Empassion Health

Care Coordinator - LPN - Fully Remote

Posted on:

February 14, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

LPN/LVN

State License:

New York

Empassion is one of the most impactful and exciting start ups in health care. We are focused on improving the experience and lowering costs for seniors at end of life. Specifically, we provide palliative and hospice care for seniors with serious illness and high risk of an over-medicalized death. This population is highly neglected in the current market. Empassion clients are payers and risk-bearing entities and we work with community palliative and hospice partners to deliver superior outcomes. We are live today across 44 states and growing rapidly. Empassion is a hybrid remote/in-person company, with headquarters in NYC. We prioritize asynchronous work and communication but are quick to get on a call or Zoom

We are hiring a Care Coordinator/LPN to work within our contact center, including directly interfacing with patients, providers, and families in our palliative care program managing day to day functions such as educating patients by phone and scheduling them for palliative appointments. Working with clinical files to close out palliative visits and enter notes into the systems. The Care Coordinator/LPN will spend part of the day on the phones and part of the day doing administrative work. Looking for someone with an empathetic ear and strong multitasking skills to ensure our patients are getting the care they need and deliver on our mission of getting them more good days. The Care Coordinator/LPN will join our Central Operations team, looking for a candidate with deep healthcare, clinical and contact center experience. Empassion will provide in-depth training and resources to ensure that you will be successful in this role. This position is fully remote, but our team communicates regularly on Zoom and Slack.

Minimum 3+ years as an LPN Minimum 3+ years of reading and updating clinical notes Minimum of 1+ years of relevant work experience in a customer service call center Able to receive calls from patients, caregivers, and providers Bring with you strategic thinking to get the job done Enthusiastic about providing an outstanding experience for Empassion Health’s patients and their caregivers Passionate about making a change in the healthcare experience: you love to serve and make a difference, and you go the extra mile for patients, by insisting on the highest standards from the Care Coordinators Strong communication and written skills Detailed oriented Comfortable working with technology and in a dynamic, startup environment Secure Wi-Fi connectivity Spanish-speaking a plus but not required

Help the patient understand the value of palliative care Ensure you spend time connecting to the patients in need of the program to the palliative care providers Answer questions that patients have about palliative care or the program more broadly Confirm patient encounters are documented and triage of patient needs has taken place Review follow up with patients to ensure they are receiving high-quality care from Empassion’s network of providers Review and close cases that are completed daily Assist your supervisor by balancing your time between clinical triage and patient calls

CVS Health

Utilization Management Nurse Consultant - Remote

Posted on:

February 14, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

New York

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.

Utilization Management is a 24/7 operation and work schedule may include weekends, holidays and evening hours.

Required Qualifications: 3+ years of acute experience as a Registered Nurse Must have active current and unrestricted RN licensure in state of residence 1+ year(s) of MS Office suites experience Preferred Qualifications: Managed Care experience Medicare experience Education: Associates degree required BSN preferred

Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedures to render precertification coverage determinations or make recommendations to Medical Directors Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs Identifies opportunities to promote benefit utilization Typical office working environment with productivity and quality expectations Sedentary work involving periods of sitting, talking, listening Work requires sitting for extended periods, talking on the telephone and typing on the computer Ability to multitask, prioritize and effectively adapt to a fast paced changing environment Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding Effective communication skills, both verbal and written

Northeast Healthcare Recruitment, Inc.

Telemedicine Nurse Practitioner - Multiple State Licenses

Posted on:

February 14, 2025

Job Type:

Part-Time

Role Type:

Primary Care

License:

NP/APP

State License:

Compact / Multi-State

Looking for a Flexible Telemedicine job where you can work from home and control your schedule? We’re seeking skilled clinicians with multiple state licenses to provide virtual care across tele-urgent care, medical weight loss, primary care, and specialty services. ***If you do not have at least 8+ active state licenses- Do not apply, unless you can speak Spanish

Licensure: We have needs in all states! Active non-restrictive APRN licensure in 8 States minimum, or less if you can speak Spanish Experience: 1+ years of experience in primary or urgent care, MUST have experience with weight loss Board Certification: ANP, FNP, AGNP (must be able to see all patients 18+) Availability: Ability to work 20 hours per week

Provide virtual care across tele-urgent care, medical weight loss, primary care, and specialty services.

CareCentrix

Director – UM PAC

Posted on:

February 14, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Conneticut

The Director of Utilization Management for the Post- Acute Care (PAC) Program will provide leadership and oversight of clinical and utilization management (UM) activities for programs in accordance with company policies and procedures. Works with the CareCentrix operations management team to develop, implement and manage effective UM initiatives designed to position CareCentrix as an industry leader for excellent clinical outcomes by obtaining optimal financial results for CareCentrix and their customers. Supports and oversees Utilization Management activities to assure positive outcomes and that expectations are exceeded. Assures that UM activities are compliant with regulatory and accreditation agency standards and client specific requirements. Collaborates with Medical Directors, Product, Account Management, Clinical Management, Client Services and Health Plans in the development of clinical and UM program initiatives. Works with CCX senior leadership Clinical Management to develop, direct and implement best practices for utilization and authorization management. Sets priorities and goals ensuring utilization performance, compliance and quality standards are met. Assists with the development of reporting strategies and implements plans to ensure all outcomes are within stated objectives. Ensures appropriate staff training for all new clinical initiatives and monitors outcomes/performance. Directs and implements performance improvement activities to achieve desired goals when necessary. Ensures that information is documented/identified enabling the collection and root cause analysis of data to identify opportunities for improvement related to clinical programs. Participates in educating associates, management, customers, payers and physicians in best practices and protocols of care that drive excellent clinical performance and exceptional quality outcomes as well as optimizing financial results. Is the primary point of contact and responsible individual in internal and external audits of UM activities and outcomes.

Bachelor or Master’s degree in Healthcare field preferred Active RN licensure required with a minimum of 8 years of clinical experience Licensed professionals are required to possess a current license from their home state without restrictions Wide-ranging knowledge and experience with utilization management and accrediting agency standards Inclusive of industry standard guidelines such as Interqual, MCG and CMS Advanced education highly desired with additional training in the applicable clinical field Experience with program development desired Experience with data analysis and the design and use of clinical measurement systems Excellent verbal/written communication and presentation skills also required

Possess excellent communication (verbal/written), organizational and interpersonal skills Manage multiple tasks, be detail oriented, be responsive, and demonstrate independent thought and critical thinking Support and oversees Utilization Management activities to assure positive outcomes and that expectations are exceeded Assure that UM activities are compliant with regulatory and accreditation agency standards and client specific requirements Collaborate with Medical Directors, Product, Customer Service Center (CSC), Account Management, Clinical Management, Client Services and Health Plans in the development of clinical and UM program initiatives Work with CCX senior leadership Clinical Management to develop, direct and implement best practices for utilization and authorization management Set priorities and goals ensuring utilization performance, compliance and quality standards are met Assist with the development of reporting strategies and implements plans to ensure all outcomes are within stated objectives Ensure appropriate staff training for all new clinical initiatives and monitors outcomes/performance Collaborate with account management, client services and network management to provide education and training to referral sources and providers Direct and implements performance improvement activities to achieve desired goals when necessary Ensure that information is documented/identified enabling the collection and root cause analysis of data to identify opportunities for improvement related to clinical programs Participate in educating associates, management, customers, payers and physicians in best practices and protocols of care that drive both excellent clinical performance as well as optimizing financial results Be the primary point of contact and responsible individual in internal and external audits of UM activities and outcomes Participate in client meetings (JOCs) and provider/market meetings as the senior UM leader Participate in the UM management team as a leader in the organization Encourage and fosters an environment of teamwork, communication, collaboration and readiness for change Set an example for excellence, professionalism, accountability, innovation, compassion, integrity, and honesty Interview, selects, manages and develops new and existing associates to develop a high-performing team with opportunities for growth in the organization. Participates and is timely and compliant with the performance review and management process Conduct regular team meetings and meetings with direct reports Administer CareCentrix employee terminations, ensures appropriate paperwork is processed, conducts exit interviews, and monitors/tracks reasons for termination Participate in special projects and performs other duties to make the operation successful

Hippocratic AI

Nurse Reviewer - RN

Posted on:

February 14, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

California

We are a passionate group of medical professionals and engineers dedicated to bringing safety to AI within healthcare. Our mission is to ensure that AI applications in patient-facing scenarios are safe, empathetic, and unbiased.

We are seeking licensed nurses with diverse patient care experience to help make AI safe for patient-facing applications. In this task-based role, you will leverage your unique frontline experience and knowledge to supervise patient interactions across various dimensions, including medical safety, empathy, and bias.

Requirements: Registered Nurse Minimum 3 years of care management experience Intermediate skill level in G Suite products Excellent time management skills Strong attention to detail Ability to work 20-30 hours per week Weekend/Evening hours Preferred Qualifications: Spanish-speaking Experience in AI or healthcare technology

Supervise patient calls and interactions with AI systems Perform error and quality reviews of AI-patient communications Assess AI performance in terms of medical safety, empathy, and potential bias Provide feedback and insights to improve AI systems based on your nursing expertise Collaborate with our team of medical professionals and engineers to enhance AI safety in healthcare

IntellaTriage

Remote Hospice Triage RN - FT Baylor Shift (Sat, Sun & Monday)

Posted on:

February 14, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

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

We invite you to join our growing team! IntellaTriage Nurses enjoy the benefits of working from home, providing care, without the stress and expense of commuting each day! **MUST have or be willing to obtain a Compact RN license **MUST live in/work from a Compact US state **Experience with end-of-life care is strongly preferred **Must have high speed internet **Must be tech savvy, enjoy a fast-paced environment, and have keyboard competence **Full-time Baylor nurses only work 6 days out of a 14-day pay period Baylor schedule: Sat & Sun 4:30AM – 4PM, Mon 3:30p-12a

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

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

IntellaTriage

Remote Hospice Triage RN- PT 1 shift 6p-12a rotating Sat & Sun 7:30-4p

Posted on:

February 14, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

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

We invite you to join our growing team! IntellaTriage Nurses enjoy the benefits of working from home, providing care, without the stress and expense of commuting each day! **MUST have or be willing to obtain a Compact RN license **MUST live in/work from a Compact US state **Experience with end-of-life care is required **Must have high speed internet **Must be tech savvy, enjoy a fast-paced environment, and have keyboard competence **Part-time nurses only work 4 days out of a 14-day pay period Part- time schedule: Work a minimum 1 evening shift weekly 6p-12a CST (shift times are set/ week day flexes) Work every other weekend, both Saturday and Sunday 7:30a-4p CST

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

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

Tailored Management

Prior Authorization Nurse

Posted on:

February 14, 2025

Job Type:

Contract

Role Type:

Behavioral Health

License:

LPN/LVN

State License:

Ohio

Job Title: Prior Authorization Nurse Location: 100% Remote Schedule: Monday - Friday, 8:00 AM - 5:00 PM CST (Must work every 6th weekend, with days off during the week) Training: Same hours as the regular schedule Initial Assignment Length: 3-4 months contract with potential for extension or conversion based on performance and business need Pay Range: Up to $27 per hour (final pay rate pending) Start Date: 02/17/2025 (tentative) Benefits: Weekly pay, health, dental, and vision insurance available Join a global healthcare leader focused on improving the health, well-being, and peace of mind of those we serve. We’re looking for a Prior Authorization Nurse to join our team and make a difference!

Non-Negotiable Skills: Excellent computer skills Prior Authorization experience Strong attention to detail Required: Active, unrestricted LPN or LVN license

Deliver professional activities in the Case Management job family Coordinate care for assigned members, ensuring their needs are met Interview members and relatives to gather relevant social and medical history Serve as a liaison between primary care teams, members, and outside agencies Provide standard professional advice and support, including reports and analyses

Empo Health

Remote Patient Monitoring LPN Contractor

Posted on:

February 14, 2025

Job Type:

Contract

Role Type:

Telehealth

License:

LPN/LVN

State License:

Compact / Multi-State

Founded in 2020 and based in Silicon Valley, Empo Health is a seed-funded, VC-backed, and NSF-supported startup developing revolutionary in-home health monitoring products. We’re assembling a contracted team of experienced Remote Patient Monitoring LPNs to provide clinical services to our customer podiatrists. Empo Health’s first product, the Empo Footprint, is an in-home imaging scale that helps doctors and patients monitor for early signs of diabetic foot ulcers. After running a successful pilot study with results that exceeded all expectations, the team is hard at work preparing the world-class device and associated Empo Remote Health Link service for launch in a few months. This is a hands-on role: you will monitor patient data and work with a supervising podiatrist on the practice side, as well as an operations supervisor on the Empo side. Your work will directly contribute to detecting the diabetic foot ulcers that impact millions of at-risk patients, potentially preventing amputations and saving lives. If you’re passionate about remote care and helping prevent the worst outcomes for diabetic patients, then we’d love to hear from you!

This role will be a part-time contracted position with the opportunity to grow hours to near-full-time. LPNs will be contracted by Empo and managed by Empo, but will be assigned under the general supervision of customer podiatrists to provide clinical services.

Are accredited as a Licensed Practical Nurse in Maryland Have experience with working with diabetic patients Learn new clinical protocols quickly Communicate well with both patients and providers Have excellent English verbal and written communication skills Are passionate about improving access to high quality healthcare Are tech-savvy with strong proficiency in using various digital tools and software beyond Microsoft Office. You should be comfortable with tasks such as converting files (e.g., Word to PDF), using cloud-based software and online portals, downloading and installing apps, and uploading documents to web platforms. Have an interest in learning new technologies Have a laptop that can run modern software and browsers Even better if you: Have a compact license Have experience working with diabetic foot complications Have experience with remote patient monitoring or telehealth Can communicate effectively verbally or in writing in other languages Have clinical research / GCP experience

Monitoring foot images and weight data collected by the Empo Footprint and displayed in the Empo Remote Health Link web portal daily. Escalating critical findings to the podiatrists and/or patients as necessary. Conducting routine patient check-ins and adherence reminders, ensuring proper documentation is completed for each check-in. Check-ins will occur as frequently as once per month for a caseload of up to 50 patients initially. Providing additional outreach to patients who have questions, experience changes in their health, or encounter issues with their Empo devices, ensuring timely resolution, support, and accurate documentation of all interactions. Fielding questions from patients and delegating to other members of the Empo team as needed Interacting with customer podiatrists

Molina Healthcare

Care Review Clinician, Inpatient Review (RN): Remote, CALIFORNIA ( 3 - 12 shift )

Posted on:

February 14, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

California

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

EMERGENCY ROOM ADMISSIONS REVIEW NURSE 1 opening for 12 hour NIGHT SHIFT: 7:30PM (in the evening) - 08:30AM (in the morning) PACIFIC HOURS NON EXEMPT, 3 days a week will rotate. 1 opening for 12 hour DAY SHIFT 8:30AM (in the morning) - 7:30PM (in the evening) PACIFIC HOURS NON EXEMPT, 3 days a week will rotate. TRAINING SCHEDULE WILL BE Monday thru Friday 8:30AM to 5:30PM PACIFIC throughout a 2 - 3 month training and then will move to a 3 day/12 hour shift after training is completed. Training hours are mandatory. This position supports our California Health Plan. Candidates can live anywhere in the USA if they have a valid CALIFORNIA RN license and must work the Pacific Time Zone shift hours as posted. Job Summary: Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.

