborate on care plan development and coordination with members and physicians by screening, assessing, planning, facilitating, monitoring and giving input when adjustment is needed, and advocating for the member on an individual basis. Health coaches use clinical and motivational interviewing skills to assess member’s need and establish mutually agreeable goals while supporting member in developing self-management skills in adopting positive behavior changes. Health Coaches work with the member to identify and address barriers to member’s adherence to standards of evidence-based medicine. The health coach facilitates communication between the patient, family, and members of the health care team while acting as an educator and link between the patient, providers and the plan, ensuring high quality, cost-effective services are delivered. Helps members coordinate care and navigate the healthcare system.

Current, active, and unrestricted Pennsylvania (PA) Registered Nurse licensure. Three years any of combination of clinical, case management and/or disease/condition management experience. Exceptional communication and problem-solving ability. Ability to work flexible hours. Basic computer skills. Strong clinical knowledge. Fully Remote: This role is designated by Independence as fully remote. The incumbent will not be required to report to one of Independence’s physical office locations to perform the work. However, the work must be performed in the Tri-State Area of Delaware, New Jersey, or Pennsylvania.

Functions as a primary nurse for members across the continuum of health and health-related services including information and support for lifestyle improvement, acute symptoms, treatment decisions, targeted health conditions, chronic conditions and complex conditions. Engages with the members ranging from coaching to intensive case management with the goal to develop and support the member’s ability to self-manage. Provides appropriate clinical coaching support to members placing in-bound calls seeking assistance with acute symptoms, chronic conditions and/or health information regarding, specific topics. Conducts appropriate surveys/assessments to proactively identify needs. Develops appropriate care plans and establishes goals. Assessment includes working with member/family/significant other to identify barriers of adherence to the physician’s plan of care as well as achieving lifestyle improving goals. Continues to work with member via on-going telephonic communication to achieve the agreed upon goals. Proactively incorporates lifestyle improvement and prevention opportunities into member interactions and coaching. Contacts member’s physician when needed especially in more complex medical situations requiring case management intervention to facilitate care coordination. Monitors the quality of service, seeking member/family input. Communicates safety issues to manager and utilizes the occurrence screening for quality-of-care tracking. Identifies on-line, telephonic and community-based resources that can assist the member in achieving and maintaining their personal health goals. Assist the member in accessing those services. In addition, assist in maximizing the use of member’s benefits and ensuring coordination of services and outcomes. Provides exceptional customer service. Maintains and communicates accurate information in associate self-serve program. Attends educational programs/training to maintain state license, CCMC licensure and updated knowledge of Health Coach process. Ensures all activities are documented and conducted in compliance with applicable regulatory requirements and accreditation standards. Other duties as assigned.

CVS Health

Quality Management Nurse Consultant

Posted on:

January 9, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Florida

Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver. Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.

Required Qualifications: 5+ years of clinical experience required 2+ years of experience as a Registered Nurse Must have active current and unrestricted RN licensure in state of residence 1+ years of Microsoft Office products experience, including Outlook and Excel, and previous experience using Internet Explorer and Google Chrome to effectively utilize review resources and conduct reviews. Must be willing and able to work Monday through Friday 8:00am - 5:00pm in time zone of residence Preferred Qualifications: Utilization Management review Managed Care experience Client processing experience Education: Associates degree required BSN preferred

Responsible for the review and evaluation of clinical information and documentation. Reviews documentation and interprets data obtained from clinical records or systems and uses clinical decision making to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider claims. Independently coordinates the clinical resolution with clinician/MD support as required. Considers all documentation provided including medical records and system documentation to evaluate post-service claims for payment based on clinical policies, legislation, regulatory requirements, and plan benefits. Review requires navigation through multiple system applications as well as potential requirement to outreach to internal department or providers. Accurately applies review requirements to assure case is reviewed according to all company policies and procedures as well as state and federal laws and regulations. Adhere to company policies regarding confidentiality to protect member information.

The Cigna Group

RN Case Manager- NICU- Remote

Posted on:

January 9, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Conneticut

Case managers are healthcare professionals, who serve as customer advocates to coordinate, support, and guide care for our customers, families, and caregivers to assist with navigating through the healthcare journey. Additionally, the candidate will be responsible for the adoption and demonstration of the Care Solutions cultural beliefs. They will be responsible for role modeling the six cultural beliefs to drive personal accountability and organizational results. Customer Strong: I deliver world-class experiences for all my customers. Me to We: I take accountability to trust, partner, and deliver. Own It: I see a need and deliver value because I care. Evolve and Adapt: I learn and adapt to meet evolving business needs. Be Bold: I pioneer and think broadly to solve challenges. Take Care: I prioritize self-care and act with compassion toward colleague.

Minimum requirements: Active unrestricted Registered Nurse (RN) license in state or territory of the United States. Minimum of two years full-time direct patient care as an RN required. Preferred requirements: Experience working with NICU population Must have an active and unencumbered RN License Within four (4) years of hire as a case manager will possess a URAC-recognized certification in case management. Excellent communication skills including telephonic (verbal) and digital (messaging, emails). Skilled in clinical acumen to form a judgement and act. Strong computer skills in Microsoft word, Excel, Outlook, and ability to perform thorough internet research. Ability to recognize, address and resolve conflicts in a professional, collaborative manner. Demonstrates sensitivity to culturally diverse situations, participants, and customers. Demonstrates effective organizational skills and flexibility to meet the business needs. Adapts approach and demeanor in real time to match the shifting demands of different situations. Ability to manage multiple, complex situations in a fast-paced environment collaborating with clinical and other business partners. If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.

Collaborates with customer in creation of care plan and documents plan in medical management system. Partners with each customer to establish goals and interventions to meet the customer’s needs. Establishes plan of care in conjunction with the customer and provider then document into a medical management system. Utilizes motivational interviewing, behavior change, and shared decision making to help customers achieve optimal health and well-being. Empowers customers with skills to enhance interaction with their providers. Interfaces with the customer, family members/caregivers, providers, and internal partners to coordinate the needs of the customer through telephonic, email, text, and chat interactions. Collaborates with nutritionist, pharmacist, behavioral clinician, Medical Director and customer's provider and other Cigna Medical Management programs to provide whole-person health support. Tracks daily activities to trend volume and outcomes. Follows standard operating procedures. Toggles between multiple systems and applications. Research relevant topics in health promotion and disease prevention, as required for specific customers. Prioritizes work to meet commitments aligned with organizational goals. Understands and adheres to Case Management performance measures to deliver on key results. Completes training within the communicated time limit as required per role. Demonstrates evidence of continuing education to maintain clinical expertise and certification as appropriate.

The Cigna Group

RN Nurse Case Management Lead Analyst - Work from Home, Anywhere, USA

Posted on:

January 9, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Conneticut

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

The Nurse Clinician – RN is responsible for reviewing escalated clinical criteria reviews for providers, members and patient client advocates within the Prior Authorization/Utilization Management department. Identify and track trends for analytics reporting to ensure clinical criteria program integrity. Maintain a professional and ethical behavior at all times as outlined by the Nurse Practice Act and applicable company policies. Ideal candidate must be available to work CST, MST or PST time zones.

Active, unencumbered Registered Nurse (RN) license in state of residency. High School Diploma or GED, plus 8+ years of relevant RN experience; or 5+ years of relevant RN experience with an ASN degree; or 2+ years of relevant RN experience with a BSN degree Case management experience preferred 5+ years of experience is preferred in prior authorization or utilization review and appeals Demonstrated proficiency with Microsoft Office software; basic database navigation Ability to multitask in both PC/Phone related tasks Ability to build strong working relationships with colleagues and customers Strong time management skills and the ability to prioritize work and meet deadlines Excellent verbal and written communication skills Ability to work Monday-Friday, 8am-5pm, Eastern time Adequate home internet access will be required in this role TECHNICAL SKILLS: Experience with Cover My Meds Tool Experience with Myndshft Tool 5+ years of experience is preferred in prior authorization or utilization review and appeals Case Management experience a plus Demonstrated proficiency with Microsoft Office software; basic database navigation Ability to multitask in both PC/Phone related tasks SOFT SKILLS: Ability to build strong working relationships with colleagues and customers Strong time management skills and the ability to prioritize work and meet deadlines Excellent verbal and written communication skills Ability to work Monday-Friday, 8am-5pm, Eastern time Adequate home internet access will be required in this role COMPETENCIES: Communicates Effectively Collaborates Customer Focus Decision Quality Nimble Learning If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.

Conduct criteria reviews for commercial payers, Medicare, and Medicaid Provide prior authorization assistance, and denial appeal assistance Prepare and write medical necessity appeal letters for claim denials for commercial and government payers. Support all aspects of Patient Access and Revenue Cycle Management (PARCM), including clearance and reimbursement for multiple Therapeutic Resource Centers.

Syneos Health

Sr Clinical Research Associate / CRA II - Blended TAs (Regionally Aligned Across US)

Posted on:

January 8, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

North Carolina

Over the past 5 years, we have worked with 94% of all Novel FDA Approved Drugs, 95% of EMA Authorized Products and over 200 Studies across 73,000 Sites and 675,000+ Trial patients. No matter what your role is, you’ll take the initiative and challenge the status quo with us in a highly competitive and ever-changing environment. Learn more about Syneos Health.

Syneos Health® is a leading fully integrated biopharmaceutical solutions organization built to accelerate customer success. We translate unique clinical, medical affairs and commercial insights into outcomes to address modern market realities. Our Clinical Development model brings the customer and the patient to the center of everything that we do. We are continuously looking for ways to simplify and streamline our work to not only make Syneos Health easier to work with, but to make us easier to work for. Whether you join us in a Functional Service Provider partnership or a Full-Service environment, you’ll collaborate with passionate problem solvers, innovating as a team to help our customers achieve their goals. We are agile and driven to accelerate the delivery of therapies, because we are passionate to change lives. Discover what our 29,000 employees, across 110 countries already know: WORK HERE MATTERS EVERYWHERE Why Syneos Health: We are passionate about developing our people, through career development and progression; supportive and engaged line management; technical and therapeutic area training; peer recognition and total rewards program. We are committed to our Total Self culture – where you can authentically be yourself. Our Total Self culture is what unites us globally, and we are dedicated to taking care of our people. We are continuously building the company we all want to work for and our customers want to work with. Why? Because when we bring together diversity of thoughts, backgrounds, cultures, and perspectives – we’re able to create a place where everyone feels like they belong.