Required Education: Graduate from an Accredited School of Nursing. Required Experience: 3+ years hospital acute care/medical experience. Required License, Certification, Association: Active, unrestricted State Registered Nursing (RN) license in good standing. Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation. CA Qualifications: Licensed within the state of California Preferred Education: Bachelor's Degree in Nursing Preferred Experience: Previous work experience in hospital Acute care including 2 years in ER or ICU Previous work experience with InterQual or MCG guidelines

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

Humana

Associate Director, UM Nursing

Posted on:

February 14, 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.

Humana Healthy Horizons is seeking an Associate Director, Utilization Management Nursing, who utilizes clinical nursing skills to support the coordination, documentation, and communication of medical services and/or benefit administration determinations. The Associate Director, Utilization Management Nursing, requires a solid understanding of how organization capabilities interrelate across department(s) The Associate Director, Utilization Management Nursing, 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 no disciplinary action. 3+ years of management/leadership experience. 4+ years of utilization management experience, preferably in prior authorization. Experience leading UM trend initiatives. Experience with Medicaid plans. Advanced Proficiency in Microsoft Office Products (i.e. Word, Excel, PowerPoint, Teams). Proven problem-solving skills (i.e. adept at research, analysis, and data driven decision making/generating creative solutions). Ability to operate in a fast-paced environment under tight deadlines and in ambiguous situations. Must work hours within the eastern standard time zone. Preferred Qualifications: Licensed Registered Nurse (RN) with compact license with no disciplinary action. Certified Managed Care Certification. Experience leading multi-state teams. Behavioral health UM experience. Bachelor's Degree. Work at Home Requirements: 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. Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job. Employees 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. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

The Associate Director coordinates and communicates with providers, members, or other parties to facilitate optimal care and treatment. Decisions are typically related to identifying and resolving complex technical and operational problems within department(s) and could lead multiple managers or highly specialized professional associates.

Froedtert Health

RN UTILIZATION REVIEW, FCH - ENTERPRISE QUALITY CDI/UR/DM

Posted on:

February 14, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Compact / Multi-State

The Froedtert & the Medical College of Wisconsin regional health network is a partnership between Froedtert Health and the Medical College of Wisconsin supporting a shared mission of patient care, innovation, medical research and education. Our health network operates eastern Wisconsin's only academic medical center and adult Level I Trauma center engaged in thousands of clinical trials and studies. The Froedtert & MCW health network, which includes ten hospitals, nearly 2,000 physicians and more than 45 health centers and clinics draw patients from throughout the Midwest and the nation.

EXPERIENCE DESCRIPTION: Minimum of 3 years of acute care nursing experience is required; Prior utilization management or case management experience is required. A minimum of 5 years of acute care nursing experience is preferred. Utilization of Interqual, MCG care web QI or Indicia evidence based guidelines is strongly preferred. EDUCATION DESCRIPTION: Professional knowledge of nursing theory and practice at a level normally acquired through completion of a program at an accredited School of Nursing is required. Bachelor's Degree in Nursing is preferred. SPECIAL SKILLS DESCRIPTION: Knowledge of Medicare inpatient only surgical list, Medicare guidelines for admission, working DRG, and some familiarity with hospital coding is preferred. LICENSURE DESCRIPTION: Requires current state of Wisconsin Registered Nurse License or a Multi-state Nursing License from a participating state in the NLC (Nurse Licensure Compact). MCG certification is required within 18 months of hire. Accredited Case Manager (ACM) or Certified Case Manager (CCM) certification preferred.

Assumes responsibility for assessing a patient's clinical status on admission and daily to determine the appropriate admission status type and level of care. Refers cases to the physician advisor, PA moonlighter, for a second level review as needed. Facilitates communication with service based multidisciplinary team as it relates to the patient and identified treatment plan. Works in accordance to established policies and procedures to ensure optimal patient outcomes. Has the ability to work with variable service lines and with multiple care teams.

HonorHealth

RN UTILIZATION REVIEW SPECIALIST Per Diem

Posted on:

February 14, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Compact / Multi-State

Looking to be part of something more meaningful? At HonorHealth, you’ll be part of a team, creating a multi-dimensional care experience for our patients. You’ll have opportunities to make a difference. From our Ambassador Movement to our robust training and development programs, you can select where and how you want to make an impact. HonorHealth offers a diverse benefits portfolio for our full-time and part-time team members designed to help you and your family live your best lives. Visit honorhealth.com/benefits to learn more. Join us. Let’s go beyond expectations and transform healthcare together. HonorHealth is one of Arizona’s largest nonprofit healthcare systems, serving a population of five million people in the greater Phoenix metropolitan area. The comprehensive network encompasses nine acute-care hospitals, an extensive medical group with primary, specialty and urgent care services, a cancer care network, outpatient surgery centers, clinical research, medical education, a foundation, an accountable care organization, community services and more. With nearly 16,000 team members, 3,700 affiliated providers and close to 1,100 volunteers dedicated to providing high quality care, HonorHealth strives to go beyond the expectations of a traditional healthcare system to improve the health and well-being of communities across Arizona. Learn more at HonorHealth.com.

The Utilization Review RN Specialist reviews and monitors utilization of health care services with the goal of maintaining high quality cost-effective care. Ensures appropriate level of care through comprehensive review for medical necessity of extended stay, outpatient observation, and inpatient stays and the utilization of ancillary services. Responsible for coordinating and conducting medical necessity reviews for all Medicare, AHCCCS, Self-pay, and all other payers, upon admission and concurrently throughout the admission.

Education: Associate's Degree in Nursing from an accredited NLN/CCNE institution Required Experience:3 years Registered Nurse in an acute care setting. Required 1 year experience in UR/UM or Case Management Required Licenses and Certifications: Registered Nurse (RN) State And/Or Compact State Licensure Required

Reviews clinical documentation and facilitates modifications (as needed) to ensure that documentation accurately reflects the level of service rendered and severity of illness (in compliance with government and other regulations) for all patients. Performs initial and concurrent reviews on all patients entering the health care continuum. Facilitates the delivery of services to patients and families through effective utilization of available resources. Performs medical record reviews, as required by payer. Interfaces with Care Management team to provide information regarding quality outcome measurements (such as timeliness and appropriateness of services). Collaborates with physicians, case managers, payers and others to appeal individual denials and trended issues related to contract guidelines. Works with medical records, finance and physician groups to develop systems to facilitate complete documentation for data reporting purposes. Initiates chart reviews, conducts follow-up reviews, and rounds on patients to ensure continuity of UR reviews. Maintains a system to identify admissions with specific diagnosis / DRG classifications or other categories of admissions. Notifies attending physicians and house staff or other appropriate staff of documentation issues requiring clarification. Determines qualifications for hospital level of care based on set criteria. Performs other duties as assigned.

Cook Children's Health Care System

RN Case Manager - Health Plan

Posted on:

February 13, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Texas

Cook Children's Health Plan provides vital coverage to nearly 120,000 people in low-income families who qualify for government-sponsored programs in our six county service region. Cook Children's Health Plan provides health coverage for CHIP, CHIP Perinatal, STAR (Medicaid) and STAR Kids Members in the Tarrant county service area. The counties we serve includes Tarrant, Johnson, Denton, Parker, Hood and Wise.

Performs case management activities across the continuum of care in order to promote and facilitate quality, cost effective outcomes and minimize fragmentation of health care delivery for the assigned member population. The Health Plan Case Manager identifies and coordinates short and long term needs of catastrophically/chronically ill and/or injured children/adolescents and their families.

Associate degree in nursing, BSN preferred. Three (3) years experience of any combination of experiences working in/with case management, care coordination, utilization review, patient intake, discharge planning and troubleshooting fund resources, quality assurance, clinical pathways, continuous quality improvement, or state and federal health plans or commercial insurance plans in a clinical or managed care environment. Competent in Microsoft Office software, general computer knowledge and ability to type and use computers required. Must be familiar with various community resources and charitable organizations. Must be able to adapt to changing healthcare environments and work with all members of the healthcare team to achieve positive outcomes. Must have experience using or navigating electronic medical records (e.g., EPIC, Meditech, Healthy Planet, etc.). Bilingual (English/Spanish) preferred. Licensure, Registration, and/or Certification: Current RN license from Texas Board of Nursing required Certification in Case Management (CCM) preferred.

This RN Case Management position will work remotely to perform case management activities across the continuum of care in order to promote and facilitate quality, cost-effective outcomes and minimize fragmentation of health care delivery for the assigned member population. The Health Plan Case Manager identifies and coordinates short and long-term needs of catastrophically/chronically ill and/or injured children/adolescents and their families. Members may have behavioral health conditions, pediatric conditions, high-risk pregnancy, targeted chronic conditions, or need transition of care services. The Case Manager acts as a member advocate, facilitates communication and coordinates care with physicians, clinics, hospital facilities, family, caregivers and other healthcare providers and implements creative solutions to meet members healthcare needs without compromising quality outcomes. Expectations also include supporting health risk reduction through behavioral change and patient education. Case Management activities are completed primarily by telephone.

Teladoc Health

Nurse Member Advocate

Posted on:

February 13, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

New York

Teladoc Health is a global, whole person care company made up of a diverse community of people dedicated to transforming the healthcare experience. As an employee, you’re empowered to show up every day as your most authentic self and be a part of something bigger – thriving both personally and professionally. Together, let’s empower people everywhere to live their healthiest lives.

The Critical Care Member Advocate plays a crucial role in a cross-functional clinical team, consisting of both clinical and support staff, to deliver the Expert Medical Opinion for critical care cases. This role ensures the effective utilization of diverse internal and external healthcare resources to enhance health outcomes. The Critical Care Member Advocate is responsible for supporting and interacting with members requesting a virtual second medical opinion, with a focus on maintaining the highest clinical quality and ensuring member and client satisfaction.

Active Registered Nurse license BSN 5+ years recent clinical experience in ICU/PICU/Critical Care (Step down Unit) Ability to work a flexible schedule to provide evening and/or weekend on-call coverage Quality driven with a focus on flawless customer service Proficiency using technology and software including Microsoft Word and Outlook Ability to understand and learn CRM and case management systems Ability to work independently and recognize when escalation is warranted Strong organizational skills: ability to multitask and manage competing priorities Outstanding team player and strong interpersonal skills with a sense of empathy Qualifications Preferred for Position: MSN (Masters of Nursing) Preferred Bilingual-Spanish Speaking a plus

Serve as the primary case owner of the critical care expert medical opinion case. Provide support to clinical team partners, support staff and members (including family members) to address inquiries, provide guidance in a timely manner as needed and in accordance with service-level agreements (SLA). Obtain and document a comprehensive health history by leading members through a systematic and dynamic intake assessment to capture all relevant data about current condition and health history. Ensure accurate case documentation throughout the life of the case. Identify and collect relevant medical data. Provide clear, concise communication to members, internal and external partners. Conduct daily follow-ups and set appropriate member expectations. Utilize the company’s proprietary database to match the most appropriate expert to the case. Use clinical judgment in the review of complex medical issues to ensure accuracy of clinical summaries and expert reports.

Adventist HealthCare

Case Manager RN (Remote), Day Shift, Utilization Management

Posted on:

February 13, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Maryland

As a faith-based organization, with over a century of caring for the communities in the Maryland area, Adventist HealthCare has earned a reputation for high-quality, compassionate care. Adventist HealthCare was the first and is the largest healthcare provider in Montgomery County. If you want to make a difference in someone’s life every day, consider a position with a team of professionals who are doing just that, making a difference.

Remote If you are a current Adventist HealthCare employee, please click this link to apply through your Workday account. Adventist HealthCare seeks to hire an experienced Case Manager, RN for our Utilization Management department who will embrace our mission to extend God’s care through the ministry of physical, mental, and spiritual healing.

Proficient in Standard Business Applications, such as word processing, spreadsheets, Internet, email, and other applications Strong problem-solving and analytical skills Conflict resolution and crisis management skills Good verbal and writing/documentation skills Able to handle a multi-task environment Strong customer service skills Ability to exercise sound judgment and maintain confidentiality Ability to work independently and handle multiple tasks at one time Minimum formal education required, including degree level (e.g. Bachelor’s) and type/field (e.g. business, health care, etc.) Bachelor’s degree in Nursing (BSN) or Experience: Minimum years of experience required, and what type of experience qualifies Minimum of 2 years' experience in an acute hospital or acute rehabilitation setting Supervisory/Management Experience Minimum years of supervisory/management experience required Certification and/or Licensure Any required certifications or licensures required Maryland RN license

Develops treatment programs by setting schedules and routines; coordinating services being provided; including transportation. Monitors cases by verifying clients' attendance; and observing and evaluating treatments and responses. Maintains clients' records by reviewing case notes and logging events. Tracks clients' progress by conducting weekly interdisciplinary meetings and evaluations. Prepares patient discharge by reviewing discharge plans and coordinates discharge and post-discharge requirements. Answers patient questions about their care, treatment plans, illness progression, and all other issues. Monitor and adjust patient statuses based on changing needs and conditions. Provides individual and group counseling to patients and families.

Inova Health System

Registered Nurse (RN) Oncology Phone Triage

Posted on:

February 13, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Virginia

We are Inova, Northern Virginia’s leading nonprofit healthcare provider. Every day, our 24,000+ team members provide world-class healthcare to the communities we serve. Our people are the reason we're a national leader in healthcare safety, quality and patient experience. And from best-in-class facilities to professional development opportunities, we support them at every step. At Inova, we're constantly striving to be ever better — to shape a more compassionate future for healthcare.

Inova Schar Cancer Institute is looking for a dedicated Phone Triage Registered Nurse to join the team. This role will be full-time day shift from Monday – Friday and fully remote. Our nurses work five 8-hour shifts and our clinic is open from 8:00 am to 5:00 pm. No weekends, no holidays, no call. The Inova Schar Cancer Institute is a state-of-the-art cancer center in the Washington, DC metro area designed to bring healing and hope to every patient. Inova Schar gives patients unmatched logistical, clinical and emotional support. Our team of nationally renowned doctors, specialists, surgeons, genetic counselors, nurses and caregivers are backed by the latest in drug discovery, clinical trials, research and advanced treatments. Together, we are dedicated to delivering the best quality cancer care, from diagnosis to survivorship. This is a fully remote position Remote Eligibility: This position is eligible for remote work for candidates residing in the following states – AL, AZ, DC, DE, FL, GA, KY, ME, MD, MO, NC, OH, PA, SC, TN, TX, UT, VA, WV Inova is consistently ranked a national healthcare leader in safety, quality and patient experience. We are also proud to be consistently recognized as a top employer in both the D.C. metro area and the nation.

A minimum of 1 year of Registered Nurse clinical experience. Education: BSN or ADN - If ADN then complete BSN within 5 years of start date BLS for Healthcare Provider Certification from the American Heart Association required RN licensed, and eligible to practice in the Commonwealth of Virginia. Proficient in English, strong verbal and written communication skills. Exceptional interpersonal skill and the ability to display a caring demeanor towards others. Proficient computer skills required.

The Registered Nurse provides knowledgeable and caring clinical practice and care coordination through an understanding of patients, families, nurses and healthcare delivery teams. Consistently provides safe and therapeutic care in a holistic and systematic way while incorporating differences into the provision of care and conducting all patient care in a patient/family centered manner. Integrates knowledge, skills and experiences to meet the needs of patients and families throughout the continuum, to include patient and family education. Communicates effectively and works cooperatively with others while having respect for and an understanding of other clinical disciplines. Determines processes for delivery of care from direct patient/family communication, technology and other healthcare team member collaboration.

Syneos - Clinical and Corporate - Prod

Research Nurse- St. Louis, MO

Posted on:

February 13, 2025

Job Type:

Part-Time

Role Type:

Clinical Operations

License:

RN

State License:

Missouri

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) PLEASE NOTE This role will require you to travel, a driving license and access to a vehicle is essential.

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

CVS Health

Care Management Associate

Posted on:

February 13, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

None Required

State License:

Louisiana

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 Care Management Associate (CMA) role is a full time remote telework position. Qualified candidates must reside in Louisiana. This position manages enrollment for foster, child and family welfare population health members, and carries a caseload. The Care Management Associate supports comprehensive coordination of medical services including Care Team intake, screening and supporting the implementation of Wellness Plans to promote effective utilization of healthcare services. This position promotes/supports quality effectiveness of healthcare services.

Must reside in Louisiana. 2-4 years’ experience in healthcare field or working with foster, child and family welfare populations (e.g., experience in a medical office, hospital setting, case worker in community health setting). Effective communication, telephonic and organization skills with ability to be agile, managing multiple priorities at one time, and adapting to change with enthusiasm. Demonstrates ability to meet daily metrics with speed, accuracy and a positive attitude. Strong customer service skills to coordinate service delivery including attention to customers, sensitivity to issues, proactive identification and resolution of issues to promote positive outcomes for members, adhering to care management processes (to include, but not limited to, privacy and confidentiality, quality management processes in compliance with regulatory, accreditation guidelines, company policies and procedures). Completes documentation of each member call in the electronic record, thoroughly completing required actions with a high level of detail to ensure compliance requirements are met with efficiency. Works independently and competently, meting deliverables and deadlines while demonstrating an outgoing, enthusiastic and caring presence telephonically. Ability to effectively participate in a multi-disciplinary team including internal and external participants. 2+ years demonstrated proficiency with personal computers, keyboard and multi-system navigation, and MS Office Suite applications (Outlook, Word, Excel, SharePoint, etc.) Flexibility to work occasional nights and weekends outside of standard business hours which can span from 8:00 am to 8:00 pm. Education: High School Diploma or G.E.D. Please be aware that if changes have been made to core requirements (Required Qualifications or Education) that you will need to keep your HR Business Partner informed. Should you have any questions or need to make any amendments to the information listed above, please reach out to your Talent Acquisition Partner immediately. Thank you in advance.

Responsible for initial review and triage of Care Team tasks. Manages population health member enrollment for child and family welfare. Manages a low tier member caseload. Development of wellness plans, providing community resources, reviewing gaps in care, administering health questionnaires, and other targeted child welfare goals applicable to population health. Completes outbound calls to identify and engage appropriate community resources. Responsible for initial review and triage of Care Team tasks. Screens patients using targeted intervention business rules and processes to identify needed medical services, make appropriate referrals to medical services staff and coordinate the required services in accordance with the benefit plan. Monitors non-targeted cases for entry of appropriate discharge date and disposition. Identifies and refers outlier cases (e.g., length of stay) to clinical staff. Identifies triggers for referral into Aetna's Case Management, Disease Management, Mixed Services, and other Specialty Programs. Utilizes Aetna systems to build, research and enter member information, as needed. Supports the development and implementation of care plans. Coordinates and arranges for health care service delivery under the direction of nurse or medical director in the most appropriate setting at the most appropriate expense by identifying opportunities for the patient to utilize participating providers and services. Promotes communication, both internally and externally to enhance effectiveness of medical management services (e.g., health care providers, and health care team members respectively). Performs non-medical research pertinent to the establishment, maintenance and closure of open cases. Provides support services to team members by answering telephone calls, taking messages, researching information and assisting in solving problems. Adheres to compliance with policies and regulatory standards. Maintains accurate and complete documentation of required information that meets risk management, regulatory, and accreditation requirements. Protects the confidentiality of member information and adheres to company policies regarding confidentiality. May assist in the research and resolution of claims payment issues. Supports the administration of the hospital care, case management and quality management processes in compliance with various laws and regulations, URAQ and/or NCQA standards, Case Management Society of America (CMSA) standards where applicable, while adhering to company policy and procedures. Manage population health member enrollment for child and family welfare. Development of Wellness Plan, providing community resources, reviewing gaps in care, administering health questionnaires, and other targeted child welfare goals applicable to population health.

Molina Healthcare

Care Review Clinician, Inpatient Review (RN) Remote in New York

Posted on:

February 13, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

New York

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

Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service. We are seeking a candidate with a RN licensure, UM and Inpatient Review experience. The Care Review Clinician must be able to work independently in a high-volume environment. Candidates with managed care organization (MCO) and NYS Medicaid guidelines experience are highly preferred. Further details to be discussed during our interview process. Remote- requires NY RN license Work schedule MONDAY - THURSDAY 8:00 AM to 5:30 PM EST. SUNDAY 10:00AM - 2:00PM EST, rotating weekend and holiday coverage- 2 hour shifts.

Required Education: Graduate from an Accredited School of Nursing. Required Experience: 3+ years hospital acute care/medical experience Required License, Certification, Association: Active, unrestricted State Registered Nursing (RN) license in good standing. Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation. Preferred Education: Bachelor's Degree in Nursing Preferred Experience: Recent hospital experience in ICU, Medical, or ER unit. Previous experience in utilization management, inpatient preferred; knowledge of NYS Medicaid guidelines Preferred License, Certification, Association: Active, unrestricted Utilization Management Certification (CPHM).

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

Personify Health

Manager of Intake

Posted on:

February 13, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

LPN/LVN

State License:

California

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

In order to represent the best of what we have to offer you come to us with a multitude of positive attributes including: 3-5 years’ experience in a lead or supervisor role is required Associate degree required or LVN/LPN licensure or social work degree Bachelor’s degree preferred Minimum 3 years of experience in medical management services, medical billing, hospital or emergency services or any combination of medical experience is required to meet the needs of job duties Minimum of 2 years of supervising a call center preferred Minimum 1 year of compliance related experience preferred Managed Care experience preferred in UR, CM or DM You also take pride in offering the following Core Skills, Competencies, and Characteristics: Strong written, verbal and presentation communication skills Microsoft Office and other computer skills Flexible and able to prioritize day-to-day position requirements Strategic thinking with proven ability to communicate a vision and drive results Proficient in analysis and interpretation of clinical data Comfortable with multiple accountabilities and matrix management Proven record of strong relationships and collaborating with diverse teams Demonstrated ability to work independently with excellent judgment Strong interpersonal skills necessary to effectively communicate with medical personnel and members Analytical and problem-solving skills necessary to identify and review pertinent information The ability to incorporate analytical data into new or existing clinical programs to enhance quality of care Ability to maintain a very high level of confidentiality Able to successfully manage competing priorities Experience in the Utilization Review and Case Management Intake Process Knowledgeable of the Federal, State and ERISA regulations

Responsible for the overall intake and administrative duties of the Care Management Team. Supervise daily activity of Case Management intake team personnel including participating in interviewing, hiring, and training employees; plan, assign, and direct work; appraise performance; rewarding and disciplining employees; addressing complaints and resolving problems. Keep team informed of department updates. Work in conjunction with Directors to establish work procedures and processes that support company and departmental standards, procedures, and strategic directives. Use appropriate judgment in upward communication regarding department or employee concerns. Maintain and improve UR and/or CM team’s operations by monitoring system performance; identify and resolve problems; audit and analyze staff performance; prepare and complete action plans; assist in managing system and process improvement and quality assurance programs as it relates to clinical management and plan language interpretation.

Personify Health

PT Disease Management Nurse -RN

Posted on:

February 13, 2025

Job Type:

Part-Time

Role Type:

Case Management

License:

RN

State License:

California

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

As a Disease Management Nurse, you will telephonically coordinate wellness and disease management, with a primary focus on conditions such as diabetes, asthma, COPD, CAD, CHF, atrial fibrillation, hypertension, and hyperlipidemia but not limited to this list.

In order to represent the best of what we have to offer you come to us with a multitude of positive attributes including: Graduation from an accredited RN program and possession of a current United States RN license. May require additional licensing as business needs change. Prior experience in case management, coordinating wellness programs, or an equivalent combination of education and experience. You also take pride in offering the following Core Skills, Competencies, and Characteristics: Strong written and verbal communication skills Proficient in Microsoft Excel, Word, PowerPoint and Outlook Demonstrate ability to work independently with excellent judgment Excellent interpersonal and communication skills including able to give presentations to groups and individuals as needed. Good time management skills, highly organized.

Contact targeted member for health promotion and restoration by the use of national care guidelines to compare patient’s current level of care with industry standards. Use claims processing tools to review and research paid claim data to develop a clinical picture of a member’s health; create an individual care plan for each patient; provide close follow-up with patients actively managed. Work with patients to ensure they have a primary care provider; assist in referrals to specialists if needed; assist in obtaining durable medical equipment, review pricing for high-cost drugs. Evaluate and make referrals for case management, prenatal program or pharmacology review as indicated. Document interventions and patient contact; maintain privacy of member’s records and assist in providing quarterly reports to clients. Track groups of high-risk members and interventions to show overall health improvement within the organization. Be able to meet productivity, quality and turnaround time requirements on a daily, weekly and monthly basis.

Personify Health

Lead Utilization Review - RN

Posted on:

February 13, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

California

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

Provide daily direction and communication to utilization review staff through motivating, coaching, counseling, training and problem-solving.

In order to represent the best of what we have to offer you come to us with a multitude of positive attributes including: Knowledge of medical claims and ICD-10, CPT, HCPCS coding. Ability to critically evaluate claims data and determine treatment plan. Excellent interpersonal and communication skills; strong customer orientation; good time management skills; highly organized. Proficiency in software applications including, but not limited to, Microsoft Word, Microsoft Excel, Microsoft PowerPoint and Outlook Excellent verbal and written communication skills. Ability to speak clearly and convey complex or technical information in a manner that others can understand. Ability to understand and interpret complex information from others. You also take pride in offering the following Core Skills, Competencies, and Characteristics: RN Licensure required. Licensed in the state of California preferred Prior supervisory experience in utilization review, case management, or an equivalent combination of education and experience. 5 + years combined clinical experience required. > 2 years utilization review experience required

Supervises all LVN and RN work and gives direction as needed. Provides supervision first level review for all outpatient and ancillary pre-certification requests for medical appropriateness using established guidelines. Provide first level review for all inpatient hospital stay including mental health, substance abuse, skilled nursing and rehabilitation for medical necessity. Assist in audit preparation and provides training as needed on a variety of topics. Works with hospital staff to prepare for inpatient discharge planning needs to ensure a smooth transition to the next level of care. Plan, organize and distribute work; keep team informed of updates and changes in policy or procedure; instruct employees regarding procedures and methods; resolve difficult or non-routine situations or problems. Process appeals for non-certification of services; complete non-certification letter. Review plan document for benefit determinations; refer requests that fall outside the guidelines to advance review or senior care consultants. Use appropriate judgment in upward communication regarding department or employee concerns Serves as resource to other members of the UR team.

Point32Health

Clinical Reviewer, Inpatient RN

Posted on:

February 13, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Massachusetts

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

The Clinical Reviewer, Inpatient RN, is a licensed professional that is expected to function independently in her / his role and is responsible for managing a clinically complex caseload of members across one or more types of inpatient settings; acute, subacute, acute rehabilitation, LTAC, CORF and others. The Clinical Reviewer, Inpatient RN is responsible for making the determination of medical necessity and, therefore, benefit coverage for multiple products / lines of business, such as Commercial (FI, SI and exchange products), state specific Medicaid programs, or Federal programs or in and out of area (Carelink/Cigna). The Clinical Reviewer, Inpatient RN is expected to demonstrate the ability to work independently as well as collaboratively within a team environment. The Clinical Reviewer, Inpatient RN will be expected to demonstrate sound clinical and health plan business knowledge in their decision-making processes, on behalf of the health plan. A working understanding of departmental and corporate business objectives and accountability for outcome measures are critical to the Clinical Reviewer, Inpatient RN’s success in this role. The Clinical Reviewer, Inpatient RN provides timely, clinically appropriate and cost-effective utilization management and discharge planning activities for THP members receiving services at her / his assigned facilities and may be required to float to provide coverage at unassigned facilities. Inpatient management II functions include but are not limited to; application of clinically relevant criteria sets in order to determine medical necessity, level of care and/or readiness for transition to a lesser level of care setting. The Clinical Reviewer, Inpatient RN will develop effective working relationships with providers to facilitate the transition of the member through their continuum of care following department work processes and policies. The Clinical Reviewer, Inpatient RN will be expected to have direct experience with licensed clinical criteria sets (such as InterQual or MCG), THP proprietary Medical Necessity Guidelines and product specific payment policies. The Clinical Reviewer, Inpatient RN may have responsibility for multiple types of service reimbursement models, depending upon the LOB and/or assigned facilities contractual arrangements. Examples include but may not be limited to DRG (APR and MS), case rate and/or per diem reimbursement models. The Clinical Reviewer, Inpatient RN works under the general direction of the Inpatient Team Manager or department Manager.

EDUCATION: Registered Nurse with current, unrestricted MA license BSN: Preferred EXPERIENCE: Minimum of three years of clinical nursing experience. Minimum 3 years of UM experience, preferably in an inpatient setting or managed care environment SKILL REQUIREMENTS: Excellent interpersonal skills to form positive and collaborative relationships. Strong communication skills Excellent negotiation skills Ability to manage tasks to leverage non-clinical resources on team, provides quarterly audits of the non-clinical denial letter team Use professional and clinical judgment to identify issues and escalate accordingly to a supervisor and relevant Tufts Health Plan departments Ability to apply nationally recognized standards to support utilization management Ability to mentor Ability to assume additional responsibilities such as special projects, while managing a case load Ability to use a laptop to accurately document utilization management activities adhering to department documentation standards Ability to work independently; highly motivated and self–directed with strong time management skills flexibility Proficiency with or ability to learn technology for initiating and participating in web/system-based communications: webinar, instant messaging, thin client, soft phone or others Proficiency with or ability to learn technology-based programs such as Microsoft Word and Excel; other programs as needed WORKING CONDITIONS AND ADDITIONAL REQUIREMENTS: Fast paced business environment that requires the balancing of multiple demands. Must be able to exercise sound judgment and make evidence based clinical and business decisions Requires skill in responding to inquiries from providers as well as telephonic inquiries from internal and external customers.