Bachelor’s degree or RN in a related field or equivalent combination of education, training and experience Knowledge of Good Clinical Practice/ICH Guidelines and other applicable regulatory requirements Must demonstrate good computer skills and be able to embrace new technologies Excellent communication, presentation and interpersonal skills Ability to manage required travel of up to 75% on a regular basis

Performs site qualification, site initiation, interim monitoring, site management activities and close-out visits (performed on-site or remotely) ensuring regulatory, ICH-GCP and/or Good Pharmacoepidemiology Practice (GPP) and protocol compliance. Uses judgment and experience to evaluate overall performance of site and site staff and to provide recommendations regarding site-specific actions; immediately communicates/escalates serious issues to the project team and develops action plans. Maintains a working knowledge of ICH/GCP Guidelines or other applicable guidance, relevant regulations, and company SOPs/processes. Verifies the process of obtaining informed consent has been adequately performed and documented for each subject/patient, as required/appropriate. Demonstrates diligence in protecting the confidentiality of each subject/patient. Assesses factors that might affect subject/patient’s safety and clinical data integrity at an investigator/physician site such as protocol deviation/violations and pharmacovigilance issues. Per the Clinical Monitoring/Site Management Plan (CMP/SMP): Assesses site processes Conducts Source Document Review of appropriate site source documents and medical records Verifies required clinical data entered in the case report form (CRF) is accurate and complete Applies query resolution techniques remotely and on site, and provides guidance to site staff as necessary, driving query resolution to closure within agreed timelines Utilizes available hardware and software to support the effective conduct of the clinical study data review and capture Verifies site compliance with electronic data capture requirements May perform investigational product (IP) inventory, reconciliation and reviews storage and security. Verifies the IP has been dispensed and administered to subjects/patients according to the protocol. Verifies issues or risks associated with blinded or randomized information related to IP. Applies knowledge of GCP/local regulations and organizational procedures to ensure IP is appropriately (re)labelled, imported and released/returned. Routinely reviews the Investigator Site File (ISF) for accuracy, timeliness and completeness. Reconciles contents of the ISF with the Trial Master File (TMF). Ensures the investigator/physician site is aware of the requirement of archiving essential documents in accordance with local guidelines and regulations. Documents activities via confirmation letters, follow-up letters, trip reports, communication logs, and other required project documents as per SOPs and Clinical Monitoring Plan/Site Management Plan. Supports subject/patient recruitment, retention and awareness strategies. Enters data into tracking systems as required to track all observations, ongoing status and assigned action items to resolution. For assigned activities, understands project scope, budgets, and timelines; manages site-level activities / communication to ensure project objectives, deliverables and timelines are met. Must be able to quickly adapt to changing priorities to achieve goals / targets. May act as primary liaison with study site personnel, or in collaboration with Central Monitoring Associate. Ensures all assigned sites and project-specific site team members are trained and compliant with applicable requirements. Prepares for and attends Investigator Meetings and/or sponsor face to face meetings. Participates in global clinical monitoring/project staff meetings (inclusive of Sponsor representation, as applicable) and attends clinical training sessions according to the project specific requirements. Provides guidance at the site and project level towards audit readiness standards and supports preparation for audit and required follow-up actions. Maintains a working knowledge of ICH/GCP Guidelines or other applicable guidance, relevant regulations, and company SOPs/processes; completes assigned training as required. For Real World Late Phase, the CRA II will use the business card title of Site Management Associate II. Additional responsibilities include: Site support throughout the study lifecycle from site identification through close-out Knowledge of local requirements for real world late phase study designs Chart abstraction activities and data collection Collaboration with Sponsor affiliates, medical science liaisons and local country staff The SMA II may be requested to train junior staff Identify and communicate out of scope activities to Lead CRA/Project Manager Proactively suggest potential sites based on local knowledge of treatment patterns, patient advocacy and Health Care Provider (HCP) associations

Syneos Health

Research Nurse- Houston, TX

Posted on:

January 8, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Texas

Illingworth Research Group provides a range of patient focused clinical services to the pharmaceutical, healthcare, biotechnology and medical device industries. These include mobile research nursing, patient concierge, medical photography and clinical research services. Illingworth are experts with experience across all study phases and in a diverse range of therapeutic areas. Illingworth Research Group is a global organization operating in over 45 countries, bringing clinical research directly into the home of the patient, to improve the experience of patients involved in clinical trials and the quality of their lives. Are you a Registered Nurse who would like to be involved in working in a variety of research projects for ground-breaking patient treatments? We are looking for motivated and enthusiastic nurses who combine high quality clinical skills with a compassionate, engaging personality and a dedication to ensure exceptional patient outcomes.

Experienced Registered Nurse (Adult or Pediatric) Experience and knowledge of working in clinical research trials with ICH-GCP (Good Clinical Practice) Certification - (Training can be provided) Attention to detail and highly organized Ability to prioritize and manage multiple tasks Excellent verbal and written communication skills in English and the ability to complete detailed data Ability to work with initiative independently and as part of a wider team Good IT (Information Technology) skills and a working knowledge of computer software Trained in Handling and Transport of Hazardous Substances (preferable- training can be provided) Our studies require a variety of Clinical skills (some desirable and not all essential, depending on project requirements). Phlebotomy skills (Venipuncture) and handling, processing of blood. Sub cutaneous injections ECGs, observations and taking specimen collections. Cannulation and administration of Intravenous Therapies Experience working with central venous access PLEASE NOTE This role will require you to travel, a driving license and access to a vehicle is essential.

UnitedHealthcare

Field Care Coordinator, RN – Remote in Las Cruces, NM

Posted on:

January 8, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

New Mexico

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

The RN Clinical Care Coordinator will be the primary care manager for a panel of members with complex medical/behavioral needs. Care coordination activities focus on supporting member’s medical, behavioral, and socioeconomic needs to promote appropriate utilization of services and improved quality of care. This position is full – time (40 hours / week) Monday – Friday. Employees are required to have flexibility to work any of our 8 – hour shift schedules during our normal business hours of 8am to 5pm. It may be necessary, given the business need, to work occasional overtime. This position is a field – based position with a home – based office. If you reside in Las Cruces, New Mexico or within a commutable driving distance, you will have the flexibility to work remotely* as you take on some tough challenges.

Required Qualifications: Current, unrestricted independent licensure as a Registered Nurse 3+ years of clinical experience 2+ years of relevant health care experience 1+ years of experience with MS Office, including Word, Excel, and Outlook Reliable transportation and the ability to travel within assigned territory to meet with members and providers Currently reside in SW, New Mexico, preferably Las Cruces, NM Willing or ability to travel locally up to 50% of the time Preferred Qualifications: Master’s degree or Higher in Clinical Field Commission for Case Manager (CCM) certification 3+ years clinical experience as a Registered Nurse 1+ years of community case management experience coordinating care for individuals with complex needs Experience working in team-based care Background in Managed Care

Engage members face-to-face and/or telephonically to complete a comprehensive needs assessment, including assessment of medical, behavioral, functional, cultural, and socioeconomic needs 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 Partner and collaborate with internal care team, providers, and community resources/partners to implement care plan Provide education and coaching to support member self-management of care needs and lifestyle changes to promote health Support proactive discharge planning and manage/coordinate Care Transition following ER visit, inpatient or Skilled Nursing Facility (SNF) admission Advocate for members and families as needed to ensure the member’s needs and choices are fully represented and supported by the health care team Ability to transition from office to field locations multiple times per day Ability to navigate multiple locations/terrains to visit employees, members and/or providers Ability to transport equipment to and from field locations needed for visits (ex. laptop, stethoscope, etc.) Ability to remain stationary for long periods of time to complete computer or tablet work duties

TotalMed, Inc.

Case Management Nurse

Posted on:

January 8, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

California

Responsible for supporting the clinical Utilization Management activities for members. Conducts medical necessity review of referral requests including but not limited to requests for DME, outpatient therapies, and prior authorizations for outpatient procedures and prospective inpatient stays. Utilizes Milliman and Medicaid criteria to facilitate decision making. Refers cases to the Medical Director when clinical information does not support medical necessity. Functions as a key resource to the Non-Clinical Intake Coordinators for questions or clarifications on criteria, interpretation of benefits, or whenever they need additional clinical expertise and/or guidance

Active & unrestricted CA RN license 2+ or more years of Managed Care experience preferable in Utilization and Case Management 3+ years clinical experience in an acute care setting Knowledge of Medi-Cal regulations required Experience with evidenced based criteria (Milliman, InterQual) Experience in a medical/public health setting preferred.

Performs review of requested outpatient and elective, prospective inpatient medical services. Under the direction of the UM Outpatient Clinical Supervisor coordinates and refers members for services which are carved out of KHS medical coverage. Assists in the authorization and processing of automatic referral requests. Collaborates with the KHS Member Service Department and the Provider Relations Department regarding quality of care and other grievance issues to facilitate timely problem resolutions. Utilizes clinical guidelines as well as Medi-Cal criteria to review outpatient service requests for medical necessity and benefit coverage while processing referral request. Identifies and refers cases for quality of care, coordination of benefits, and third-party liability issues as appropriate. Identifies and refers cases appropriate for various internal programs. Shares information as necessary with appropriate Population Health Management team: Case Management, Transitions of Care, Major Organ Transplant and Community Support Services including but not limited to Extended Care Management.

LanceSoft, Inc.

Utilization Management Nurse

Posted on:

January 8, 2025

Job Type:

Contract

Role Type:

Utilization Review

License:

RN

State License:

New Mexico

The role works with the Utilization Management team, primarily responsible for inpatient medical necessity/utilization reviews and other UM activities aimed at ensuring Client's Healthcare members receive appropriate care in the right setting at the right time. Key responsibilities include daily review and evaluation of members requiring hospitalization and/or procedures, providing prior authorizations and/or concurrent review, and ensuring services are cost-effective and compliant with state and federal regulations.

Knowledge, Skills, and Abilities: Strong communication, problem-solving, and organizational skills. Ability to manage multiple priorities independently. Knowledge of state and federal regulations, Interqual, and other length-of-stay/medical necessity references. Experience with NCQA. Proficiency in Microsoft Office. Strong verbal and written communication skills. Ability to maintain confidentiality and comply with HIPAA requirements. Required Qualifications: Education: Completion of an accredited Registered Nursing program (or equivalent combination of education and experience). Experience: 0–2 years of clinical practice, preferably in hospital nursing, utilization management, and/or case management. Licensure/Certification: Active, unrestricted State Nursing license (RN, LVN, LPN) in good standing.

Conducts concurrent reviews and prior authorizations according to Client policy for members. Identifies appropriate benefits, eligibility, and expected length of stay for members requesting treatments or procedures. Collaborates with other departments to enhance continuity of care for members, including Behavioral Health and Long-Term Care. Maintains productivity and quality standards within the department. Participates in staff meetings and assists with mentoring new team members. Completes assigned work plan objectives and projects on time. Maintains professional relationships with providers and internal/external customers. Regularly consults with and refers cases to Client medical directors as needed. Ensures compliance with workplace safety standards and company policies.

IMCS Group

CASE MANAGER (Registered Nurse)

Posted on:

January 8, 2025

Job Type:

Contract

Role Type:

Case Management

License:

RN

State License:

North Carolina

Job Title: LTSS Service Care Manager (RN) Duration: 6 months Contract (Potential to Extend) Location: Charlotte/Gastonia, NC Desired Start Date: 1/13/2025 End Date: 6/13/2025 Shift Type: 8am-5pm EST, Mon-Fri Pay rate: $40 per hour

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

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

Actalent

CDI Specialist (100% Remote)

Posted on:

January 8, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Minnesota

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 Inpatient Clinical Documentation Integrity (ICDI) Specialist is accountable for reviewing patient medical records in the inpatient and/or outpatient setting to capture accurate representation of the severity of illness and facilitate proper coding.

High School diploma or GED required. Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Registered Nurse (RN), Registered Respiratory Therapist, Certified Coding Specialist (CCS), or Certified Coding Specialist-Physician-based (CCS-P), or International or Domestic Medical Degree also required. MUST HAVE: Experience in Trauma or Transplants, 3+ CDI experience, Large Facility (need complexity), 100% Production, very flexible and willing to adapt to a very complex environment. MUST HAVE: Certified Documentation Improvement Practitioner (CDIP) certification or Certified Clinical Documentation Specialist (CCDS) certification required. Bonus: 3M360 and Optum and Epic experience a huge plus. CCS and/or CRC are also a huge plus. DRG validation/ DRG auditor experience are also a plus. Experience Level: Intermediate Level

Validates coding reflects medical necessity of services and facilitates appropriate coding which provides an accurate reflection and reporting of the severity of the patient's illness along with expected risk of mortality and complexity of care. Documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient's clinical status and care. Utilizes advanced knowledge of disease processes (pathophysiology), medications, and have critical thinking skills to analyze current documentation to identify gaps. Identifies opportunities in concurrent and retrospective inpatient clinical medical documentation to support quality and effective coding. Understands and applies regulatory compliance related to documentation, coding and billing for all health insurance plans. Facilitates appropriate modifications to documentation through extensive interactions and collaboration with physicians, coding, case management, nursing and other care givers. Serves as an effective change agent as an educator and resource for physicians and allied health staff to improve the quality and completeness of the clinical documentation. Performs all duties and responsibilities in accordance with ethical and legal business procedures, compliant with federal and state statutes and regulations, official coding rules, guidelines and accepted standards of coding practice including appropriate clinical documentation policies.

Actalent

LVN Care Navigator

Posted on:

January 8, 2025

Job Type:

Contract

Role Type:

Care Management

License:

LPN/LVN

State License:

Texas

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 Specialty Authorization Team is looking for a Care Navigator to process authorizations and follow-ups for DME, MHM, DAHS, and reductions/denials. This role involves supporting vulnerable populations with chronic or complex conditions.

Essential Skills: 2+ years of experience in a managed care environment or working with people who have disabilities and/or vulnerable populations with chronic or complex conditions. Experience in healthcare, outbound calls, and insurance support. LPN, LVN, or similar license required. Additional Skills & Qualifications: LPN, LVN, or similar license required. Strong skills in care coordination and case management. Work Environment: This position is fully remote, requiring a strong internet connection. The work hours are Monday through Friday from 8:00am to 5:00pm, and the dress code is business casual.

Process authorizations and follow-ups for DME, MHM, DAHS, and reductions/denials. Make outbound calls related to healthcare services. Coordinate care and manage cases for individuals with disabilities and/or vulnerable populations. Support insurance-related inquiries and processes.

Stormont-Vail HealthCare, Inc.

Ambulatory Registered Nurse (Remote phone triage) - 901 Internal Medicine - FT - Day

Posted on:

January 8, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Kansas

Provides professional nursing care for clinic patients following established standard and practices. The delivery of professional nursing care at Stormont Vail Health is guided by Jean Watson's Theory of Human Caring and the theory of Shared governance, both of which are congruent with the mission, vision, and values of the organization.

Education Qualifications: Bachelor's Degree Bachelor's of Science in Nursing (BSN) Preferred Experience Qualifications: 1 year Nursing experience. Preferred Skills and Abilities: Skill in applying and modifying the principles, methods and techniques of professional nursing to provide on-going patient care. (Required proficiency) Skill in establishing and maintaining effective working relationships with patients, medical staff and the public. (Required proficiency) Ability to maintain quality control standards. (Required proficiency) Ability to react calmly and effectively in emergency situations. (Required proficiency) Licenses and Certifications: Registered Nurse - KSBN Required Required for All Jobs: Complies with all policies, standards, mandatory training and requirements of Stormont Vail Health Performs other duties as assigned Patient Facing Option: Position is Not Patient Facing Remote Work Guidelines: Workspace is a quiet and distraction-free allowing the ability to comply with all security and privacy standards. Stable access to electricity and a minimum of 25mb upload and internet speed. Dedicate full attention to the job duties and communication with others during working hours. Adhere to break and attendance schedules agreed upon with supervisor. Abide by Stormont Vail’s Remote Worker Policy and will review and acknowledge the Remote Work Agreement annually. Remote Work Capability: Full-Time Scope: No Supervisory Responsibility No Budget Responsibility No Budget Responsibility Physical Demands Balancing: Rarely less than 1 hour Carrying: Rarely less than 1 hour Eye/Hand/Foot Coordination: Occasionally 1-3 Hours Feeling: Rarely less than 1 hour Grasping (Fine Motor): Occasionally 1-3 Hours Grasping (Gross Hand): Rarely less than 1 hour Handling: Rarely less than 1 hour Hearing: Occasionally 1-3 Hours Kneeling: Rarely less than 1 hour Sitting: Frequently 3-5 Hours Standing: Rarely less than 1 hour Stooping: Rarely less than 1 hour Talking: Frequently 3-5 Hours Walking: Rarely less than 1 hour

Triage of all incoming phone calls by evaluating the physical and psychosocial health status of patients. Follows nursing protocols and guidelines for answering and directing calls. Record and reports patient’s condition and reaction to drugs and treatments to interdisciplinary team. Provide instruction to patients/family regarding treatment. Maintains and reviews patient records, charts, and other pertinent information. Oversee appointment bookings and ensure preferences are given to patients in emergency situations. Arranges for patient testing and admissions. Refill prescribed medications per standing orders. Clarify medication orders and refills to pharmacies as directed by providers. Perform medication prior authorizations as needed by providing needed clinical information to insurance. Maintain timely flow of patient to include scheduling of follow up appointments if needed. Working of in-basket medication refill requests for providers. Provide education to patient and family on medications, treatments and procedures. Record and report patient’s condition and reaction to drugs and treatments to interdisciplinary team, reviewing patient records and other pertinent information. Ensure patients receive appointments that align with triage disposition and that maintain timely flow of patients. Coordinate patient testing, referrals, and admissions Work collaboratively with on-site staff to provider coordinated patient care

Medcor Inc

Telephonic Injury Triage Registered Nurse-FT

Posted on:

January 8, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Illinois

Medcor embraces a set of simple, interconnected practices that everyone can tailor to their own life and work. To preserve our pioneering, entrepreneurial spirit, we impart our values through the ongoing Better@Medcor campaign: encouraging our advocates to make a conscious choice to practice our values, to celebrate and recognize each other via our peer recognition program, and to support one another during tough times.

We are looking for full-time RNs for our innovative Telehealth service line! This RN position is like no other that you’ve ever worked. Here are a few reasons why: This is a home-based position! You get to help clients from the comfort of your home! Leave behind the physically demanding part of your job - it’s telephonic triage, which also means there is no exposure to high-risk infectious diseases. Handle only one caller at a time instead of dealing with an entire caseload. You keep 100% focus on the person you’re talking to, and only that person. Finally, you’ll receive ongoing training in a unique virtual atmosphere. Things change; new advancements are constantly being made, and here at Medcor, you’ll be at the cutting edge in the growing technological area of nursing. If you’re interested in continuing your nursing career in a new and innovative way, Medcor could be the solution! We are now hiring for our 1/20/25 training class. We are currently hiring for 8-hour and 10-hour shifts between the hours of 11a-11p CST with a rotating weekend schedule.

Must possess a valid Registered Nurse license in at least one U.S. state at time of hire. Valid BLS (CPR) card required. Ability to enter data into software programs, understand and navigate MS Windows at no less than an intermediate level of proficiency. Must have access to high speed cable internet and Email programs. Experience with MS office including Excel preferred, with a typing speed of 40 wpm. Must have effective written, verbal, and interpersonal communication skills. Ability to read, analyze, and interpret triage tools and information along with care instructions to injured employees and their managers. While performing the duties of this job, you are regularly required to talk and/or hear. You are required to sit and use hands. Specific vision abilities required by this job include close vision for computer and written work with the ability to adjust focus. Ability to work every other weekend is required. Our advocates rotate working major U.S. holidays on a two-year basis, as determined by our Workforce Management Team. Ability to work on a computer for long periods of time. Training: The training will be completed from the comfort of your own home and will last 5-6 weeks. The first 5-6 weeks of classroom training/precepting will be Monday - Friday, from 8:00am – 4:00pm CT. The training schedule is not negotiable, and all training must be successfully completed within the 5-6 week time frame. All permanent shifts are determined by our workforce management team and all schedules are in CT (Central Time zone). Changes to the assigned permanent schedule are not allowed within the first 12 months of employment. Again, we are currently hiring for 8-hour and 10-hour shifts between the hours of 11a-11p CST with a rotating weekend schedule.

By joining our nursing team, you will be helping thousands of employers better manage their workplace injuries and improve the quality of healthcare for their employees. Nurses who are successful in this position must be able to talk on the phone while typing and navigating through various software applications at the same time. Our nurses must have the ability to visualize an injury while on the phone and ask questions as appropriate to get clarification about the injury, while following our propriety algorithms to guide the triage of the injured worker.

Texas Oncology

Virtual Care Triage RN Sr.

Posted on:

January 8, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Texas

Texas Oncology is the largest community oncology provider in the country and has approximately 600+ providers in 220+ sites across Texas and southeastern Oklahoma. Our founders pioneered community-based cancer care because they believed in making the best available cancer care accessible to all communities, allowing people to fight cancer at home with the critical support of family and friends nearby. Our mission is still the same today—at Texas Oncology, we use leading-edge technology and research to deliver high-quality, high-touch, evidence-based cancer care to help our patients achieve “More breakthroughs. More victories.” ® in their fight against cancer. Today, Texas Oncology treats half of all Texans diagnosed with cancer on an annual basis.

Texas Oncology is looking for a Virtual Care Triage Nurse (RN) to join our team! These positions will support the Virtual Care Program and will work remotely. We are willing to consider candidates across the state of Texas or outside of Texas as long as you have an RN license that is recognized by the state of Texas. The hours for this position will be 8:15am-5:15pm CST. The telephone triage nurse assesses patient needs over the telephone, collaborates with a physician or qualified staff member to meet those needs, then documents all elements of care in the patient’s medical record. The telephone triage nurse will accurately identify patients with high risk conditions and will direct care to the appropriate resources if they cannot be managed by the nurse and/or within the clinic. Under general supervision, provides professional nursing care for patients adhering to national and organizational standards and guidelines for specialty care and scope of practice per state licensing board. Must recognize physical, psychological, and spiritual aspects of care and participates in company-wide quality initiatives. Supports and adheres to the US Oncology Compliance Program, to include the Code of Ethics and Business Standards.

The ideal candidate for the Virtual Triage Nurse (RN) will have the following background and experience: Graduate from an accredited program for professional nursing education, BSN preferred. Minimum of 3 years nursing experience needed. Willing to consider a mid or senior level experienced candidate. Oncology or applicable specialty experience required. Current RN state license with the applicable State Board of Nursing. Current CPR certification required. Physical Requirements: Large percent of time performing computer-based work is required. The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to stand; use hands to finger, handle, or feel; and reach with hands and arms. The employee frequently is required to walk and talk or hear. The employee is occasionally required to sit; climb or balance; and stoop, kneel, crouch, or crawl. The employee must frequently lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds.