Provide a range of utilization management activities for members in an inpatient setting. Utilize industry standard / plan proprietary criteria for determining the appropriateness of the inpatient setting on an initial and concurrent review basis, both acute and post-acute (as noted above). Determines reimbursement methodology and schedules concurrent review appropriately Reviews inpatient admissions, continued stays, telephonically or by other electronic means for length of stay (LOS), medical necessity, discharge planning and care coordination requirements / needs. Identifies and determines medical necessity of out of network requests for services Performs discharge planning for both acute and post-acute admissions. Identifies complex members and refers member to case management or disease management program based on member specific diagnoses, circumstances or psychosocial needs, and product / LOB program requirements. May require telephonic and/or onsite presence at assigned facilities Redirects members and providers to in network or in network preferred providers, including transition back to the Tufts Health Plan service area. Identifies potential High Risk High Needs members and presents at case rounds for inclusion of additional interventions. Identifies potential high-cost members for reserve or re-insurance planning. May be required to conducts preauthorization of transplant requests Performs case documentation according to Department standards including but not limited to timely completion of daily tasks, timely management of assigned UM events and same day case data entry Mentor new and existing staff in process and system changes/updates Facilitate UM/CM rounds Become subject matter expert (SME’s) to support the Inpatient Management Initiatives including but not limited to Progeny, OON Management, MedHok, Medical Trend Management, Cigna Self Insured accounts etc. Assist the Team Manager in day-to-day activities/assignments to the team as needed. Develop effective and collaborative relationships with key customers: With clinical and business staff of assigned facilities and physicians providing direct care to THP members in order to: actively participate in the assessment of the member’s needs, matching the available in network provider and community services to those needs; recommend and facilitate adjustments to the care plan and services in place including the transition of OON admissions back into the network. With THP Medical Directors to determine ongoing coverage for inpatient services, including approved, denied and/or redirected services, ensuring that department business processes are followed or variances to the process are escalated, if needed, and agreed to and well documented With entities who support the UM function of the Carelink product, Cigna Travel With partner departments in / across THP to coordinate and expedite clinical and administrative processes as needed Prepare cases for presentation at and actively participate in weekly UM/CM Integrated Rounds. Participate in committees or as team liaison as needed. Maintains professional growth and development through self-directed learning activities and/or involvement in professional, civic, and community organizations. Performs additional related duties as assigned.

CGS Administrators

Medical Review Manager

Posted on:

February 13, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Compact / Multi-State

We are currently hiring for a Medical Review Manager to join BlueCross BlueShield of South Carolina. In this role as a Medical Review Manager, you will oversee the accurate processing of claims that have been deferred for medical necessity review. Ensures compliance with nationally recognized standards, and local, state, and federal laws and regulations. Identifies and implements process improvement opportunities. This open position is within one of our subsidiary companies called CGS Administrators. CGS has been a proven provider of administrative and business services for state Medicaid agencies, managed care organizations, commercial health plans, Medicaid members, Medicare beneficiaries, healthcare providers, and medical equipment suppliers for more than 50 years. Here is your opportunity to join a dynamic team at a diverse company with secure, community roots and an innovative future. Logistics: This position is full time (40 hours/week) Monday-Friday from 8:00am-4:00pm and can be on-site or remote depending on the applicant’s location.

Graduate of Accredited School of Nursing OR Associate's in a job-related field. (Bachelor's degree required for the Celerian Group or Palmetto GBA). 5 years clinical and utilization review to include 2 years supervisory or team lead experience or equivalent military experience in grade E4 or above. Excellent verbal and written communication, organizational, customer service, analytical or critical thinking, and presentation skills. Good judgment skills. Proficient spelling, grammar, punctuation, and basic business math. Ability to persuade, negotiate or influence, and handle confidential or sensitive information with discretion. Knowledge of government programs and guidelines, medical and legal terminology, and disease management and litigation processes. Required Licenses and Certificates: Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC). Microsoft Office. What We Prefer: Previous Medicare/DME Experience Previous experience leading a team to meet specific KPI’s and production points. Previous experience with data analysis Must have keen attention to detail.

Manages the medical review process. Maintains a well-trained staff. Develops/implements medical review strategy with the ultimate goal of reducing the error rate. Ensures timeliness of review, quality of decisions, set productivity levels, and compliance with all nationally recognized standards, and local/state/federal laws and regulations. Identifies missed standards and implements corrective actions. Provides comprehensive and accurate feedback to provider community regarding results of medical review and correction action. Investigates all internal and external inquiries and ensures they are responded to in a timely and accurate manner. Interfaces with internal and external customers such as appellants/attorneys, congressional offices, and other regulatory bodies as required to build and maintain positive customer relationships.as assigned by management.

CGS Administrators

RN Training and Quality Assurance Coordinator (Remote)

Posted on:

February 13, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

We are currently hiring for an RN Training and Quality Assurance Coordinator to join BlueCross BlueShield of South Carolina. In this role as an RN Training and Quality Assurance Coordinator, you will coordinate the quality control program for the medical review area. Researches the Center for Medicare and Medicaid services (CMS) changes. Trains new staff and provides continuing education to clinical staff. This open position is within one of our subsidiary companies called CGS Administrators. CGS has been a proven provider of administrative and business services for state Medicaid agencies, managed care organizations, commercial health plans, Medicaid members, Medicare beneficiaries, healthcare providers, and medical equipment suppliers for more than 50 years. Here is your opportunity to join a dynamic team at a diverse company with secure, community roots and an innovative future. Logistics: This position is full-time (40 hours/week) Monday-Friday from 8:00 am-4:30 pm CST and will be fully remote.

Graduate of an Accredited School of Nursing OR Associate's in a job-related field 4 years combination of clinical, utilization review, training, quality assurance, or case management experience. Excellent verbal and written communication, customer service, organizational, and analytical or critical thinking. Good judgment. Proficient spelling, grammar, punctuation, and basic business math. Ability to persuade, negotiate or influence, and handle confidential or sensitive information with discretion. Knowledge of mathematical or statistical concepts and medical terminology. Microsoft Office. Active unrestricted RN licensure in state hired, OR, active unrestricted compact multistate RN license as defined by the Nurse Licensure Compact (NLC). What We Prefer: Prior SNF (Skilled Nursing Facility) experience Prior IRF (Inpatient Rehabilitation Facility) experience

Reviews medical review decisions for accuracy and to ensure CMS instructions have been applied correctly. Develops/implements the quality control program used as an intense review of clinical staff's technical knowledge and evaluation of medical judgment ability. Provides feedback to management and staff, and, if necessary, provides remedial training. Assists provider service departments with medical coverage issues to ensure continuity of application of CMS guidelines. Responds to specific provider inquiries and appeals requests. Develops and maintains departmental reference manuals used for proper application of CMS instructions. Provides continuing education workshops on coverage issues and medical advances. Trains new staff on CMS guidelines and medical review procedures. Coordinates system access and security clearance of new staff. Creates monthly reports for management outlining quality control results, adjustment data, and reopen results summary. Provides input to medical review audit department regarding actions taken in response to provider billing practices in order to target program abuse.

Included Health

Nurse Care Manager, RN Oncology, Adult

Posted on:

February 13, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Compact / Multi-State

Included Health is a new kind of healthcare company, delivering integrated virtual care and navigation. We’re on a mission to raise the standard of healthcare for everyone. We break down barriers to provide high-quality care for every person in every community — no matter where they are in their health journey or what type of care they need, from acute to chronic, behavioral to physical. We offer our members care guidance, advocacy, and access to personalized virtual and in-person care for everyday and urgent care, primary care, behavioral health, and specialty care. It’s all included. Learn more at includedhealth.com.

We're looking for an experienced Oncology Nurse to join our team in a full-time, dual role. You'll provide virtual oncology support (approx. 0.2 FTE) while also contributing to our care and case management team (approx. 0.8 FTE). You will report to the Manager, Care and Case Management. This is a great opportunity to use your clinical expertise and case management skills to support oncology patients and others facing complex health challenges. We are looking for nurses with oncology experience, and care and case management experience, specifically with a health plan, health navigator, of third-party administrator (TPA). If you're passionate about providing compassionate, comprehensive virtual care with experience in Oncology and Care and Case Management, we'd love to have you on board! Compact License is required + license in following states IL, MA, MI, and MN #LI-Remote

Bachelor of Science in Nursing (BSN) Active Oncology Certified Nurse (OCN) Must reside in a compact NLC state. Active Compact RN license in good standing with the nursing board of their state Willingness to obtain additional licensure 3+ years of experience working with oncology patients 2+ years experience working in care, case and disease management Demonstrated case management skills. Experience with technology and an understanding of digital tools and EMR platforms Strong empathy and commitment to patient-centered care. Ability to meet volume goals while maintaining quality standards. Flexibility and comfort in an evolving environment. Strict adherence to security and HIPAA regulations. Physical/Cognitive Requirements: Prompt and regular attendance at assigned work location. Capability to remain seated in a stationary position for prolonged periods. Eye-hand coordination and manual dexterity to operate keyboard, computer and other office-related equipment. No heavy lifting is expected, though occasional exertion of about 20 lbs of force (e.g., lifting a computer / laptop) may be required. Capability to work with leadership, employees, and members in an appropriate manner.

Oncology Support Program (0.2 FTE): Provide telehealth nursing support by phone and video. Educate patients and families on diagnosis, treatment, and side effect management. Offer emotional support and guidance to patients and loved ones. Collaborate with the healthcare team to develop personalized care plans. Contribute to the growth and development of the telehealth oncology support program Care and Case Management (0.8 FTE): Deliver patient-centered virtual care management by phone. Develop impactful care plans with members and the care team. Guide members through complex medical conditions, treatments, and benefits. Collaborate with local providers to ensure seamless care coordination. Build supportive, long-term relationships through compassionate follow-up. Assist during acute health episodes, including hospitalizations and rehab stays. Connect members with clinical and social resources to address their needs.

Included Health

Behavioral Health / Substance Use Nurse Care Manager, Adult

Posted on:

February 13, 2025

Job Type:

Full-Time

Role Type:

Behavioral Health

License:

RN

State License:

Compact / Multi-State

Included Health is a new kind of healthcare company, delivering integrated virtual care and navigation. We’re on a mission to raise the standard of healthcare for everyone. We break down barriers to provide high-quality care for every person in every community — no matter where they are in their health journey or what type of care they need, from acute to chronic, behavioral to physical. We offer our members care guidance, advocacy, and access to personalized virtual and in-person care for everyday and urgent care, primary care, behavioral health, and specialty care. It’s all included. Learn more at includedhealth.com.

We're looking for Nurse Care Managers for our Care and Case Management team, who are passionate about caring for members holistically through their healthcare journey and ensuring needs are met with industry-leading interventions. As a telephonic Nurse Care Manager you will report to the Manager, Care and Case Management and will guide members through complex medical and behavioral health situations, partnering with a diverse clinical team that includes a variety of healthcare professionals, care coordinators, and records specialists, to deliver integrated remote care in a creative way. This role focuses specifically on members with behavioral health and substance abuse or substance abuse disorder needs, requiring experience with complex psychiatric and substance abuse disorders. The Nurse Care Manager should enjoy spending time on the phone, listening to members' needs, answering questions, and serving as an advocate. You will excel at creating cohesive care plans, and have the clinical skills to guide members clinically and navigate available benefits and resources. Nurse Care Managers will support members through complex care management, disease management, and acute case management, ensuring they receive longitudinal care that results in excellent health outcomes. #LI-Remote

Bachelor of Science in Nursing (BSN). 5+ years of experience in nursing 2+ years experience working in care management 2+ years experience working in Behavioral Health and or substance use field 2+ years experience working in care, case and disease management, preferably in a health plan, health navigator or third party administrator (TPA) environment. Must reside in a compact NLC state (Florida) Active Compact RN license in good standing with the nursing board of their state. Willingness to become (and maintain) licensure in multiple states. Work until 9-6PM Local Time Be comfortable discussing several medical conditions and experience with populations across the age ranges Spanish speaking desirable Experience working remotely, and strong competence and ability to use multiple computer/medical record systems. Be empathetic. We work with patients and their families who are going through challenging times. You practice empathy and reassure patients that we are available to help them. We are a fast-growing company and we are busy. Our team will meet volume goals without sacrificing quality. Strictly follow security and HIPAA regulations to protect our patients' medical information. Be pleasant, responsive, and willing to work with and learn from our team. A lot of time is spent on the phone with patients and families, and a lot of time communicating with colleagues. Therefore, the ability to gather a clinical history, answer questions at a patient level, and summarize findings is critical. Efficient at writing medical information in easy-to-understand, patient-centric language. Physical/Cognitive Requirements Prompt and regular attendance at assigned work location. Capability to remain seated in a stationary position for prolonged periods. Eye-hand coordination and manual dexterity to operate keyboard, computer and other office-related equipment. No heavy lifting is expected, though occasional exertion of about 20 lbs of force (e.g., lifting a computer \/ laptop) may be required. Capability to work with leadership, employees, and members in an appropriate manner.

Deliver coordinated, patient-centered virtual Care Management by telephone or video that improves members' health outcomes. Create impactful care plans together with members and our diverse care team, and help members achieve the desired goals. Help members navigate complex medical conditions, treatment pathways, benefits, and the healthcare system in general. Partner with the members' local providers to ensure coordinated care. Provide compassionate, longitudinal follow-up care, building supportive relationships. Assist throughout acute healthcare episodes, such as hospitalizations and rehabilitation stays, providing coordinated Case Management to support the member and their family. Coordinate necessary resources that holistically address members' problems, whether clinical or social

UVA Health

Registered Nurse (RN) - Neurology Triage (Remote)

Posted on:

February 13, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Virginia

This job description integrates the AAACN Scope and Standards of Practice for Professional Ambulatory Care Nursing, the ANA Nursing: Scope and Standards of Practice, and the ANA Code of Ethics for Nurses with Interpretive Statements, with the UVA Nursing Professional Practice Model. ANA Scope and Standards of Practice definition of nursing: Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, groups, communities and populations. Relationship Based Care - Self and Colleagues: reflects the influence of the nurse's relationship with self, colleagues, and patient/family on the patient's experience. Relationship Based Care - Patients and Families: reflects the influence of the nurse's relationship with self, colleagues, and patient/family on the patient's experience. Expert Caring: encompasses clinical assessment, planning, prioritizing, coordinating, and implementation of care. Empowered Leaders: demonstrate knowledge of and actively participate in shared governance. Lifelong Learners: encompasses professional development through formal education, professional certification, and internal and external learning opportunities and recognizes the value of external professional organizations. Supports onboarding of new team members and precepts as applicable. Quality Achievement: includes adherence to clinical documentation guidelines, comprehension of outcomes data, engagement in performance improvement activities, and commitment to standard work. Innovation: is demonstrated by the application of technologies that support patient care, actively seeking to implement evidence-based practice and new knowledge generated by nursing research. In addition to the above job responsibilities, other duties may be assigned.