Addresses patient calls, portal messages and emails in a timely manner concerning a wide range of symptom / side effect related topics Assesses urgency of patient symptoms / side effects and addresses them appropriately, aggressively managing them to prevent unnecessary emergency department and hospital utilization Documents all conversations with patients to maintain a comprehensive medical record Provides clear instruction and education to patients via the telephone Collaborates with physicians via electronic communication, face to face, or the telephone to discuss patient care needs that cannot be independently and appropriately addressed using standing orders or practice protocols Sets up same day and/or future provider/infusion room appointments to address symptom management concerns

CVS Health

Special Investigation Unit Nurse Consultant - Remote

Posted on:

January 8, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Ohio

Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver. Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.

This is a full-time remote position with less than 5% required travel. Requirement to reside in the contiguous U.S. Hours for this position are 8am-5pm in time zone of residence.

Required Qualifications: 5+ years of clinical experience required 2+ years of experience as a Registered Nurse Must have active, current and unrestricted RN licensure in state of residence 2+ years of experience using Microsoft Office products, including Outlook and Excel, and previous experience using Internet Explorer and Google Chrome to effectively utilize review resources and conduct reviews. Must be able to work Monday through Friday 8:00am to 5:00pm in time zone of residence Must have coding certification (ex: CPC) Must be willing and able to travel up to 5%. Reliable transportation required. Mileage is reimbursed per our company expense reimbursement policy. 1+ year of Coding experience Preferred Qualifications: Utilization Management review Managed Care experience Education: Associates degree required BSN preferred Certified Coder

RN and certified coder Responsible for the review and evaluation of clinical information and documentation related to SIU flagged providers. Reviews documentation and interprets data obtained from clinical records or systems and uses clinical decision-making to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider claims. Independently coordinates the clinical resolution with clinician/MD support as required. Acts as a resource for Investigators customer service and claims processing areas. Requires an RN with unrestricted active license. Must be a Certified Coder. Must have experience using Microsoft Office products, including Outlook and Excel, and previous experience using Internet Explorer and Google Chrome to effectively utilize review resources and conduct reviews.

Humana

RN Utilization Management Review - SNF

Posted on:

January 8, 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 Registered 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.

Licensed Registered Nurse (RN) in the (appropriate state) with no disciplinary action. MUST have Compact License 3+ years of Skilled Nursing Facility experience Previous experience in utilization management required Prior clinical experience preferably in an acute care, skilled or rehabilitation clinical setting Comprehensive knowledge of Microsoft Word, Outlook and Excel Ability to work independently under general instructions and with a team Must have the ability to provide a high speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 10x1 (10mbs download x 1mbs upload) is required Must be passionate about contributing to an organization focused on continuously improving consumer experiences Preferred Qualifications: Education: BSN or Bachelor's degree in a related field Health Plan experience Previous Medicare/Medicaid Experience a plus Call center or triage experience Bilingual is a plus

The Utilization Management Registered 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.

WakeMed Health & Hospitals

Telephone Triage Nurse-Nurse Advice

Posted on:

January 8, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

North Carolina

Serving the community since 1961, WakeMed Health & Hospitals is the leading provider of health services in Wake County. With a mission to improve the health and well-being of our community, we are committed to providing outstanding and compassionate care. For more information, visit www.wakemed.org.

Licensure: Registered Nurse Required Education: Graduate Nursing Required - Or College Courses Nursing Required - With Required Licensure/Certification - And Bachelor's Degree Nursing Preferred Experience: 2 Years Nursing - Related Area Required - And 3 Years Nursing - Related Area Preferred

The Telephone Triage Nurse is responsible for providing appropriate health information as well as triaging the patient to the most appropriate level of care. By utilizing assessment skills in conjunction with established medical protocols, will provide phone advice, education, and triage within a full spectrum of acuity. Utilizing comprehensive nursing skills to assess and advise patients and their families, a plan of care is implemented. The plan is based upon the patient's developmental and health care needs as identified through the telephonic assessment of the patient and/or the caller's physical and psychological status in response to the established clinical guidelines. In addition, the Telephone Triage Nurse will provide additional support by managing after-hours calls for various other services outside of triaging, including follow up phone calls to discharge patients from the WakeMed emergency departments meeting a certain criteria. The Telephone Triage Nurse understands the needs of the organization and supports the mission, values, and management of patient care services. Calls from community physicians are given priority service to ensure communication with their peers as well as provide expedient referral services for either emergency department arrivals or inpatient transfers.

LanceSoft, Inc.

RN - Case management/ Care manager

Posted on:

January 7, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Michigan

LanceSoft is a certified Minority Business Enterprise (MBE) and an equal opportunity employer. We prohibit discrimination and harassment of any kind based on race, color, sex, religion, sexual orientation, national origin, disability, genetic information, pregnancy, or any other protected characteristic as outlined by federal, state, or local laws. This policy applies to all employment practices within our organization, including hiring, recruiting, promotion, termination, layoff, recall, leave of absence, compensation, benefits, training, and apprenticeship. LanceSoft makes hiring decisions based solely on qualifications, merit, and business needs at the time. LanceSoft is rated as one of the largest staffing firms in the US by SIA. Our mission is to establish global cross-culture human connections that further the careers of our employees and strengthen the businesses of our clients. We are driven to use the power of our global network to connect businesses with the right people, and people with the right businesses without bias. We provide Global Workforce Solutions with a human touch.

*RN Case Manager/Nurse Case Manager Position type : Full time Locations: Multiple Locations at Michigan Onsite Flexibility: Remote role /Field 30-40% Pay range hourly : ($43.00 - $47.00) Schedule: Monday thru Friday 8:30 - 5:00 The Case Manager utilizes a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual’s benefit plan and/or health needs through communication and available resources to promote optimal, cost-effective outcomes.

3 years Clinical practice experience, e.g., hospital setting, alternative care setting such as home health or ambulatory care required. Healthcare and/or managed care industry experience. Case Management experience preferred-- Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding Effective communication skills, both verbal and written. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer. Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor. See members in their home and documentation from home office. Education: RN with current unrestricted state licensure Preferred case management experience

Through the use of clinical tools and information/data review, conducts comprehensive assessments of referred member's needs/eligibility and determines approach to case resolution and/or meeting needs by evaluating member's benefit plan and available internal and external programs/services Application and/or interpretation of applicable criteria and guidelines, standardized case management plans, policies, procedures, and regulatory standards while assessing benefits and/or member’s needs to ensure appropriate administration of benefits Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures

Meridian

Care Manager (RN)

Posted on:

January 7, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Compact / Multi-State

https://jobs.centene.com/us/en/jobs/1553904/care-manager-rn/

You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility.

This is remote position for candidates located in MI. Ideal candidate will have experience working with pediatric, NICU or foster care members. 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

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. 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

EPITEC

Case Management Nurse

Posted on:

January 7, 2025

Job Type:

Contract

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

EDUCATION AND EXPERIENCE: Nursing Diploma or Associates degree in nursing required. Bachelor’s degree in nursing strongly preferred. 3 years of clinical nursing experience in a clinical, acute/post-acute care, and community setting required. 1 year of case management experience in a managed care setting strongly preferred. Experience managing patients telephonically and via digital channels (mobile applications and messaging) preferred. CERTIFICATES, LICENSES, REGISTRATIONS: Current, active, and unrestricted Compact Registered Nurse license required Certification in Case Management (CCM) required or to be obtained within 18 months of hire Certification in Chronic Care Professional (CCP) preferred QUALIFICATIONS To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. OTHER SKILLS AND ABILITIES: Ability to think critically, be decisive, and problem solve a variety of topics that can impact a member’s outcomes. Empathetic, supportive and a good listener. Proficient in motivational interviewing skills. Demonstrated time management skills. Organizational skills with the ability to manage multiple systems/tools, while simultaneously interacting with a member. Must have intermediate computer knowledge, typing capability and proficiency in Microsoft programs (Excel, OneNote, Outlook, Teams, Word, etc.). Must embrace teamwork but can also work independently. Excellent interpersonal and communication skills both written and verbal.

The Care Manager RN leads the coordination of a multidisciplinary team to deliver a holistic, person centric care management program to a diverse health plan population with a variety of health and social needs. They serve as the single point of contact for members, caregivers, and providers using a variety of communication channels including phone calls, emails, text messages and the BCBSM online messaging platform. The Care Manager RN uses the case management process to assess, develop, implement, monitor, and evaluate care plans designed to optimize the member’s health across the care continuum. They work in partnership with the member, providers of care and community resources to develop and implement the plan of care and achieve stated goals.

Apidel

Nurse Case Manager

Posted on:

January 7, 2025

Job Type:

Contract

Role Type:

Case Management

License:

RN

State License:

Michigan

Position: Nurse Case Manager Location: Remote in Wayne and Macomb Counties Duration: 04+ Months (with higher possibilities of extension) Shift: Monday - Friday 8am - 5pm Position Summary: Nurse Case Manager is responsible for telephonically planning, implementing, and coordinating all case management activities with members to evaluate the medical needs of the member to facilitate the member’s overall wellness. Develops a proactive 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. Services strategies policies and programs are comprised of network management and clinical coverage policies.

Experience: 2 years Clinical practice experience, e.g., hospital setting, alternative care setting such as home health or ambulatory care required. Healthcare and/or managed care industry experience. Case Management experience preferred-- Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding Effective communication skills, both verbal and written. Ability to multitask, prioritize and effectively adapt to a fast-paced changing environment Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer. Work requires the ability to perform close inspection of hand written and computer-generated documents as well as a PC monitor. Education: RN with current unrestricted state licensure. Case Management Certification CCM 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 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.

Theoria Medical

Clinical Care Specialist

Posted on:

January 7, 2025

Job Type:

Role Type:

License:

RN

State License:

Illinois

Leading the charge in healthcare innovation, Theoria Medical offers a unique blend of medical excellence and technological advancement, primarily serving the post-acute and primary care sectors. Our extensive network includes multispecialty physician services and RPM, covering skilled nursing facilities across the country. In our national push for expansion, we're scouting for the brightest nurse practitioners and physicians eager to drive change and deliver superior care. Join us for a rewarding career that promises professional growth, flexibility, and the chance to shape the future of healthcare.

Shift Structure: Monday-Friday, 8 hour shift (Typically 9am-5pm but can vary) Requirements and Qualifications: RN in Applicable State Fast home internet and strong computer skills required Five years of experience practicing nursing required Excellent communication and time management skills required Strong critical thinking and problem solving required Self-motivated and independent worker Experience serving chronically ill patients preferred Telephonic case management or care coordination experience preferred Compassionate and friendly demeanor Physical Requirements: Must be punctual or on time and adhere to the company's Time and Attendance policy. Must be able to remain sitting for the majority of their shift.

Maintain, monitor, and manage your own patient census across multiple facilities to: Coordinate the implementation of Chronic Care Management (CCM) services amongst chronically ill patients residing in long term care facilities Create individualized Care Plans for patients with chronic conditions. Responsible for updating and tracking monthly Responsible for monitoring labs, vitals, medications, and testing for patient census. Conduct care coordination with patients, their care team, and their families (this is done through email, text, and phone communication) Provide patient education on management of chronic conditions, medications, and testing Constant communication and coordination with members of the care team such as physicians, physician assistants, nurse practitioners, pharmacists, and other health care professionals Assess, identify, and close clinical and non-clinical gaps in patient care Provider and CCS team training and support

UnitedHealthcare

Field Care Coordinator - Licensed Social Worker or LPN - Remote in Shelby County, TN

Posted on:

January 7, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

LPN/LVN

State License:

Tennessee

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.

As part of a care management team who will manage a caseload of complex members, the Field Care Coordinator will be the primary care manager for elderly and/or disabled members with complex medical/ behavioral health needs. Care coordination activities will focus on supporting member’s medical, behavioral, and socioeconomic needs to promote appropriate utilization of services and improved quality of care. This is a home-based position with field responsibilities. If you are located in Shelby County, TN, or the close surrounding areas, you will have the flexibility to work remotely* as you take on some tough challenges.

Required Qualifications: Active/unrestricted LPN or Social Worker (LBSW, LMS, LPC or LCSW) License for the state of TN 2+ years of experience working within the community health setting or in a health care role 1+ years of experience with local health providers and/or community support organizations addressing the SDoH (e.g., food banks, non-emergent transportation, utility assistance, housing / rapid re-housing assistance, etc. 1+ years of experience with MS Office, including Word, Excel, and Outlook Reliable transportation and live within or commutable distance to Shelby County, Tennessee to meet with members and providers Preferred Qualifications: Certified Case Manager (CCM) Home Health or Long-Term Care experience Case management experience Experience in Home Health and/or Long-Term Care Experience working in team-based care Background in managing populations with complex medical or behavioral needs Background in Managed Care

Serve as primary care manager for elderly and/or disabled members who live in individual housing, community-based housing (ALF or CLS homes) or nursing facilities Engage members and/or their families face-to-face and/or telephonically to complete a comprehensive needs assessment, including assessment of medical, behavioral, functional, cultural, and socioeconomic (SDoH) needs Develop and implement individualized, person-centered care plans inclusive of goals, opportunities and interventions aligned with a person’s readiness to change to support the best health and quality of life outcomes by meeting the member where they are Partner and collaborate with internal care team, providers, and community resources/partners to implement care plan Provide referral and linkage as appropriate and accepted by member (may include internal consult opportunities such as Housing Navigator, Pharmacy Team, Peer Specialist, etc. or community-based provider referrals such as PCP, specialists, medication assisted therapy referrals, etc.)

W3R Consulting

Registered Nurse

Posted on:

January 7, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Illinois

Apply: Email your resume to tezava@w3r.com or call 925-326-2471. Title: Medical Management Specialist Location: Alexander, Union, and Pulaski Counties Alexander, Union, and Pulaski Counties Illinois (this position is 100% remote, but will require to conduct home assessments to members within the given area) Duration: Contract to Hire Permanent Pay: $40.00 - $43.00/hr on W2. Description: This position is responsible for conducting medical management and health education programs for customers on government health care programs. This role will include gathering, analyzing and providing date for regulatory reports. This position will represent the company to members.

3 years clinical experience. Patient education experience. Condition Management experience. Bilingual in English and Spanish. Transition of Care experience. Experience in managing complex or catastrophic cases. Certification in Case Management, Training, Project Management or nationally recognized health care certification.

This position is responsible for conducting medical management and health education programs for customers on government health care programs. Accountabilities include gathering, analyzing and providing date for regulatory reports. This position will represent the company to members. JOB QUALIFICATIONS: Registered Nurse (RN), with 3 years direct clinical care to the consumer in a clinical setting or Licensed Professional Counselor (LPC), or Licensed Master Social Worker (LMSW), which includes 2 years of clinical practice to obtain their LPC or LMSW license. Current, valid, unrestricted license in the state of operations (or reciprocity). For compact licensee changing permanent residence to state of operations, you must obtain active, unrestricted RN licensure in the state of operations within 90 days of hire. Plus 3 years wellness or managed care experience presenting clinical issues with members/physicians. Knowledge of the health and wellness marketplace and employer trends. Verbal and written communication skills including discussing medical needs with members and interfacing with internal staff/management and external vendors and community resources. Analytical experience including medical data analysis. Current driver's license, transportation and applicable insurance. Ability and willingness to travel within assigned territory. PC proficiency to include Word, Excel, and PowerPoint, database experience and Web based applications.

Life Line Screening

LPN/RN - Remote Nurse Consult Team

Posted on:

January 7, 2025

Job Type:

Full-Time

Role Type:

Primary Care

License:

LPN/LVN

State License:

Compact / Multi-State

LPN/RN - Remote Nurse Consult Team This is a fully remote position working from a home office environment. Join our compassionate healthcare team! We are seeking an LPN or RN to enhance patients' health and well-being within our national Remote Nurse Consult Team. As a team nurse, your duties involve evaluating patients' health, guiding them on adopting healthier lifestyles like proper nutrition and exercise, and equipping them with tools to achieve specific goals in a designated care plan. In addition, you may review various test results with our patients, providing education and appropriate next steps. In this role, you will work autonomously overseeing a monthly patient caseload to ensure all individuals receive necessary consultations and/or care. To excel as a member of this team, you should display a positive attitude, strong clinical abilities – especially in preventive care/screenings and the management of hypertension and obesity, effective communication skills, and a dedication to excellence in patient care and customer service.

LPN or RN degree with an active, unrestricted license (in a state that is part of the Nurse Licensure Compact). Possesses excellent clinical knowledge concerning the aging adult population and healthy practices. Demonstrates strong organizational skills and attention to detail. Proficient in using various systems and software programs. Previous experience in prevention, health coaching, fitness, or nutrition is advantageous. Capable of working from a remote or home-based location. Maintains a pleasant phone manner and shows compassion. Self-managing in a fast-paced, high-volume work environment with a willingness to assist in other projects during downtime. Availability during standard business hours, 9am-5:30pm Eastern Standard Time with flexibility across national time zones as needed.

Collaborate with other Nurses and Nurse Practitioners to develop care plans for patients. Regularly follow up with patients to assess blood pressure or weight readings and adherence to care plans. Offer guidance to address unhealthy behaviors. Evaluate critical findings and liaise with Primary Care Provider (PCP) to help them implement a treatment plan for the patient. Record all interactions and details in Electronic Health Record (EHR) chart notes. Manage and organize a high volume of patient calls efficiently. Review test results with patients and provide education on conditions, prevention and follow up care. Schedule: Set, but flexible schedule. We are willing to consider temporary, part time or full-time work within the standard business hours.

Southern New Hampshire University

Online Adjuncts - Undergraduate Nursing

Posted on:

January 7, 2025

Job Type:

Part-Time

Role Type:

Coaching

License:

RN

State License:

Compact / Multi-State

Southern New Hampshire University is a team of innovators. World changers. Individuals who believe in progress with purpose. Since 1932, our people-centered strategy has defined us — and helped us grow a team that now serves over 180,000 learners worldwide. Our mission to transform lives is made possible by talented people who bring diverse industry experience, backgrounds and skills to the university. And today, we're ready to expand our reach. All we need is you. Make an impact — from near or far We currently have remote adjunct opportunities available in all US States, with the exception of California.

Southern New Hampshire University is looking for adjunct faculty to teach in our undergraduate Nursing program. You will provide high-quality academic experiences and support students as they work toward their educational goals. Online faculty members work collaboratively in a supportive academic environment, partnering with student advising and the academic team to ensure that each student has support and resources they need to be successful. As an adjunct in the online nursing program, you'll teach students critical skills and competencies, including evidence-based care, health promotion, disease prevention and leveraging technology to enhance their clinical and professional development. Course Available To Teach NUR307 - Exploring Information Technology for Professional Practice

MSN required Active, unencumbered multi-state RN license 2+ years of clinical nursing experience 2+ years of online teaching experience

Provide a high level of student outreach and connect with students, academic advisors and team leaders on a frequent basis to ensure student success Engage with students, offering an increased presence in the classroom Provide substantial student feedback and offer a quick turnaround on grades

Iowa Total Care

Care Manager (RN)

Posted on:

January 7, 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. Applicants for this role have the flexibility to work remotely from their home anywhere within the state of Missouri. **

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

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. 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

Meadows Behavioral Healthcare

Utilization Review Coordinator

Posted on:

January 7, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Arizona

At Meadows we understand that new directions to career advancing and improvement can be scary, but we are excited to offer you a possible new rewarding chapter with us! Come join us in transforming lives! Who are we? Meadows Behavioral Healthcare is a leader in the behavioral health industry. Meadows Behavioral Healthcare offer a range of specialized programs including residential, outpatient and virtual treatment. We provide care for drug and alcohol addiction, trauma, sexual addiction, behavioral health conditions, and co-occurring disorders. We offer state-of-the-art care including neurofeedback and other services. Our evidence-based approach is rooted in decades of clinical experience, with more than 45 years in the field. Our approach is different and success stories from our patients are the proof.

Level: Experienced Job Location: MBH 7th Street Corporate Offices - Phoenix, AZ Remote Type: Fully Remote Position Type: Full Time Travel Percentage: No Travel Job Shift: Regular 8:00 am to 5:00 pm Who are you? Are you compassionate, innovative and have a passion to make an impact? Are you looking to get your foot in the door with a company that will believe in your abilities and train you to advance? 80% of our current top-level executive staff are organic internal promotions from within. We might be a perfect fit for you! Position Summary: As the Utilization Review Coordinator you will develop and implement systems for the authorization, concurrent and retrospective review of inpatient admissions and services. May also be involved with writing and facilitating appeals for denied treatment days

Bachelor/Associates Degree in Nursing preferred or related job experience Registered Nursing licensure/certification in good standing (RN) CPR Certification optional. Prefer a minimum of two years experience in a psychiatric setting or behavioral health utilization review. Knowledge of medical terminology, psychiatric interventions and medications and insurance is essential to this position.

Provide professional and thorough communication with external representatives to obtain authorization for admission and continued stay. Monitor each step of the authorization process to proactively identify potential problems and optimize outcome. Minimize the number of cases that need to be referred for psychiatric peer/peer review. Interact with patient care staff to assure patient assessment and treatment plan is accurately and consistently reflected in facility documentation. Prioritize multiple and various types of case activity; coordinate with UM team to ensure all deadlines are met with highest possible quality of delivery. Maintain cumulative documentation regarding actions taken during the UR process. Conduct reviews to ensure that services and documentation conform to the facility protocols, and the requirements of third party payer sources. Attend treatment staffing and other scheduled meetings to obtain and present information on patient status, care and stay. Communicate authorization status, issues or problems to appropriate staff/departments Payor Management: Obtain and maintain authorization for each patient. Problem-solve issues relating to stay or service. Respond quickly and effectively to requests for information. Nurture positive and professional relationships with external (third party payer) sources.

Morgan Stephens

Director of Nursing (Remote)

Posted on:

January 7, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Florida

Job Title: Director of Nursing – Home Training Division Location: Remote with Local Travel ** Candidates must live in Sarasota County Position Overview: The Director of Nursing is responsible for overseeing the daily operations of the Home Training Division within a dialysis healthcare organization. This role ensures the provision of safe, high-quality patient care, focusing on patient education and home dialysis training. The Director of Nursing will manage the coordination and supervision of staff, optimize patient care delivery, and maintain regulatory compliance. Additionally, this position plays a key role in fostering a collaborative team environment, enhancing patient outcomes, and supporting staff development.