Education: Graduate of an accredited nursing program required. Bachelor of Science in Nursing required within 5 years of hire. Experience: 1 year of relevant experience. Licensure: Licensed to Practice as a Registered Nurse in the Commonwealth of Virginia. American Heart Association (AHA) Healthcare Provider BLS certification required. PHYSICAL DEMANDS: Job requires standing for prolonged periods, frequently traveling, bending/stooping. Proficient communicative, auditory and visual skills; Attention to detail and ability to write legibly; Ability to lift/push/pull 20 - 50lbs. May be exposed to chemicals, blood/body fluids and infectious disease

Capable clinician, focused on expanding knowledge and skills. Consistently provides effective direct care, as part of the interdisciplinary team, to a variety of complex patients. Manages care and implements treatment plans at a refined skill level in collaboration with patients, their families, physicians, and other members of the health care team. Seeks as well as provides feedback for improved clinical practice. Assumes a beginning leadership role but seeks mentoring in this process.

Teladoc Health

Lead Quality Improvement Specialist

Posted on:

February 12, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

New York

Teladoc Health is a global, whole person care company made up of a diverse community of people dedicated to transforming the healthcare experience. As an employee, you’re empowered to show up every day as your most authentic self and be a part of something bigger – thriving both personally and professionally. Together, let’s empower people everywhere to live their healthiest lives.

The Lead Quality Improvement Specialist plays a critical role ensuring success in our Commercial, Employer, and Government contracts with a focus on quality measures including, HEDIS, MIPS, and internal custom clinical quality measure improvement. The Specialist will enhance Clinical Quality at Teladoc Health by facilitating cross-functional collaboration and coaching for diverse stakeholders to achieve specific value-based and integrated care delivery KPIs. The Specialist must be service-oriented, well-versed in quality measures, and familiar with approaches for reviewing charts to identify and submit documentation to address quality measure gap closure. This role requires meticulous attention to detail, exceptional communication skills (both oral and written), and a passion for leveraging formal improvement science to achieve top-tier quality measure performance in a virtual-first care delivery setting.

Required Qualifications: Bachelor's degree required; RN or other clinical background with Master's degree (or other) focused on Healthcare Quality strongly preferred. Non-clinical professional backgrounds with deep front-line experience driving clinical quality improvement work side-by-side front-line clinicians in large care delivery organizations will be also considered. 7+ years of experience in a formal quality improvement role in a large health care delivery or health plan setting. Formally trained with a minimum of 7 years of experience in quality improvement methods, preferably Model for Improvement, including deep understanding and experience leveraging statistical process control (SPC) and run charts to drive iterative improvement. 7+ years of experience leveraging clinical informatics in at least one (1) major Electronic Health Record system (athenaHealth, eCW, Epic, Cerner) Preferred Qualifications: Exquisite ability to work cross-functionally with diverse clinical and non-clinical stakeholders including physicians, nurses, administrative staff, clinical informatics, data scientists, as well as Product, Commercial, and other business leaders. Experience working with NCQA HEDIS measures and Medicare Advantage Stars program Comfortable manipulating, analyzing, and synthesizing data as well as reporting out results through clear and compelling visual presentations (Microsoft Excel, Word, PowerPoint) Able to work independently, problem solve, and prioritize deadlines, particularly in a dynamic and evolving virtual care delivery setting. For novel improvement projects, manual EHR chart review may be required. Track and communicate progress; quickly escalate barriers to performance Exemplary written and verbal communication and project management skills with exceptional attention to detail. Telehealth experience This is a remote position within the U.S., with some limited travel anticipated to be quarterly at most.

Use formal quality improvement methods to achieve top-tier quality measure performance with a strong focus on process measure development and analyzing quality data over time using statistical process control (SPC) to inform serial PDSA cycles Apply knowledge of HEDIS and MIPS quality measures for addressing incentivized, contract measures across multiple commercial health plans and government plans to ensure practice credit for services received by patients Responsible for educating providers, staff, and business leaders on HEDIS, and other quality focused measures. Recommend workflow efficiencies to providers and their staff to improve measure performance Participate in optimizing Electronic Health Record (EHR) system to facilitate quality measures reporting and continuous quality improvement Create and present provider training materials to individuals as well as in small and large group settings Access practices remotely to retrieve documentation to address quality gaps Provide market updates and chart review feedback for assigned practices Submit actionable work plans to health plans and track progress. Manage multiple projects simultaneously in a fast-paced environment and meet necessary deadlines. Successful candidate will lead specific projects and activities with direct support from a Senior Medical Director in virtual primary care.

International Medical Group

Workers Compensation Case Manager

Posted on:

February 12, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Indiana

As one of the world's top International Medical Insurance companies, IMG helps individuals and companies of all sizes. Every second of every day, vacationers, those working or living abroad for short or extended periods, people traveling frequently between countries, and those who maintain multiple countries of residence use our products to give themselves global peace of mind® We are looking to grow our teams with people who share our energy and enthusiasm for creating the best experience for travelers.

The Workers Compensation Case Manager provides case management services to coordinate health care for injured workers, both foreign and domestic. Evaluates medical treatment and helps mitigate risk and exposure with appropriateness, and efficiency of the use of health care services, procedures, and facilities. Work as a liaison between the Insured, the insurance carrier and the insured’s healthcare team to meet the requirements of the work injury jurisdiction in the United States and abroad.

RN License -- Must have an active RN license in good standing in Indiana. Location: Hybrid or Remote working options. Corporate office is in Indianapolis, IN. Relocation Expenses Reimbursed: No Qualified candidates must be legally authorized to be employed in the United States. IMG will not be providing sponsorship for employment visa status (e.g., H-1B or TN status) for this position. QUALIFICATIONS: Active RN license in good standing is mandatory Minimum two years’ experience as a work comp case manager Excellent computer skills, including database knowledge Excellent customer service skills and phone etiquette. Excellent organizational skills and attention to detail. PREFERRED SKILLS: Certified Case Manager preferred (CCM) Experience auditing medical charts against itemized medical bills. Bilingual – Proficient verbal and written communication skills in a foreign language (including but not limited to Spanish, Portuguese, Mandarin, and/or French) a plus but not required PROFESSIONAL COMPETENCIES: Communication - Must be able to express ideas clearly, concisely, and logically. Must make effective and persuasive arguments when discussing medical care issues. Initiative – proactive in resolving problems, reporting discrepancies, suggesting new ideas and seeking process improvements. Judgment - use of good clinical judgment as it relates to medical treatment in case management. Flexibility – must be willing to adjust as the industry or job requirements change. Teamwork – must work well in a team and help foster a cooperative environment. Represent a positive, professional image of the company.

Reviews medical services for medical necessity. Direct and/or re-direct claimant to appropriate approved care. Negotiate discounts with out-of-net network providers. Direct healthcare team members to utilize alternative care settings when appropriate. Identify claimant needs by priority, diagnosis, dollar amount and/or high utilization of medical services and coordinate care to satisfy the carrier, insured, provider, claimant, and medical team. Document information and status in ACM systems and documents. Participate in the on-call rotation schedule emergent Certifications, Concurrent Reviews, Retrospective Reviews, and Medical Evacuations/Repatriations including inpatient and outpatient management of assistance cases. The provision of telephone and email based pre-travel advice Direct and/or re-direct members to in-network providers. Negotiate discounts with out-of-net network providers. Medical evacuation calls. Prepare case management reports monthly and as needed. Use good judgment when evaluating medical cases and confer with Medical Director when appropriate. Communicate with other members of the team as needed and ensure that information is shared appropriately. Maintain confidentiality and privacy of all protected health information. Continue education through relevant reading materials, online courses and/or seminars. Support and participate in Quality Management activities. Utilize clinical support tools as indicated. Maintain a working knowledge of the case management process & standards established by URAC and any applicable state or federal regulations as appropriate for job duties. Reports & documents complaints when/if received. Demonstrates excellent communication skills. Any other job duties or tasks assigned.

St. Luke's University Health Network

Clinical Triage Specialist, RN - Access Center, Remote Position (Local to NJ/PA)

Posted on:

February 12, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Pennsylvania

St. Luke's is proud of the skills, experience and compassion of its employees. The employees of St. Luke's are our most valuable asset! Individually and together, our employees are dedicated to satisfying the mission of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care.

The Clinical Triage Specialist (CTS) (RN) - Access Center will compassionately deliver an exceptional patient experience and provide clinical support to CTS-MA team members by serving as a clinical resource. The CTS-RN is responsible for using nursing judgment in answering/returning patient calls related to direct care provided by the practices. When appropriate, the caller’s symptoms will be assessed and triaged using approved nursing protocols and guidelines to assist in obtaining the appropriate level of care and/or self-care advice.

EDUCATION: Graduate of an accredited nursing program. Active Registered Nurse licensure in the state of Pennsylvania and New Jersey or other nursing compact state and other states as deemed necessary by state law. TRAINING AND EXPERIENCE: Minimum 2 years recent clinical experience in a physician office, home health, critical care and/or emergency room is required. Strong communication skills Focused on compliance Demonstrates continuous growth Quality-driven Service-oriented Excels at time management Strong problem-solving skills Ability to work from home in accordance with the Network Work from Home Policy if needed.

Answers telephones, prioritizes clinical triage calls, follows clinical protocols, and coordinates services, as needed. Verifies patient demographic information and accurately enters the updated information into electronic health record. Serves as an escalation point for clinical patient issues and other POD team members requiring clinical support, and provides clinical advice based on clinical protocols and procedures. Manages and responds to escalated electronic patient messages whenever not answering inbound patient calls and uses clinical judgment to prioritize and accommodate patients. Creates a positive patient experience at every encounter, attempting to independently resolve any issues or concerns of the patient at the time of the phone call, within the scope of the role. Consistently meets productivity, schedule adherence, and quality standards as set by the Access Center. Utilizes all resources and guidelines at his/her disposal to effectively assess, prioritize, advise, schedule appointments, or refer calls when necessary to the appropriate medical facility or personnel. Accurately documents symptoms/complaints, nursing assessment, advice provided and patient/caller response. Partners with other Access Center teams/PODs and respective practice clinical team on behalf of the patient to assist with clinical concerns, medication refills, or scheduling appointments. Other duties as assigned.

Tufts Medicine

Clinical Documentation Integrity Specialist Remote

Posted on:

February 12, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

Tufts Medicine is a leading integrated health system bringing together the best of academic and community healthcare to deliver exceptional, connected and accessible care experiences to consumers across Massachusetts. Comprised of Tufts Medical Center, Lowell General Hospital, MelroseWakefield Hospital, Lawrence Memorial Hospital of Medford, Care at Home - an expansive home care network, and large integrated physician network. We are an equal opportunity employer and value diversity and inclusion at Tufts Medicine. Tufts Medicine does not discriminate on the basis of race, color, religion, sex, sexual orientation, age, disability, genetic information, veteran status, national origin, gender identity and/or expression, marital status or any other characteristic protected by federal, state or local law. We will ensure that individuals with disabilities are provided reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. Please contact us to request accommodation by emailing us at careers@tuftsmedicine.org.

Location: 100% Remote Job Profile Summary ​This role focuses on activities related to revenue cycle operations such as billing, collections, and payment processing. In addition, this role focuses on performing the following CDI related duties: Facilitates improvement in overall quality, completeness, and accuracy of medical record documentation, obtains appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and coding staff to ensure that documentation reflects the level of service rendered to patients is complete and accurate, and serves as a resource to all team members on documentation guidelines, provides guidance and support as well as assisting in the education and training related to improving clinical documentation. A professional individual contributor role that may direct the work of other lower level professionals or manage processes and programs. The majority of time is spent overseeing the design, implementation or delivery of processes, programs and policies using specialized knowledge and skills typically acquired through advanced education. An entry level role that applies broad theoretical job knowledge typically obtained through advanced education. May require the following proficiency: work is closely supervised, problems faced are not typically difficult or complex, and explains facts, policies and practices related to job area. Job Overview The position is responsible for review and analysis of the medical record to improve overall quality and completeness of clinical documentation. The position facilitates and obtains appropriate modifications to clinical documentation, including clinical conditions and procedures, for accurate representation of severity of illness, expected risk of mortality, and complexity of care of the patient through extensive interaction with physicians, HIM professionals, and other interdisciplinary team members.

Minimum Qualifications: Associate’s degree in Nursing Active Registered Nurse (RN) license in Massachusetts or compact state Five (5) years’ experience in an acute-care hospital setting (ICU, ED, Critical Care, strong Med/Surg Specialty) OR case management, utilization review, or denials management in an acute-care hospital setting Preferred Qualifications: Bachelor’s degree in nursing Physical Requirements: Professional office environment with typical office requirements such as computers, phones, photocopiers, filing cabinets, etc. This is largely a sedentary role, which involves sitting most of the time, but may involve movements such as walking, standing, reaching, ascending / descending stairs, and operate office equipment. Frequently required to speak, hear, communicate, and exchange information. Able to see and read computer displays, read fine print, and/or normal type size print and distinguish letters, numbers and symbols. Occasionally lift and/or move up to 25 pounds. Skills & Abilities: Ability to read and write in the English language. Ability to understand and speak English fluently enough to be easily understood by patients, hospital personnel, physicians, and visitors. Strong critical thinking skills and sound clinical background with a working knowledge of disease processes, anatomy and physiology, and treatment regimens. Ability to analyze and interpret clinical information in the patient’s medical record. Strong written and verbal communication skills demonstrated by the ability to effectively communicate with physicians and other clinicians. Willingness to work collaboratively within a team. Open, flexible, and adaptable to a changing environment as the CDI industry continues to change and evolve. High level Computer literacy and efficiency with technology, Microsoft Office Suite (including Word, Excel, Teams), Zoom, Epic, 3M360. Ability to use good judgment in an emergency situation. Commitment to upholding and providing services in a manner that is congruent with the Hospital’s mission statement.

Performs initial concurrent review of new patients every day and concurrent re-reviews approximately every two days until the patient is discharged except weekends and company-approved holidays. Evaluates the medical record for completeness, consistency, precision, clarity, and legibility. Aligns with the coding professionals by maintaining knowledge of the current Coding Guidelines, ongoing communication, and serving as a liaison between physicians and coders. Thoroughly documents reviews, query follow up, and other pertinent information in designated systems by established deadlines. Exhibits strong critical thinking skills and medical knowledge of disease processes with an exceptional ability to integrate knowledge. Ability to analyze complex clinical information to identify areas within the medical record for potential gaps in physician documentation. Identifies opportunities and provide rationale with supported clinical criteria such as pathology of disease processes, diagnostic findings, lab values, and signs/symptoms and/or coding guidelines when applicable and forward such discrepancies to management staff in a timely manner for resolution. Provides relevant feedback and compliant, clinically credible clarifications with the ability to communicate clearly, proactively, and concisely when interacting with physicians. Provides education to physicians and other members of the patient care team to ensure their understanding of the clarification process and the desired outcome of documentation excellence for severity of illness and intensity of care. Provides feedback and education in proficient verbal and written formats both remotely and onsite. Simultaneously uses multiple technologies to complete unique patient reviews. Responsible for effective time management and efficient prioritization to achieve and maintain key operating metrics consistent with CDI Department needs and requirements. Independently takes proactive steps toward problem solving, conflict resolution, and troubleshooting of technology errors. Responsible for self-development and completes all mandatory and assigned education by established deadlines. Attends scheduled meetings and continuing education programs. Actively encourages collaboration and possesses excellent interpersonal skills in building and maintaining crucial relationships.