Minimum Qualifications: Active RN licensure in the state of practice. Graduation from an accredited nursing program. Minimum of 1 year of nursing experience, including at least 6 months in dialysis care. At least 3 months of experience in home dialysis training programs (if applicable). Prior supervisory or management experience in a healthcare setting. Certification in Nephrology Nursing preferred. In-depth knowledge of dialysis systems and procedures, particularly home dialysis modalities. ICU or CCU experience is desirable. Strong leadership, interpersonal, problem-solving, and organizational skills. Completion of CCPD/CAPD training courses. Ability to travel as required for business purposes, with a valid driver’s license and reliable transportation. Proficiency in computer systems preferred. Current CPR Healthcare Recognition according to the American Heart Association. Reliable, with a strong sense of accountability and emotional maturity. Additional Qualifications: Ability to be available outside of normal business hours for emergencies and staff support. Maintain effective communication with both patients and staff to enhance care delivery and team performance.

Lead and manage daily operations of the Home Training Division to ensure effective patient care and smooth operations. Supervise nursing staff and ensure they provide appropriate training for patients undergoing home dialysis (CAPD, CCPD). Monitor quality outcomes and patient satisfaction to ensure high standards of care. Provide leadership and mentorship to nursing staff, promoting professional development and adherence to clinical standards. Oversee patient care scheduling and staffing mix to optimize outcomes while controlling labor expenses. Collaborate with multidisciplinary teams to ensure comprehensive care and continuous improvement. Manage the budget for the Home Training Division, preparing financial forecasts and ensuring adherence to fiscal targets. Stay current with industry trends, regulations, and best practices, and apply them to improve the division’s performance. Develop and implement patient care protocols and training procedures in compliance with internal and external regulatory standards. Maintain a positive work culture, ensuring employee satisfaction and retention.

Guidehealth

Utilization Nurse

Posted on:

January 7, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Illinois

Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. Our goal is to make great healthcare affordable, improve the health of patients, and restore the fulfillment of practicing medicine for providers. Driven by empathy and powered by AI and predictive analytics, Guidehealth leverages remotely-embedded Healthguides™ and a centralized Managed Service Organization to build stronger connections with patients and providers. Physician-led, Guidehealth empowers our partners to deliver high-quality healthcare focused on outcomes and value inside and outside the exam room for all patients. BENEFITS: While you are hard at work advancing value-based healthcare, we are here to ensure YOU have the care you and your family need and the opportunities for growth and development. Our commitments to you include: Work from Home: Guidehealth is a fully remote company, providing you the flexibility to spend less time commuting and more time focusing on your professional goals and personal needs. Keep Health a Priority: We offer comprehensive Medical, Dental, and Vision plans to keep you covered. Plan for the Future: Our 401(k) plan includes a 3% employer match to your 6% contribution. Have Peace of Mind: We provide Life and Disability insurance for those "just in case" moments. Additionally, we offer voluntary Life options to keep you and your loved ones protected. Feel Supported When You Need It Most: Our Employee Assistance Program (EAP) is here to help you through tough times. Take Time for Yourself: We offer Flexible Time Off tailored to meet your needs and the needs of the business, helping you achieve work-life balance and meet your personal goals. Support Your New Family: Welcoming a new family member takes time and commitment. Guidehealth offers paid parental leave to give you the time you need. Learn and Grow: Your professional growth is important to us. Guidehealth offers various resources dedicated to your learning and development to advance your career with us.

Registered Nurse with an active and unrestricted License in the state of Illinois required. Five years of experience in a variety of health care settings. Knowledge of utilization review, managed care and community health. Computer skills including MS Word, Excel, MS Access, etc. Strong organizational, writing and speaking skills necessary. Ability to prioritize and react based on rapidly changing business needs. Excellent clinical judgment, compassion and a positive attitude WOULD LOVE FOR YOU HAVE : An advanced degree or certification in Case Management, Utilization Review and/or Quality Interest in Informatics Knowledge in Population Health and Disparities

Performing utilization review services in compliance with federal and state regulations, and the URAC standards for client members seeking healthcare treatment and services. Obtaining, analyze and document all supporting clinical within the documentation record. Completing a timely review of health care services utilizing and documenting the appropriate medical criteria used to make a clinical determination. Completing timely written and / or verbal communication of pre-certifications and concurrent review determinations for healthcare services to all parties required by regulations, URAC standards and Guidehealth policies. Communicating with the Medical Director and Peer Reviewer(s) for cases requiring review of medical necessity, appropriate treatment, intensity/ number of inpatient and outpatient treatment or quality of care issues. Interfacing with ordering providers and provider organizations on a routine basis. In some instances, communication with members or their representatives may be appropriate. Initiating the referral of targeted patients into organized disease management programs to assist with continuity and quality of care. Managing and documenting after-hours phone calls from members and providers on a rotational basis Maintaining confidentiality of member information, case records and file entries Participating in quality management activities Responsible for sending client specific benefit exhaustion letters upon request. Assisting with coordination and the design and development of clinical and client specific reports. May assist in the development of materials and packets for the QM/ UM Committee meetings, the documentation of minutes, preparation of spreadsheets, data collection and analysis, and follow-up tasks. Maintaining current knowledge and comply with regulatory requirements for multiple jurisdictions and medical groups Integrating ongoing, accurate knowledge of medical group guidelines and URAC standards into daily duties Responsible for continued professional growth and education that reflects knowledge and understanding of current nursing care practice as outlined in the Illinois Nurse Practice Act. Interacting with the IT Department for technical support related to computer systems, upgrades and other data

Medcor

Telephonic Injury Triage Registered Nurse - FT Evenings

Posted on:

January 7, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Illinois

At Medcor, we’re passionate about caring for our advocates as much as you are passionate about caring for your patients! Join our team and receive the support you need to be successful in your practice and to focus on your patients. In addition to a collaborative work environment, we offer great pay and benefits and emphasize your wellness. Here’s why people love working for Medcor: Stability! We’ve been around since 1984. Potential for retention and performance incentives Opportunities galore! Medcor has a lot more to offer than just this job. There are opportunities to move vertically, horizontally, and geographically. Annually, 20% of our openings are filled by internal employees. The fact is, opportunity exists here! Training! We believe in it and we’ll train and support you to be the best you can be. We feel we offer more training than most other companies. We have an open-door policy. Do you have something to say? Speak your mind! We encourage it and we look forward to how you can help our organization.

Medcor is looking to hire a full-time Registered Nurse for our remote 24/7 Occupational Health triage call center! The hours for this position include 8-hour shifts between 10:00am and 10:00pm. For example, shifts could include 10:00am-8:00pm or 2:00pm-10:00pm. The start date for this triage class will be 02/10/2025. Job Type: Full-time - 40 hours per week Salary: $28 per hour with additional shift differential pay available for evenings, nights & weekends By joining our nursing team, you will be helping thousands of employers better manage their workplace injuries and improve the quality of healthcare for their employees. Nurses who are successful in this position must be able to talk on the phone for long periods while typing and navigating through various software applications simultaneously. Our nurses must be able to visualize an injury while on the phone and clarify details about the injury while following our propriety algorithms to guide the triage of the injured worker. Training: Training for this role will last 6 weeks, with 3 weeks of classroom instruction and 3 weeks of precepting. These first 6 weeks of training are held Monday through Friday, from 8a-4p CT. The training schedule is non-negotiable, and all training must be successfully completed within the 6-week time frame. Following training, you will transition to your permanent schedule between the hours of 10a and 10p with an every-other-weekend requirement and holiday rotation. Changes to the permanent schedule are not allowed within the first 12 months of employment.

Have a valid RN license and current BLS (CPR) certification Be able to handle a high volume of consecutive calls Have strong technological skills as well as a typing speed of at least 30 WPM Work a major U.S. holiday rotation Work every other weekend Have effective written, verbal, and interpersonal communication skills. Ability to read, analyze, and interpret triage tools and information along with care instructions to injured employees and their managers. Be able to talk and/or hear. You are required to sit and use your hands. Specific vision abilities required by this job include close vision for computers and written work with the ability to adjust focus Be able to work on a computer for long periods Have a private space in your home with 4 walls and a door for patient privacy Have access to high-speed internet (no satellite) within your primary residence Be able to receive and apply feedback It's a Plus If: You have call center experience You have occupational health experience

Manage a rapid flow of incoming telephone calls from Medcor customers in a call center environment Document each call efficiently and accurately Monitor and track individual as well as call center goals, productivity metrics, and statistics Reflect all shift activities using the phone system and be responsible for personal schedule adherence Provide superior customer service to Medcor’s clients and employees Complete accurate assessment of symptoms and/or concerns utilizing Medcor’s Triage Algorithms Follow HIPAA Compliance Policies

Medcor

Bilingual Spanish/English Telephonic Injury Triage RN - FT

Posted on:

January 7, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Illinois

At Medcor, we’re passionate about caring for our advocates as much as you are passionate about caring for your patients! Join our team and receive the support you need to be successful in your practice and to focus on your patients. In addition to a collaborative work environment, we offer great pay and benefits and emphasize your wellness. Here’s why people love working for Medcor: Stability! We’ve been around since 1984. Potential for retention and performance incentives Opportunities galore! Medcor has a lot more to offer than just this job. There are opportunities to move vertically, horizontally, and geographically. Annually, 20% of our openings are filled by internal employees. The fact is, opportunity exists here! Training! We believe in it and we’ll train and support you to be the best you can be. We feel we offer more training than most other companies. We have an open-door policy. Do you have something to say? Speak your mind! We encourage it and we look forward to how you can help our organization.

Medcor is looking to hire a full-time bilingual Spanish-speaking Registered Nurse for our remote 24/7 Occupational Health triage call center! The hours for this position include 8-hour shifts between 10a-10p CST. Job Type: Full-time - 40 hours per week Salary: $30 per hour with additional shift differential pay available for evenings, nights & weekends By joining our nursing team, you will be helping thousands of employers better manage their workplace injuries and improve the quality of healthcare for their employees. Nurses who are successful in this position must be able to talk on the phone for long periods while typing and navigating through various software applications simultaneously. Our nurses must be able to visualize an injury while on the phone and clarify details about the injury while following our propriety algorithms to guide the triage of the injured worker. Training: Training for this role will last 6 weeks, with 3 weeks of classroom instruction and 3 weeks of precepting. These first 6 weeks of training are held Monday through Friday, from 8a-4p CST. The training schedule is non-negotiable, and all training must be successfully completed within the 6-week time frame. Following training, you will transition to your permanent schedule between the hours of 10a-10p with an every-other-weekend requirement and holiday rotation. Changes to the permanent schedule are not allowed within the first 12 months of employment.