Centene

Medical Policy Analyst

Posted on:

February 12, 2025

Job Type:

Full-Time

Role Type:

License:

RN

State License:

Missouri

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.

Education/Experience: BSN, MSN or equivalent; Desire Masters degree in nursing, public health or health care administration or equivalent. Minimum three years experience in an acute care setting. Three years experience in the managed health care industry. License/Certification: Must have and maintain current, valid and unrestricted RN or CPC license.

Designs, develops, and distributes evidence-based medical documents, including clinical practice guidelines, criteria sets, and technology assessments for inclusion into the "Guide for Evidence-Based Medicine. Researches topics utilizing medical texts and on-line medical literature. Presents draft document at the Health Net, Inc Medical Director Forum and the Health Net of California Medical Policy Committee. Investigates and responds to inquiries on medical topics requested by various groups; collects, trends and maintains outside independent review decisions regarding technology assessment and experimental/investigational services. Works closely with other departments to ensure dissemination of reliable and accurate medical information to physicians and members. Performs annual reviews of all medical policy documents.

CVS Health

Quality Management Nurse Consultant - Arizona

Posted on:

February 12, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Arizona

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.

Must reside in Arizona, preferably in the Phoenix Metro area. Hours: Monday- Friday 8:00am-5:00pm

Required Qualifications: Active and unrestricted Arizona RN license Must reside in Arizona Must have reliable transportation and willing and able to participate in local travel up to 10% of the time. Mileage will be reimbursed per company policy 3+ years of clinical experience Preferred Qualifications: Preference for candidates in the Phoenix Metro area Managed Care experience Computer literacy and proficiency with navigating through internal/external computer systems, electronic medical record systems, and MS Office Suite applications, including Word and Excel Education: Associate's degree in nursing required Bachelor's degree in nursing preferred

Responsible for the review and evaluation of clinical information and documentation. Reviews documentation and interprets data obtained from clinical records or systems to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider issues. Independently coordinates the clinical resolution with internal/external clinician support as required. Requires some travel to provider locations as needed.

Xtensys Connected Health Solutions

Clinical Appeals Specialist - Registered Nurse

Posted on:

February 12, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

New York

We are new but mighty. Xtensys, a recently established managed service provider, delivers cutting-edge technology to health systems, starting in NY and expanding beyond. Owned by two industry leaders focused on innovation in rural and community health, we are rapidly growing with several major initiatives underway. We seek a skilled RN Clinical Appeals Specialist to join our team of 500 and support our exciting journey. We value people and are building a culture to match. If you're a collaborative, innovative, and self-directed, we’d love to talk.

The RN Clinical Appeals Specialist is a vital member of the Revenue Cycle team, focusing on the administration and coordination of denial reviews and appeal management. RN Clinical Appeals Specialist works as an integral part of the Revenue Cycle team. Responsible for you will be responsible for reviewing and managing clinical denials, including determining whether denials can be recovered and identifying the need for additional appeal submissions. You will play a key role in the resolution of denied claims and work closely with leadership to improve denial management processes.

Education: Bachelor’s degree, or equivalent experience In the absence of a Bachelor’s degree, an Associate’s degree with 6 years of revenue cycle experience is required. Experience: Bachelor’s degree a minimum of 3 years of revenue cycle experience or an Associate’s degree with 6 years of revenue cycle experience Proficiency in medical terminology, with working knowledge of ICD10, CPT, and HCPCS codes. Experience with Microsoft Office Suite (Word and Excel). Experience with Epic preferred Skills: Proven experience in clinical denials management, healthcare billing, or coding is preferred. Strong knowledge of payer guidelines, medical necessity criteria, and insurance processes. Ability to analyze and resolve complex clinical denials and reimbursement issues. Exceptional attention to detail and strong organizational skills. Effective communication skills, both written and verbal, for preparing appeals and interacting with internal teams. Ability to work independently and as part of a team. Strong problemsolving skills with a focus on resolution and continuous improvement. Licensure: Registered Nurse (RN) Physical Requirements: Extended periods of sitting. Proficient in repetitive use of hands and fingers.

Preliminary Denial Assessment: Make a preliminary determination on whether clinical denials can be recovered and identify the need for additional appeal level submissions. Research & Appeal Preparation: Research clinical denials and prepare comprehensive appeal files in response, ensuring that all necessary documentation is included for review. Denial Analysis: Perform indepth analysis of clinical denials to identify root causes, ensuring that all contributing factors are addressed for successful resolution. Medical Necessity Review: Address denials that require medical necessity reviews, including writing appeals and preparing responses. Appeals & Documentation: Resolve clinical denials by researching and reviewing payer guidelines, and writing and submitting appeals with supporting documentation when necessary. Error Identification: Identify any coding, billing, or reimbursement errors/discrepancies related to denials or aging claims and escalate these issues to the Director of Denials for further action. Financial Analysis: Evaluate denied dollars against expected reimbursement to identify discrepancies and ensure proper financial resolution. Tracking & Trending: Track and trend denial issues, escalating significant cases to leadership to support process improvement initiatives. Special Projects: Participate in special projects as assigned to improve the efficiency of the denial resolution process and overall department performance.

University of Minnesota Physicians

Triage RN - Part Time

Posted on:

February 12, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Minnesota

University of Minnesota Physicians (M Physicians), a non-profit organization headquartered in Minneapolis, seeks motivated individuals for both clinical and non-clinical roles to drive innovation in health and medicine. Our inclusive culture offers competitive salaries, excellent benefits, and the opportunity for career development in the exciting field of health care to over 1,200 physicians, 300 advanced practice providers, and 2,200 health professionals and staff across Minnesota and beyond.

Regardless of the role, we recognize that every member of our team is vital! The Triage RN makes nursing decisions in uncertain conditions drawing on a broad based depth of knowledge and is able to recognize life threatening emergencies. Uses detailed, comprehensive patient assessment tools, and uses protocols appropriately. Uses excellent interviewing and documentation skills and well developed communication prowess to assess patients both directly and indirectly. Coordinates patient care with other health care team members. Location: Remote - MN Residents only Hours: 0.6 FTE, Clinic Hours Benefits: This is a fully benefit eligible position: Competitive wages, Healthcare (including vision & dental), 401K, parking & tuition assistance and more!

Current Minnesota RN License Associate's (ADN) or Bachelor's Degree in Nursing (BSN) BLS certification 5+ years of clinical RN experience demonstrating proven assessment and visualization skills Patient education and pro-active disease management experience

Assess the patient and identified actual or potential health, safety or educational needs Uses communication strategies to achieve desirable outcomes Evaluates care and the patient's response to interventions and expected outcomes Facilitates continuity of care through interdisciplinary collaboration and coordination of appropriate health care services

TRIUNE Health Group Inc

Nurse Case Manager

Posted on:

February 12, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Iowa

TRIUNE Health Group, a fast growing and well-known regional company, in its 31st year of business, has an excellent reputation for quality and Nurse Case Manager satisfaction whose focus is transmitting dignity and respect to the injured worker, while bringing true cost savings to the employer.

TRIUNE Health Group prides itself on ensuring that each Nurse Case Manager knows that they are a vital member of our Medical Case Management Team of RNs! You will work with our highly experienced staff of professionals, who will provide you with the tools and support to be a truly successful RN! Applying Nurse Case Manager candidates must be: Strong problem solvers Possess excellent organizational skills Ability to clearly communicate both verbally and in writing. These skills are essential for Nurse Case Managers in working with the injured worker and a variety of referring sources; Insurance carriers Attorneys Employers, TPAs and health care providers.

An active RN license within the state of Iowa (required) 3 - 5 years experience as a W/C Nurse Case Manager (preferred) Must possess a valid driver's license This is a home based office position but may include daily travel Strong computer skills are necessary

Alumus

Quality Assurance Nurse Aleca FT (Remote)

Posted on:

February 12, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Arizona

Elevate your career with a team that truly cares. Join a company that sees a better way for healthcare by being patient advocates, following evidenced-based clinical practices, caring for people holistically, improving continuity of care and providing nurturing surroundings that encourage and inspire.

The Quality Assurance (QA) Nurse is a Registered Nurse (RN) or Licensed Practical Nurse (LPN) and is responsible for the clinical review of Outcome and Assessment Information Set (OASIS) documentation for Home Health in accordance with attending physician orders and plans of care to provide the highest quality of patient care and maintain compliance with Medicare, Medicaid, accrediting bodies and other federal and state rules and regulations.

Qualifications: Registered by the state(s) where currently practicing as a Registered Nurse or Licensed Practical Nurse or hold multi-state compact RN or LPN license. Three years’ experience in health care/home care, preferred. OASIS Certification in Home Health, preferred.

Performs tasks in Wellsky-QA Manager for each open OASIS. Reviews daily Open OASIS report. Audit OASIS for omissions and discrepancies. Ensures all required goals to meet Plan of Care are included and have required interventions. With documented approval of Home Health Director of Nursing or Director of Quality Initiative, generates the Plan of Care to be sent to clinicians. Facilitates communication between coders and clinicians for OASIS compliance. Communicates with Home Health Director of Nursing and Director of Quality Initiative for further clinical education on an individual clinician basis and/or team basis for any documentation trends identified by the Quality Assurance Nurse.

Revu Healthcare LLC

Clinical Validation Reviewer

Posted on:

February 12, 2025

Job Type:

Contract

Role Type:

Clinical Operations

License:

RN

State License:

New Jersey

Join a team that values excellence, innovation, and work-life balance! We're committed to improving healthcare documentation through expert review services.

We're seeking an experienced Clinical Validation Reviewer to join our dynamic team. Your expertise in DRG validation and clinical documentation will be crucial in ensuring accuracy and compliance in healthcare documentation.

BSN or RN license required 3+ years of DRG Validation/CDI review experience Active nursing license in good standing Strong knowledge of ICD-10 and MS-DRG guidelines Preferred Qualifications: CCDS certification Experience with RAC/MAC audits Quality measures knowledge Acute care background

Perform comprehensive medical record reviews Validate clinical documentation accuracy and DRG assignments Analyze clinical indicators and treatment plans Collaborate with coding professionals and physicians Participate in denial prevention processes

Integrity Management Services, Inc.

Medical Review Nurse (Full-time, Remote)

Posted on:

February 12, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Virginia

Integrity Management Services, Inc. (IntegrityM) is an award-winning, women-owned small business specializing in assisting government and commercial clients in compliance and program integrity efforts, including the prevention and detection of fraud, waste and abuse in government programs. Results are achieved through data analytics, technology solutions, audit, investigation, and medical review. At IntegrityM, we offer a culture of opportunity, recognition, collaboration, compassion and supporting our community. We thrive off of these fundamental elements that make IntegrityM a great place to work. Our small, flexible workplace offers an exceptional quality of life and promotes corporate-driven sustainability. We deliver creative solutions that exceed goals and foster a dynamic, idea-driven environment that nurtures our employees’ professional development. Large company perks…Small company feel!

Current RN license or other professional medical license Nursing degree or other professional medical degree 2+ years’ clinical experience Demonstrated proficiency in Medical Review work Working knowledge of SNF and Medicare Excellent communication skills Demonstrated prioritization, problem solving, and organization skills Strong computer skills including Microsoft Office proficiency Enthusiastic individuals who can work effectively in a dynamic environment both in a team as well as independently is a must! All candidates MUST pass a background check and drug screening prior to employment.

Responsibilities may include research on medical claims data and other sources of information to identify problems, review sophisticated data model output, and utilize a variety of tools to detect situations of potential fraud and to support the ongoing fraud investigations and requests for information.

NavitsPartners

Clinical Documentation Specialist - Remote - NYCTECH

Posted on:

February 12, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

New York

Skills Required: Advanced proficiency in EPIC and 3M systems. Comprehensive understanding of clinical documentation improvement processes. Education: BS degree required. Valid RN, Nurse Practitioner, or Physician Assistant license. Experience: A minimum of 5 years in acute care or documentation improvement.

Ensure clinical documentation reflects accurate patient care and supports appropriate coding. Work with healthcare teams to resolve discrepancies or incomplete records. Use EPIC and 3M to analyze medical records and recommend documentation updates. Develop and deliver training materials for clinical staff on documentation standards. Monitor quality metrics and participate in quality improvement projects.

Healthcare Strategies

Registered Nurse (RN) Case Manager - Fully Remote

Posted on:

February 11, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

HealthCare Strategies has been a leader in healthcare management since 1982, delivering innovative, patient-centered solutions that drive better outcomes and lower costs. We go beyond traditional cost management to provide high-quality care coordination that truly makes a difference. Join a company that values innovation, compassion, and excellence in patient care!

We are seeking dedicated Registered Nurses (full-time positions, 32 hrs/week) to join our telephonic case management program. This fully remote position allows you to work from the comfort and safety of your home, providing an excellent opportunity to make a meaningful impact on patients' lives.

Education & Experience: Active, unrestricted RN compact license AND one of the following: Certification as a Case Manager. At least three years of clinical experience. Reliable internet with speeds of 25 Mbps download / 25 Mbps upload. Skills & Abilities: Exceptional verbal and written communication skills. Strong problem-solving and decision-making abilities. Ability to work independently and manage responsibilities effectively. Basic math and computer proficiency. Proficiency in Microsoft Outlook and basic computer skills.

Work Monday through Friday with weekends and holidays off! Collaborate with a team of highly skilled professionals. Provide case management for catastrophic injuries and acute illnesses, coordinate cost-effective care, and educate patients to improve their health outcomes.

Circle Medical

Registered Nurse, Async Clinical Experience (Remote)

Posted on:

February 11, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

Circle Medical is the fastest-growing telemedicine provider in the US and has seen incredible growth of over 100% per year over the past three years. Circle Medical is a venture-backed Y-Combinator healthcare startup on a mission to bring quality, delightful primary care to everyone on the planet. Built by top-tier physicians, engineers, and designers, our medical practice and underlying technology have pioneered how people find and receive care.

We are currently looking for a Registered Nurse to join the Clinical Operations team at Circle Medical. As we continue to grow, we are constantly searching for exceptional talent to be a part of our team. This remote position can be based in on of the following states Arizona, Colorado, Connecticut, Florida, Kansas, Louisiana, Missouri, New Jersey, North Carolina, Ohio, Pennsylvania, South Carolina, Texas, Utah, or Wisconsin. We require a compact license for this role.