Be bilingual, fluent in both the English and Spanish language Have a valid RN license and current BLS (CPR) certification Be able to handle a high volume of consecutive calls Have strong technological skills as well as a typing speed of at least 30 WPM Work a major U.S. holiday rotation Work every other weekend Have effective written, verbal, and interpersonal communication skills. Ability to read, analyze, and interpret triage tools and information along with care instructions to injured employees and their managers. Be able to talk and/or hear. You are required to sit and use your hands. Specific vision abilities required by this job include close vision for computers and written work with the ability to adjust focus Be able to work on a computer for long periods Have a private space in your home with 4 walls and a door for patient privacy Have access to high-speed internet (no satellite) within your primary residence Be able to receive and apply feedback It's a Plus If: You have call center experience You have occupational health experience

Manage a rapid flow of incoming telephone calls from Medcor customers in a call center environment Document each call efficiently and accurately Monitor and track individual as well as call center goals, productivity metrics, and statistics Reflect all shift activities using the phone system and be responsible for personal schedule adherence Provide superior customer service to Medcor’s clients and employees Complete accurate assessment of symptoms and/or concerns utilizing Medcor’s Triage Algorithms Follow HIPAA Compliance Policies

Anderson Healthcare Masters LLC

Telehealth Triage Nurse (Physically in GA or FL): Microdose Ketamine Contract

Posted on:

January 7, 2025

Job Type:

Contract

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

Anderson Healthcare Masters LLC/AQualiT Health® is looking for a Registered Nurse with a COMPACT license and physically residing in Florida or Georgia to perform a review of patient progress automation responses for a microdose ketamine treatment contract currently in progress. Due to significant growth, we are currently continuing to build our team of nurses who, each day, will review patient responses and respond back based on established protocols. This is a work from home position, and training will be provided on the automation system. The nurse will work directly with the contractor Customer Care Coordinator. Hours range from 20 hours per week to 40 hours. Coverage need varies from day to evening and weekends.

Optum

Telephonic After Hours RN - Long Term Care - NY or NJ licensure required

Posted on:

January 7, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

New York

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

An RN functions as part of the National On Call team, and reports to the National On Call Hub Clinical Services Manager. The RN performs activities that fall within the RN scope of practice. This role works in close collaboration with all the team members and may support multiple providers. The RN works under the direction of the provider, and activities are delegated to the RN by the provider or the Hub CSM. The RN understands and supports the CCM models of care including the Institutional Special Needs Plan (ISNP), Institutional Equivalent Special Needs Plan (IESNP), Dual-Eligible Special Needs Plan (DSNP), and Transitions to Skilled (TTS). The Senior Community Care (SCC) National On Call Registered Nurse is responsible for providing telephonic care and direction to members and facility staff during various overnight, weekend, and holiday hours. This role is responsible for the delivery of medical care services to a pre-designated group of enrollees. In this home-based role you will provide afterhours virtual (primarily telephonic) care for aging residents in various settings. This excellent opportunity affords an autonomous role bringing enormous satisfaction in the care and comfort of our aging population. Scheduling & Hours: This is a work from home position requiring various shift coverage with a mix of weeknights, weekend, and holiday coverage. While shift times can vary, we provide coverage to members on weeknights from 5pm- 8am local time, continuous coverage from Friday at 5pm to Monday at 8am. Holiday coverage is also provided beginning at 5pm of the end of the last business day to 8am of the resumption of business hours. Availability and Coverage expectations for this role While shift times can vary, we provide coverage to members on weeknights from 5pm- 8am local time, continuous coverage from Friday at 5pm to Monday at 8am. Holiday coverage is also provided beginning at 5pm of the end of the last business day to 8am of the resumption of business hours Availability and Coverage expectations for this role Weeknight shifts between 5pm and 8am Every other weekend coverage for 10 – 12-hour shifts covering both day and evening shifts- Expectations that you are working and/or have approved PTO for 26 weekends/ year. Each FT/PT employee is eligible to have off up to 6 weekend shifts a year for PTO Unapproved time away/Unpaid Time Off will result in need to add additional weekend shift to your schedule Overnight and holidays are required for all RNs Holiday scheduling is completed at the beginning of the year for advanced planning

Required Qualifications: Current, unrestricted RN license in the state of NY or NJ 3+ years of clinical experience in a hospital, acute care, home health/hospice, direct care, or case management position Proficient with Microsoft Word, Outlook, and Excel Computer/typing proficiency to enter and retrieve data in electronic clinical records Dedicated space for home office set up Access to high-speed internet services Residency in either NY or NJ Preferred Qualifications: Experience working with the needs of vulnerable populations who have chronic or complex bio-psychosocial needs Experience triaging calls Proven solid problem-solving skills Proven ability to communicate complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from other Proven ability to flex with change and perform positively and efficiently in production driven environment

Care Coordination Assist the provider/team with various care coordination activities to support the role of the National On Call APCs Telephonic triage of incoming calls and voicemails to determine the correct level of care Collaborating with the nursing facility, APCs, and community members to identify and respond to changes in condition Assist the provider/team with inbound and outbound communications for members including addressing handoffs, telephonic assessments, acuity follow-ups, and proactive/RED facility calls Team Support – Assist in the coordination of the follow up of members in the ER Participate in the onboarding of new clinical staff under the direction of the CSM; the RN may coordinate onboarding activities and participate in other orientation activities under the direction of the Hub CSM Documentation- Document all clinical information, telephonic assessments, and activities in the appropriate documentation tool RN to APC Hand Off- One entry by the RN and one responding entry by the APC should be recorded in the appropriate documentation tool RN is responsible for escalating appropriate calls to the On-Call APC Use of RN mini soap notes for acute change in condition calls escalated to APC Use of the fall mini soap notes for reported falls, escalate to APC

BlueCross BlueShield of South Carolina

Medical Reviewer II (DME) - CGS

Posted on:

January 7, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Compact / Multi-State

Performs medical reviews using clinical/medical information provided by physicians/providers and established criteria/protocol sets or clinical guidelines. Documents decisions using indicated protocol sets or clinical guidelines. Provides support and review of medical claims and utilization practices. Logistics: Preferred candidate will live in Nashville, TN area. For those living in Nashville, the position would be hybrid (in-office and work from home). Highly qualified candidates outside the Nashville area will also be considered. For those living outside Nashville area, the position will be fully remote. To work from home, you must have high-speed (non-satellite) internet and a private home office.

Required Licenses and Certificates: Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC). Required Education: Associate's in a job related field or Graduate of Accredited School of Nursing. Required Work Experience: Two years of clinical RN experience. Required Skills and Abilities: Working knowledge of word processing software. Ability to work independently, prioritize effectively, and make sound decisions. Good judgment skills. Demonstrated customer service and organizational skills. Demonstrated oral and written communication skills. Analytical or critical thinking skills. Ability to handle confidential or sensitive information with discretion. Required Software and Tools: Microsoft Office. Work Experience: Five years of varied RN nursing experience to include: Medical/Utilization Review, Emergency, Critical Care, Home Health, Long-term Care, Rehabilitation or Medical/Surgical experience, strongly preferred. Medicare or claims experience a plus. Software and Tools: Ability to use multiple Windows-based programs simultaneously

Performs medical claim reviews for one or more of the following: claims for medically complex services, services that require preauthorization/predetermination, requests for appeal or reconsideration, referrals for potential fraud and/or abuse, correct coding for claims/operations. Makes reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines. Determines medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement. Monitors process’s timeliness in accordance with contractor standards. Documents medical rationale to justify payment or denial of services and/or supplies. Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines. Participates in quality control activities in support of the corporate and team-based objectives. Provides guidance, direction, and input as needed to LPN team members. Provides education to non-medical staff through discussions, team meetings, classroom participation, and feedback. Assists with special projects and specialty duties/responsibilities as assigned by management.

Amwell

Virtual Clinical Nurse Associate (LPN), Amwell Medical Group

Posted on:

January 6, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

LPN/LVN

State License:

Compact / Multi-State

Amwell digitally empowers payers, providers and innovators, enabling an ecosystem of care that spans across in-person, virtual and automated care. Amwell provides a leading hybrid care enablement platform in the United States and globally, connecting and enabling providers, payers, patients, and innovators to deliver greater access to more affordable, higher quality care. Amwell believes that hybrid care delivery will transform healthcare. The company offers a single, comprehensive platform to support all digital health needs from urgent to acute and post-acute care, as well as chronic care management and healthy living. With nearly two decades of experience, Amwell powers the hybrid care of more than 55 health plans, which collectively represent more than 90 million covered lives, and many of the nation’s largest health systems, representing over 2,000 hospitals, have access to Amwell solutions. For more information, please visit Amwell.com .

As a key member of Amwell’s affiliate medical group, Amwell Medical Group (AMG), the Medical Continuity Programs Nurse Associate supports the delivery of high-quality clinical care in specific longitudinal programs leveraging the power of a digital telehealth platform. AMG will leverage the expertise of trained Licensed Practical Nurses to help manage a patient’s clinical needs between visits. As such, they assist with asynchronous clinical work, including reporting a clinician’s advice on lab results, collaborating with clinicians to complete and execute referrals, procedure and medication prior authorizations, patient-summited form completion and other duties as assigned. Reporting to the AMG Clinical Nurse Manager, the Clinical Nursing Associate will work closely with the AMG MCP Clinical Registered Nurses, AMG doctors and nurse practitioners, Quality nurses, patients, and our Clinical Services and Provider Operations teams to perform these duties.

Multistate licensure in 25+ states preferred Current LPN licensure in one of the LPN compact states Eligible for credentialing with AMG Minimum3 years of experience in direct patient care Experience and comfort using a technology platform to support clinicians and provide patient care. Flexibility with learning new technology and leveraging new tools Experience leveraging defined protocols and workflows to triage and manage patient clinical needs Strong organizational skills

Utilize Amwell’s technology platform to monitor and – where appropriate – respond to patient communications leveraging detailed clinical protocols and workflows. Clinical Nurse Associates will have access to and are encouraged to engage the treating clinician where needed. Utilize Amwell’s technology platform to monitor lab results and follow standardized clinical protocols to ensure the patient is informed of results and next steps in care. Follow defined workflows to assist with the submission and oversight of referrals, orders, and prior authorizations. Follow defined workflows to assist clinicians with filling out patient-submitted forms. Provide outreach and follow-up where needed to facilitate a patient’s care. Examples include pharmacy callbacks, record requests from specialists, communication with insurers and more.

US Tech Solutions

Clinical Reviewer Outpatient Utilization Management RN

Posted on:

January 6, 2025

Job Type:

Contract

Role Type:

Utilization Review

License:

RN

State License:

Massachusetts

US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit www.ustechsolutions.com. US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, colour, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

Duration: 4 months Contract (with the possibility of extension) Employment type : W2 License: Unrestricted Massachusetts Registered Nurse (RN) License Required Job Summary: The Clinical Reviewer is a licensed professional (RN preferred) responsible for independently managing a complex caseload of service requests. They determine medical necessity and benefit coverage for Medicaid, Medicare Advantage, and other products. The role requires adherence to compliance guidelines, timely decisions, and collaboration with Precertification and Outpatient Utilization Management teams.

Education: Bachelor’s degree in Nursing preferred. License: Active, unrestricted MA RN license required. Experience: 5+ years in utilization management, case management, or quality assurance preferred; managed care experience desirable. Strong critical thinking, problem-solving, and communication skills. Proficiency with multiple software applications. Ability to work in a fast-paced, complex environment with tight deadlines. Working Conditions: Fast-paced environment with frequent PC and phone use. Flexibility to adjust schedules based on departmental needs.