WHAT YOU WLL BRING: Excellent verbal and written communication skills Excellent organizational skills and attention to detail Excellent time management skills with a proven ability to meet deadlines Strong analytical and problem-solving skills Strong supervisory and leadership skills Ability to prioritize tasks and to delegate them when appropriate Ability to function well in a high-paced and at times stressful environment Proficient with Google Workspace, Microsoft Office Suite, or related software QUALIFICATIONS: An RN (BSN degree) with 5+ years of experience as an RN 1+ years Triage experience in a primary care, urgent care, or an emergency room setting Compact state license holder or eligible Currently living in a compact license state WHAT WILL GIVE YOU AN EDGE: Prior telemedicine experience Proven track record with other startups or VC-funded companies

Triage and address patients’ clinical concerns via chat Report lab and imaging results Assist with clinical operational tasks such as referrals, lab/imaging orders, provider letters, and medical forms Assist with pharmacy support such as verbal orders any prescription clarification Reduce conflict and increase patient satisfaction whenever possible through timely response to patient phone calls, chats, and tasks Provide patient education regarding disease processes, therapies, and healthful behaviors Create and execute standing orders as appropriate Communicate appropriately and tactfully with staff, consultants, patients, and the community Participate in staff, planning, in-service, and other meetings as needed Assist in developing and maintaining RN clinical guidelines/policies Perform other duties as assigned

MediPro Direct

RN Clinical Program Coordinator

Posted on:

February 11, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Oregon

We are industry innovators, dedicated to improving millions of lives by connecting life-changing medical and genetic services with the most far-reaching, efficient, professional medical service delivery network in the world. . Our work environment includes: Fully-remote work Small team Growth opportunities

National mobile healthcare company looking for an experienced RN to help direct clinical requirements for new business and mobile medical contractors.

The right candidate will have at least 3 years of relevant experience and be a consistent, dedicated self-starter with a positive attitude, and someone who is equally successful working individually or as a team. License/Certification: RN License (Required)

Be familiar with state and federal requirements Develop/expand HIPPA and privacy training programs Develop and manage training of staff and contractors Support other staff as needed

Mercy

Clinical Performance Coord (Remote)

Posted on:

February 11, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Missouri

Our mission is clear. We bring to life a healing ministry through our compassionate care and exceptional service. At Mercy, we believe in careers that match the unique gifts of unique individuals – careers that not only make the most of your skills and talents, but also your heart. Join us and discover why Modern Healthcare Magazine named us in its “Top 100 Places to Work.”

Experience: Clinical background with 3 or more years of clinical nursing or other healthcare discipline Required Education: Bachelor's Degree in Nursing or another health profession, science, technology, engineering or business field Licensure: Registered Nurse preferred Other: Collaborative, knowledgeable of health care environment and challenges, results oriented, change agent, people developer, critical thinker, able to work in the abstract and translate to concrete.

The Quality & Safety Clinical Performance Coordinator (CPC) supports the Clinical Performance Manager (CPM) in the development and review of pathways, order sets, care plans and other tools used across the continuum of care. To be successful in this position the CPC works directly with the CPM, Epic build teams, and clinical experts requiring effective communication skills, a thorough knowledge of evidence-based practice principles is required, and ability to develop ongoing relationships with Hospital and Ministry leadership

Davies North America

Triage Telephonic Case Manager

Posted on:

February 11, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Florida

Imagine being part of a team that’s not just shaping the future but actively driving it. At Davies North America, we’re at the forefront of innovation and excellence, blending cutting-edge technology with top-tier professional services. As a vital part of the global Davies Group, we help businesses navigate risk, optimize operations, and spearhead transformation in the insurance and regulated sectors.

We're on the lookout for a Triage Telephonic Case Manager to join our growing team! As a Triage Telephonic Case Manager, you will be responsible for the management and independent decision making on Workers’ Compensation medical claims at the outset of the claim. You will perform an initial assessment of the injured worker to ensure high quality of care and reduce recovery time to promote an appropriate, prompt return-to-work, according to parameters identified to meet required performance standards.

This role is a full-time, remote position. Your Expertise, Skills, and Abilities: Licensed RN with a minimum of three years of clinical experience (medical-surgical, orthopedic, neurological, ICU, industrial, or occupational) Workers’ Compensation and Case Management experience preferred Proficiency with Microsoft Office Suite and various other business software programs Other Skills and Abilities: Proactive, independent, and takes initiative with consistent follow through Superb communication skills, verbal and written, conducted in a timely manner Superior time management skills with capability of working with and meeting deadlines Exceptional capability to multi-task and prioritize with excellent organization and documentation skills in a fast-paced, dynamic work environment High level attention to detail and problem-solving skills Capable of working collaboratively and independently with minimal supervision Exhibit discretion with sensitive and confidential information Ability to adapt to new technologies quickly Customer service orientation, with a track record of resolving client issues efficiently and effectively Proven ability to mentor and train team members, fostering a collaborative and productive work environment

Provide triage case management in a Workers’ Compensation environment at the initial report of the claim while focusing on medical appropriateness of care to the injured worker with cost savings by coordination and utilization of all services, ensuring that as soon as medically feasible, return-to-work status is achieved Utilize keen clinical assessment skills to ascertain all pertinent information from the injured employee to facilitate appropriate care Clinically evaluate the recovery needs of an injured employee after the initial contact assessment Incorporate information obtained from the employer and provider into the initial plan Identify causal relationship issues and document the system notifying all appropriate parties Participate in the daily functioning of a round-the-clock intake call center, ensuring expedient care to the injured employees and being knowledgeable of all functions of the department Facilitate communication between the employee, the employee representative, employer, employer representative, insurer, health care provider, and the medical services organization and when authorized, any qualified rehabilitation consultant Identify barriers to recovery and document for future case planning Develop initial case-management care plan Appropriately document all data received from interviews, contacts and medical records in the computerized system Address the initial return-to-work capability with the injured worker and provider at each medical evaluation and document appropriately in computerized system Identify when initial treatment does not adhere to treatment guidelines and utilization criteria as determined by the state-mandated guidelines, proprietary and nationally published protocols, as well as account requirements, assuring smooth delivery of services to the injured worker Create, edit and/or revise correspondence in the system as necessary Assist with the tracking protocol management for appropriate utilization and delivery of medical services; outcomes will be evidenced by patient satisfaction, appropriate delivery and quality of care and timely recovery per evidence-based criteria and clinical guidelines Manage the file proactively, utilizing all appropriate case management tools Anticipate health needs during case management process and educate patient and family appropriately while encouraging the injured worker to participate in the recovery plan Maintain patient privacy by ensuring that all medical records, case specific information and provider specific information are kept in a confidential manner, in accordance with state and federal laws and regulations Serve as a patient advocate adhering to all legal, ethical and accreditation/regulatory standards Serve on appropriate committees such as the Quality Assurance and others as directed May negotiate fees with providers or channel cases to other vendors as appropriate Perform other duties as requested

TEEMA

Remote Autism Navigator - Case Manager

Posted on:

February 11, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Virginia

Job Title: Autism Services Navigator Licensure: Registered Nurse (RN) or Licensed Clinical Social Worker (LCSW) Location: Remote Employment Type: Full-Time (Contract-to-hire) Are you passionate about supporting individuals with Autism Spectrum Disorder (ASD) and their families? Do you have a background in pediatrics, case management or behavioral health? We’re seeking a dedicated Autism Services Navigator to join our team and make a meaningful difference for TRICARE beneficiaries enrolled in the Autism Care Demonstration (ACD). As an Autism Services Navigator, you’ll play a critical role in improving the lives of families navigating the complexities of autism care. You’ll work in a collaborative, supportive environment, leveraging your expertise in pediatrics, behavioral health, and case management to drive positive outcomes.

A current unrestricted license as a Licensed Clinical Social Worker or Registered Nurse. Certification in Case Management (CCM) or the ability to obtain certification within four years of hire. Minimum of three years of direct clinical care experience with a focus on pediatrics, behavioral health or autism. Familiarity with HIPAA regulations and case management best practices. Strong organizational, problem-solving, and communication skills. Preferred Qualifications: Two years of experience working with individuals diagnosed with ASD or within TRICARE’s ACD program. Proven case management experience in a healthcare setting.

Collaborate with families to assess, plan, and coordinate care for children diagnosed with autism. Develop and monitor individualized Comprehensive Care Plans (CCPs) to ensure access to quality, cost-effective care. Advocate for families by addressing barriers to services and locating specialized resources. Provide education on ACD and benefits while facilitating timely enrollment decisions. Evaluate case management outcomes to ensure beneficiary satisfaction and compliance with care plans. Participate in medical team conferences and coordinate with civilian and military healthcare providers.

TEEMA

RN Service Navigator - Autism

Posted on:

February 11, 2025

Job Type:

Full-Time

Role Type:

Behavioral Health

License:

RN

State License:

Wisconsin

Job Title: Autism Services Navigator Licensure: Registered Nurse (RN) or Licensed Clinical Social Worker (LCSW) Location: Remote Employment Type: Full-Time (Contract-to-hire) Are you passionate about supporting individuals with Autism Spectrum Disorder (ASD) and their families? Do you have a background in pediatrics, case management or behavioral health? We’re seeking a dedicated Autism Services Navigator to join our team and make a meaningful difference for TRICARE beneficiaries enrolled in the Autism Care Demonstration (ACD). As an Autism Services Navigator, you’ll play a critical role in improving the lives of families navigating the complexities of autism care. You’ll work in a collaborative, supportive environment, leveraging your expertise in pediatrics, behavioral health, and case management to drive positive outcomes.

A current unrestricted license as a Licensed Clinical Social Worker or Registered Nurse. Certification in Case Management (CCM) or the ability to obtain certification within four years of hire. Minimum of three years of direct clinical care experience with a focus on pediatrics, behavioral health or autism. Familiarity with HIPAA regulations and case management best practices. Strong organizational, problem-solving, and communication skills. Preferred Qualifications: Two years of experience working with individuals diagnosed with ASD or within TRICARE’s ACD program. Proven case management experience in a healthcare setting.

Collaborate with families to assess, plan, and coordinate care for children diagnosed with autism. Develop and monitor individualized Comprehensive Care Plans (CCPs) to ensure access to quality, cost-effective care. Advocate for families by addressing barriers to services and locating specialized resources. Provide education on ACD and benefits while facilitating timely enrollment decisions. Evaluate case management outcomes to ensure beneficiary satisfaction and compliance with care plans. Participate in medical team conferences and coordinate with civilian and military healthcare providers.

Partners Health Management

I/DD Care Management Supervisor (Mobile/Remote)

Posted on:

February 11, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

North Carolina

The I/DD Care Management Supervisor manages and supervises a team of Intellectual and/or Developmental Disability Care Management team members to ensure coverage for each area assigned to the team. This position is responsible for management duties related to the Care Management Team to ensure comprehensive assessment, care management and monitoring to individuals having a primary I/DD need, which may include a secondary physical health or behavioral health need. Travel is an essential function of this position.

Knowledge, Skills and Abilities: Comprehensive knowledge of the assessment and treatment of I/DD needs, with or without co-occurring physical health or behavioral health needs Considerable knowledge of the MH/SU/IDD service array provided through the network of the LME/MCO’s providers Working knowledge of laws, regulations, and program practices/requirements impacting members and families Exceptional leadership and interpersonal skills; highly effective communication ability Excellent computer skills including proficiency in Microsoft Office products (such as Word, Excel, Outlook, etc.) Excellent problem solving, negotiation and conflict resolution skills Propensity to make prompt, independent decisions based upon relevant facts and established processes Detail oriented, able to independently organize multiple tasks and priorities, and to effectively complete reporting measures within assigned timeframes Ability to learn and understand legal, waiver and program practices/requirements and apply this knowledge in problem-solving and responding to questions/inquiries Ability to assess an individual’s health needs, consult with subject matter experts, devise a comprehensive whole person health Individual Service Plan, and monitor its implementation. Education/Experience Required: Bachelor’s degree in a field related to health, psychology, sociology, social work, nursing, or another relevant human services area or licensure as an RN; and five (5) years of experience providing care management, case management, or care coordination to complex individuals with I/DD or TBI; OR A Master’s degree in a field related to health, psychology, sociology, social work, nursing, or another relevant human services area; and three (3) years of experience providing care management, case management, or care coordination to complex individuals with I/DD or TBI; AND Must reside in North Carolina Must have ability to travel regularly as needed to perform job duties Education/Experience Preferred: Minimum of 2 years prior supervisory experience highly preferred Experience working with individuals with co-occurring physical health and/or behavioral health needs preferred. Minimum of two years of prior long-term support services and/or Home and Community Based Services coordination experience preferred. Licensure/Certification Requirements: If a Registered Nurse (RN), must be licensed in North Carolina.

Role and Responsibilities: Responsibilities of the I/DD Care Management Supervisor include, but are not limited to, the following: Quality Care Planning and Comprehensive Care Management Support: Ensure that all Individual Support Plans (ISPs) are complete, review them for quality control, and provide guidance to care managers on how to meet members’ needs. Provide enhanced support and assistance for complex clinical situations (e.g., complex placement or discharge planning, etc.) Provide enhanced oversight of state-funded care management to ensure that this support is limited to recipients that meet identified triggers, that all timelines are met and that duration of care management does not exceed 90 days Ensure that Care Managers proactively utilize available resources to minimize risk of crisis events and improve member health/outcomes (e.g., accessing clinical consultants to provide subject matter expert advice to the care team, utilizing resources available through NC START, initiating high risk/complex case staffings, etc.) Promote access and use of assistive technologies to support individuals with I/DD and TBI Ensure that team members have a strong understanding of home and community-based setting requirements and actively monitor for and promote same Promote use of person-centered tools to support active discovery and quality planning Provide coverage for vacation and sick leave (Supervisors cannot have a caseload but will provide coverage for vacation and sick leave) Assist Care Manager, as needed, in collaboration with providers, hospitals, physicians and other care team members to develop and implement quality plans and coordinate activities Promote problem-solving and goal-oriented partnership with individuals/legally responsible persons, providers, etc. Ensure that Care Managers understand and utilize NCCARE360 Ensure that team members actively educate members/recipients about Registry of Unmet Needs and refer as applicable Support Quality Care Coordination for Members Not Receiving Tailored Care Management: Promote effective collaboration with CCNC and other entities providing Care Management to members (e.g. skilled nursing facilities, CAP/DA, CAP/C, CMARC, etc), ensuring responsiveness to care coordination needs related to access to IDD/TBI/BH services or transitional care Ensure participation of team members in weekly conference with CCNC, as needed, to share information on high-risk members, including members with a behavioral health transitional care need and members with special health care needs, who are receiving care coordination and care management from both entities or require referrals Ensure that the results of the any assessments completed, the member’s person-centered plan, and the member’s ISP (to the extent one exists) are shared with entity providing care management Ensure notification to the member’s care manager that the member is undergoing a transition and engage the member’s assigned care manager to assist with transitioning the member into the community, including in the development of the ninety (90) day post-discharge transition plan to the extent there are items within the care manager’s scope.  Ensure timely response to identified care coordination needs. Supervision / Performance and Project Management: Proactively monitor performance of team members, providing appropriate and timely support and corrective action for any team member with below acceptable performance  Provide and document supervision/coaching in adherence with Supervision/Coaching Protocol Objectively assess quality of case record documentation, achieving inter-rater reliability score of ≥85% on comprehensive record review Monitor contact frequency and contact types, ensuring that team members meet contact requirements per acuity tier and that in-person contacts are a high priority Assess and address training needs of team members Ensure timely and effective communication between Care Manager and Care Management Extenders, with Care Manager maintaining lead role and providing direction/guidance to Care Management Extender specific to member Ensure that members are accurately identified as members of special or priority populations and that such designations are updated as applicable Ensure that members are accurately identified as members of special or priority populations (e.g., LTSS, TBI, etc) and that such designations are updated as applicable Ensure that assigned projects (e.g., National Core Indicators, Budget Corrections, MIE Survey Follow-Up, annual performance reviews, etc) are completed by established due dates for self and team members  Ensure strategic deployment and case assignment, to minimize required travel time and utilize gifts/strengths of team members Other: Ensure that all concerns or grievances are reported and addressed Ensure that critical incidents and quality of care concerns are appropriately reported (e.g. reports to internal departments, DSS, DSHR, etc.) Support member’s right to choose Tailored Care Management entity, to request change in TCM entity or Care Manager