Perform clinical decision-making for utilization management and benefit determinations. Collaborate with Medical Directors on denials and ensure adherence to processes. Communicate with providers, members, and external agents on case status and determinations. Assist in policy interpretation and quality assurance. Identify trends in utilization management and support appeals processes. Provide input for medical policy development and guidelines. Support onboarding and training of new staff.

Bon Secours Mercy Health

Conduit - License Practical Nurse (LPN) Behavioral Health Transfer Specialist - Remote

Posted on:

January 6, 2025

Job Type:

Full-Time

Role Type:

Behavioral Health

License:

LPN/LVN

State License:

Ohio

At Bon Secours Mercy Health, we are dedicated to continually improving health care quality, safety and cost effectiveness. Our hospitals, care sites and clinicians are recognized for clinical and operational excellence. The Behavioral Health Access Specialist coordinates the acceptance and throughput of behavioral health patients meeting criterial for inpatient admission from one facility to another in a call center environment. This employee performs functions based on defined standards of performance and practice to meet or exceed operational expectations related to transfer center/ access center services. The employee works collaboratively with internal and external partners to facilitate patient access according to mental health needs. The Behavioral Health Access Specialist will foster relationships with referring and receiving facility physicians and employees as well as community agencies in representation of Conduit Health Partners' Mission and Values.

Full Time - Night Shift– shift time subject to change based on need of operation – shift can vary between 4-9 hour long shifts between the hours of 7pm – 7am – rotating every third weekend and holiday

LPN Active license-practical nursing Minimum Qualifications Minimum Years and Type of Experience 1-year mental health intake Other Knowledge, Skills And Abilities Required Mental health disease process, treatment modalities for acute care Other Knowledge, Skills And Abilities Preferred EPIC, telephony systems, typing IT Requirements: Minimum internet speed of primary and secondary work locations is: Download speed of 100Mpbs Upload speed of 20Mbps Many of our opportunities reward* your hard work with: Comprehensive, affordable medical, dental and vision plans Prescription drug coverage Flexible spending accounts Life insurance w/AD&D Employer contributions to retirement savings plan when eligible Paid time off Educational Assistance And much more

Coordinates functions in order to support destination placement for the mental health patient meeting criteria for inpatient admission from potential referral sources to include but not limited to hospitals, clinics, extended care facilities, and physician offices to initiate acceptance and expedite decision making relative to potential access. Proficient in EHR data entry, telephony systems, office systems as required to support operations; ensuring accurate, timely data entry, protection of PHI. Demonstrates the ability to process resulting level of care needs utilizing critical thinking, clinical decision making, and acquired knowledge skills to facilitate placement as requested by referring provider or entity. Uses problem-solving skills to make recommendations that promotes the best potential patient outcome based on clinical information, patient and / or physician preferences, and the capability / capacity of both transferring and receiving facilities. Communicates an accurate clinical presentation of the patient for consulting or accepting provider and caregivers Utilizes effective and professional communication to act as liaison on behalf of patient and client facilities between physicians, hospital staff, and outside agencies. Demonstrates knowledge of regulatory components to include but not limited to EMTALA, Ethics and Compliance, quality initiatives, and HIPAA. Works directly with providers and other healthcare providers at each client facility as well as client footprint facility to ensure timely acceptance and access to appropriate level of care/bed assignment using applicable workflows. Reports risks related to safety, compliance as well as operational inefficiencies using defined Chain of Command in a timely manner and offers recommendations for resolution or improvement if applicable. Participates in process improvement, professional development, peer development, peer review and shared governance. This document is not an exhaustive list of all responsibilities, skills, duties, requirements, or working conditions associated with the job. Employees may be required to perform other job related duties as required by their supervisor, subject to reasonable accommodation.

Wellbox Virtual Care Solutions

LPN - Telehealth (Remote)

Posted on:

January 6, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

LPN/LVN

State License:

Illinois

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; hours may be worked between the hours of 8 am – 6 pm CST, Monday – Friday.

Active Illinois (IL) LPN License. Minimum two years of clinical experience; care coordination experience preferred. Proficient with Electronic Medical Records and Microsoft Office. Excellent communication and problem-solving skills.

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

Vesta Healthcare

Clinical Manager (Remote)

Posted on:

January 6, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Compact / Multi-State

Vesta Healthcare is a specialized medical group focused on people with long-term home care needs. We help these individuals live happier, healthier lives by partnering with their aides and caregivers, as a key part of the care team. We use a combination of virtual care, home-based and mobile technologies, data integrations and partnerships with home care agencies to make the home an integrated setting of care with patients, and their Caregivers at the center. Vesta is the Roman name for the goddess of home, hearth and family. She is the caregiver. Often unseen yet greatly revered, she puts others' needs ahead of her own, keeping the hearth warm so the home and family can function. We see Caregivers and recognize the power and potential they embody. More than just assistance, Caregivers are eyes, ears and hands in the home. Caregivers play the role of Doctor, Nurse, Pharmacist, EMT and more, but without support or guidance. That is where Vesta comes in. Our program provides Caregivers with a personalized clinical team in their pocket. Our team links Caregivers to the people they care for and the other providers involved in their care. It’s an insurance covered benefit, so it’s available to most adults with Caregivers free of charge to them. We seek team members who are passionate about making home the best place it can be for people with home care needs and see the important role Caregivers play. Our team members are collaborative data-driven optimists who always focus on doing what’s best for patients and their caregivers. We see ourselves as being here to improve the quality of life for caregivers and care recipients, allowing them to focus on the important things (like going to the mall with their grandkids).

A nursing leader who is passionate about caring for our members, teammates, and clients and can leverage technology to create new programs, systems, and processes to drive exceptional clinical team performance. Someone who has a proven track record of using data to drive high quality and efficient clinical outcomes. Someone who ideally has experience in chronic care management, remote patient monitoring, and valuable based care of vulnerable populations. Love learning and helping others learn: you’re excited to bring your wisdom and coach others, and you’re equally energized to learn from other’s experience (such as product managers, software engineers, and data scientists), and then continue improving how Vesta does care management as we learn more together. They are comfortable working in an ambiguous environment within an organization that is growing and changing quickly. Curious about changing regulations within the space and how they can be leveraged to create additional revenue streams

Registered Nurse with a compact license (required) Registered Nurse with a New York State nursing license (preferred) Bilingual and fluent in both English AND Spanish (preferred) 4+ years of nursing experience within acute care (required) 2-3 years of experience leading/managing a clinical team of at least 15+ reports overseeing several complex projects simultaneously (required) Familiarity with managed care plans/structure in New York State (required) Experience managing a remote team (preferred) Passionate about our mission to improve people’s lives An ability and humility to roll up your sleeves Detail- and process-oriented, ability to context- and mode-switch easily, fast learner Excellent communication skills, combined with the ability to collaborate across functions and use available tools Self-driven, self-starter and excited to support new technology

Provide leadership, coaching, and development to a multidisciplinary team of individuals performing care management Assist in evaluating capacity planning, hiring, and training of new employees Manage, analyze and deliver productivity measures to the team and higher management while including operational metrics and benchmarks Collaborate with other Managers of Clinical Delivery in ensuring the team is appropriately staffed and find coverage when needed Assist in implementing and educating new clinical programming across our clinical pods Provide clinical oversight and utilize critical thinking skills to support the team in addressing escalated member challenges/concerns Identify inefficiencies and opportunities for quality improvement. Create process improvement to achieve member and clinician satisfaction Track, analyze and manage key performance indicators (KPIs) and metrics for their team Serve as a subject matter expert for chronic care management (CCM), Transitions of Care (TOC) and remote patient monitoring (RPM) Support the development of strategies to help scale the program Collaborate with cross departmental leads in analytics, product/engineering and business operations to drive efficiencies and quality improvement and effectiveness of the clinical team and outcomes Collaborate with Clinical Leadership and Clinical Accounts Liaison to ensure partner needs and expectations are met. Continue to push the boundaries of what technology can do to empower our caregivers and clinicians to improve health outcomes for our patients

Vesta Healthcare

REMOTE Overnight Full Time NY Licensed Nurse Practitioner (NP)

Posted on:

January 6, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

NP/APP

State License:

New York

Vesta Healthcare is a specialized medical group focused today on aging adults with long-term home care needs. We help these individuals live happier, healthier lives by partnering with their aides and caregivers, as a key part of the care team. We use a combination of virtual care, home-based and mobile technologies, data integrations and partnerships with home care agencies to make the home an integrated setting of care with patients, and their Caregivers at the center. Vesta is the Roman name for the goddess of home, hearth and family. She is the caregiver. Often unseen yet greatly revered, she puts others' needs ahead of her own, keeping the hearth warm so the home and family can function. We see Caregivers and recognize the power and potential they embody. More than just assistance, Caregivers are eyes, ears and hands in the home. Caregivers play the role of Doctor, Nurse, Pharmacist, EMT and more, but without support or guidance. That is where Vesta Healthcare comes in. Our program provides Caregivers with a personalized clinical team in their pocket. Our team links Caregivers to the people they care for and the other providers involved in their care. It’s an insurance covered benefit, so it’s available to most adults with Caregivers free of charge to them. We seek team members who are passionate about making home the best place it can be for people with home care needs and see the important role Caregivers play. Our team members are collaborative data-driven optimists who always focus on doing what’s best for patients and their caregivers. We see ourselves as being here to improve the quality of life for caregivers and care recipients, allowing them to focus on the important things (like going to the mall with their grandkids).

Certified and licensed as a Nurse Practitioner in good standing in the state of New York (required) Master’s or doctoral degree from an accredited institution for nurse practitioners (required) Medicare participation and ability to have the company bill for services on your behalf (required) Certification from ANCC (or equivalent) as an Adult, Family, Geriatric, and/or Acute Nurse practitioner (required) 1+ years of Nurse Practitioner Experience (required), qualified for independent practice in your licensed jurisdiction (preferred) 1+ years of telephonic triage or equivalent experience (required) 2+ years of clinical experience working with complex adult populations (required) Ability to practice independently with little clinical support (required) Comfort using technology like Google Suite, multiple EMRs, Slack (required) The ability to work remotely and has a private area with a computer in their home/workspace (required) Experience working in home care and/or family medicine, geriatrics (preferred) Experience working within a clinical team environment Strong organizational skills, including the ability to prioritize Passionate about our mission to improve people’s lives Comfortable in a dynamic and always evolving startup environment

Work overnights (11pm ET - 8am ET) Monday to Friday with your last shift ending 8am on Saturday morning Triage inbound calls from our members and assess actions to be taken Conduct care coordination and recommend/identify cost effective research based treatment and intervention Utilize strong clinical skills in physical assessment and chronic disease management for at risk adults and apply member specific Care Management and individualized care planning Serve as a consulting resource on care management practice as needed Attend meetings, training sessions as needed Possess a strong knowledge of clinical procedures, standards and quality control checks Possess a strong knowledge of medical conditions, interventions and treatment Provide members, caregivers and facility education Monitor the quality of member’s care and updates plan of care