Austin Regional Clinic

LVN (OB/GYN Centralized Phone Triage) - Remote Opportunity

Posted on:

February 11, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

LPN/LVN

State License:

Texas

Austin Regional Clinic has been voted a top Central Texas employer by our employees for over 15 years! We are one of central Texas’ largest professional medical groups with 35+ locations and we are continuing to grow. We offer the following benefits to eligible team members: Medical, Dental, Vision, Flexible Spending Accounts, PTO, 401(k), EAP, Life Insurance, Long Term Disability, Tuition Reimbursement, Child Care Assistance, Health & Fitness, Sick Child Care Assistance, Development and more. For additional information visit https://www.austinregionalclinic.com/careers/

Under general supervision, provides routine nursing care within the limits of nursing knowledge, education, licensure, experience and ethical, legal standards of care. Carries out all duties while maintaining compliance and confidentiality and promoting the mission and philosophy of the organization.

Required: High school diploma or equivalent. Graduation from an accredited school of vocational nursing. Preferred: Previous experience in an ambulatory or acute care setting preferred. Experience with OB/Gyn and related specialties preferred. Certificate/License: Current licensure as a Licensed Vocational Nurse (LVN) in the State of Texas and current AHA approved Basic Life Support (BLS) Healthcare Provider Cardiopulmonary Resuscitation (CPR) course completion card. Will be required to maintain a current vocational nursing license and CPR certification during employment. Knowledge, Skills and Abilities: Ability to engage others, listen and adapt response to meet others’ needs. Ability to align own actions with those of other team members committed to common goals. Excellent computer and keyboarding skills, including familiarity with Windows. Excellent verbal and written communication skills. Ability to manage competing priorities. Ability to perform job duties in a professional manner at all times. Ability to understand, recall, and communicate, factual information. Ability to understand, recall, and apply oral and/or written instructions or other information. Ability to organize thoughts and ideas into understandable terminology. Ability to apply common sense in performing job. Knowledge of all activities associated with the delivery of quality nursing practices and duties assigned to this role Skill in nursing practices within the scope of responsibilities assigned to this role Skill in organization and efficiency Excellent customer service skills. Excellent interpersonal & problem solving skills. Ability to manage multiple nursing activities simultaneously with frequent interruptions in a fast –paced environment Ability to have excellent attention to detail. Ability to work in a team environment. Work Schedule: Monday-Friday from 8:00am to 5:00pm. Work Location: Training and orientation at our Administrative facility. Work-from-home opportunities after ~90 days. Must reside in Texas and be willing to attend on-site training and occasional in-person department meetings in Austin, TX.

Accurately and completely performs patient follow-up activities including laboratory results and diagnostics, appointments, referrals, medications, and call backs. Able to assist in the ordering /re-ordering of prescriptions within the guidelines of the company protocol. Adheres to all company policies, including but not limited to, OSHA, HIPAA, compliance and Code of Conduct. Regular and dependable attendance. Follows the core competencies set forth by the Company, which are available for review on CMSweb. Works holiday shift(s) as required by Company policy. Accurately and completely reports and documents status, care rendered, response to care, provider orders, contacts with patient and/or other healthcare providers. Participates in the orientation of new employees.

Stormont Vail Health

Ambulatory Registered Nurse (Remote) - Digestive Health Center - FT - Day

Posted on:

February 11, 2025

Job Type:

Full-Time

Role Type:

License:

RN

State License:

Kansas

Member of the care delivery team that encompasses the overall care of adults in an ambulatory setting with gastroenterology associated health needs. Remotely provides professional nursing assessments and education following established standards and practices for patients preparing for endoscopy procedures. Assumes responsibility and accountability for patients under their care and guidance. Provides remote communication to these patients through the therapeutic use of self, the nursing process, and other health care team members. Schedules patient procedures following established protocols, and coordinates and collaborates with other departments to ensure consideration of patients physical and emotional needs.

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. (Preferred proficiency) Skill in establishing and maintaining effective working relationships with patients, medical staff and the public. (Preferred 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 Options: 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.

Delivers professional nursing care remotely- 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. Communicates effectively via telephone to patients scheduling endoscopy appointments. Collects pertinent data and information relative to the patient, situation, or setting. Triages and analyzes data to determine actual or potential problems, and issues. Identifies expected outcomes for a plan individualized to the patient and situation; developing a collaborative plan encompassing strategies to achieve expected outcomes. Assesses, records, and reports patient's conditions, concerns, and findings accurately and appropriately to physicians. Efficiently documents information using the appropriate forms and/or electronic applications. Ensure appropriate preferences are given to patients in urgent situations. Maintains timely flow of patient care to include scheduling of follow-up appointments if needed. Works collaboratively with other members of patient care team to provide coordinated care; also ensuring patients receive appointments that align with triage disposition and allow for timely flow of patients. Practices Diversity, Equity and Inclusion principles in their daily work by respecting others' uniqueness, perspectives, backgrounds or beliefs. Knowledgeable of and follows correct processes with scheduling, and obtaining appropriate insurance approval when necessary. Commits to lifelong learning through critical thinking, self-reflection, and inquiry for personal growth and development. Participates in intra- and interdepartmental committee activities, and attends huddles, staff meetings, or mandatory retreats in compliance with departmental requirements. Assumes responsibility for patient safety by utilizing appropriate channels to communicate issues. Responsible for understanding and showing respect for patients' rights, including confidentiality of patient information.

St. Luke's University Health Network

Clinical Resource Nurse - Remote Position

Posted on:

February 11, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

None Required

State License:

Pennsylvania

St. Luke's is proud of the skills, experience and compassion of its employees. The employees of St. Luke's are our most valuable asset! Individually and together, our employees are dedicated to satisfying the mission of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care.

This position is responsible for receiving referrals, managing and facilitating the initiation of services and responding to inquiries regarding agency services. Assures accuracy of all customer information. Identifies appropriate referral sources. Functions as a liaison within clinical delivery team to facilitate communication between staff, patients and referral sources.

Physical Demands: Medium Work Exertional activity: Occasionally lift and/or carry 50 lbs Frequently lift and/or carry 25 lbs Being able to frequently lift or carry objects weighing up to 25 pounds is often more critical that being able to lift up to 50 lbs at a time Stand and/or walk at least 6 hours in an 8-hour work day Very few medium occupations in the national economy are performed primarily in a sitting position Non-exertional activity: Stooping (bending at the waist) and crouching (stooping and bending at the knee) – required frequently in most medium jobs Handling (grasping) – required frequently in most medium jobs Fingering (fine manipulation) – required only occasionally in most medium jobs Important: The functional capacity to perform medium work includes the functional capacity to perform sedentary and light work Visual and auditory acuity required to meet functions of job. Neat appearance in keeping with professional role, clean and free from body odor. Physical stamina for walking and climbing stairs and standing for long periods EDUCATION: A basic degree in nursing from a college or university program, BSN degree preferred. TRAINING AND EXPERIENCE: Minimum 2 years Community or Home Health nursing

Responsible for receiving and processing referrals from all sources. Coordinates staff activities within the department maximizing teamwork and efficiency. Assures accuracy of referral information. Contacts attending physician to establish a verbal plan of care if needed. Coordinates insurance verification with Finance Department. Coordinates discharge plans with DME supplier and Infusion companies, as appropriate. Explains agency services and fee sources for those calling to inquire about service. Obtains pre-authorization for services for referrals as needed. Assigns cases to appropriate clinical teams based on patient’s geographical location. Facilitates appropriate communication between clinical team members, physicians and referral sources. Maintains confidentiality of all materials handled within the Network/Entity as well as the proper release of information. Complies with Network and departmental policies regarding issues of employee, patient and environmental safety and follows appropriate reporting requirements. Demonstrates/models the Network’s Service Excellence Standards of Performance in interactions with all customers (internal and external). Demonstrates Performance Improvement in the following areas as appropriate: Clinical Care/ Outcomes, Customer/Service Improvement, Operational System/Process and Safety. Demonstrates financial responsibility and accountability through the effective and efficient use of resources in daily procedures, processes and practices. Complies with Network and departmental policies regarding attendance and dress code. Participates in performance improvement activities as assigned. Participates in the development of protocols, standards of care and policy and procedures. Other related duties as assigned

FEFA LLC

RN - Telehealth Triage Nurse

Posted on:

February 11, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

FEFA, LLC. is seeking compassionate, experienced, and tech-savvy Telehealth Triage Nurses (RNs) to join our 24/7 Nurse Advice Line working within a call center environment from home. This is a remote, work-from-home position that offers the opportunity to make a meaningful impact on the lives of military beneficiaries, including active-duty service members, veterans, and their families.

We are looking for nurses with strong clinical backgrounds in emergency care, triage, or related specialties, who excel in rapid assessment, problem-solving, and patient education in a fast-paced, metric-driven telehealth environment. If you are a mission-driven nurse looking for a rewarding career that leverages your clinical expertise and emotional intelligence in a remote setting, we invite you to apply. Work Environment & Schedule: 100% Remote, Structured Work-from-Home Position (dedicated, distraction-free workspace required). Must have a hard-wired (via ethernet cable) internet connection. Speed Test will be required as part of the hiring process. Must be available evenings, nights, weekends, and holidays. Full-time position with set schedules.

Minimum Requirements: RN with a BSN degree OR ASN if you also have completed a microbiology course with lab (proof of completion will be required). Multistate License required and must be active and unrestricted (verified via Nursys). Minimum of 3 years of experience at the RN level within Emergency or Urgent Care settings. Able to work a very regimented schedule with minimal flexibility. Clinical Expertise: Additional years of nursing experience in emergency care, triage, ICU, med-surg, or urgent care is highly preferred. Previous telehealth, triage, or call center experience. Proficiency in triage protocols. Emotional Intelligence & Adaptability: Empathy & Active Listening: Ability to connect with patients over the phone, identify emotional distress, and provide compassionate care. Calm Under Pressure: Comfort handling high-volume, high-stress calls, including crisis management. Adaptability & Problem-Solving: Quick thinking in fast-changing medical situations. Technical Skills: Experience working in a metrics-driven environment (handle time, QA audits, schedule adherence). Strong computer skills: Ability to toggle between multiple screens and applications while speaking with patients. Comfortable with Microsoft Office Suite, EHR documentation, and telehealth platforms. Preferred Qualifications (Bonus Points!): Military/Veteran Healthcare Experience is highly desired. Experience in Behavioral Health, Crisis Intervention, or Substance Abuse Counseling. Licensing & Compliance: Active RN Compact License (must be in good standing). Ability to obtain licensure in all 50 states (FEFA LLC assists with this process). Must be a U.S. Citizen (Federal Public Trust Clearance required). Background Check & Drug Screening Required (as per federal regulations). Physical and Mental Demands: Work assigned shift, occasional overtime may be required dependent on business need Remain in a stationary position, often standing or sitting, for prolonged periods Prolonged use of employer provided office equipment such as a computer/laptop and monitor computer screens Dexterity of hands and fingers to operate a computer keyboard, mouse, and other computer components Unauthorized peripheral equipment (e.g. monitor, keyboard, mouse) may not be connected to employer provided equipment

Triage & Assess: Evaluate patient symptoms via phone, chat, and video using evidence-based triage protocols. Provide Immediate Care Advice: Offer appropriate self-care recommendations or escalate cases for urgent intervention. Health Education & Counseling: Guide patients on medication use, medical conditions, and diagnostic tests. Crisis Management: Handle mental health, behavioral health, and emergency triage calls with empathy and precision. Documentation & Compliance: Accurately document all patient interactions in electronic health records. Collaboration: Work alongside program and project managers as well as call center management to meet tight deadlines in a metrics-based environment. Utilization & Resource Management: Navigate through and use several of the provided tech resources to gather and deliver the best advice per protocols.

GatewayMD

FT/PT/PRN - Telehealth Nurse Care Coordinator

Posted on:

February 11, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

Compact / Multi-State

GatewayMD is a telehealth company that delivers digital technology and services to clinicians seeking to monitor their patient's chronic conditions via smart devices. GatewayMD enhances access between patients and providers by implementing the proper tools and technology for clinicians to extend care beyond office walls.

Telehealth Nurse Care Coordinator (RN or LPN) - Remote Patient Monitoring We are looking for part time, full time, and PRN (as needed), RNs or LPNs to remotely monitor patients with chronic conditions. Ideal for the role Motivated and experienced nurse Enjoys telephonic communication with patients Flexibility with coverage Available between 8 am - 4pm Able to start your workday before noon GatewayMD's turnkey remote patient monitoring solution: 1. Integrative software that gathers patient data from connected devices: blood pressure cuffs, scales, blood-glucose meters, etc. 2. Clinical staff (that would be you!) that provides monitoring and care management services to patients enrolled under the physician's general supervision. What value does GatewayMD provide to patients and providers? Clinicians can remotely monitor their patient's with chronic conditions. Through our software and devices, we enable providers to remotely track their patient's biomarkers (blood pressure, blood glucose levels, weight, etc.), increasing clinical outcomes and profitability through CMS and third-party reimbursement. By leveraging GatewayMD’s full-service solution, practices can enroll more patients into their RPM program while decreasing overall workload. If you enjoy working in an innovative culture where you can make an impact starting on your first day, then GatewayMD might be the right place for you! We are currently seeking nurses to join our team. This is a strictly commission-based role. Our nurses have a list of patients that they remotely monitor and communicate with on a regular basis. It is a great opportunity for seasoned, passionate, and caring nurses to work from home while creating their own schedule.

License/Certification: LVN or RN license (Required) BLS Certification (Required) Compact State Nurse License (Required)

A passion for connecting and building strong relationships with patients. Excellent communication skills including speaking, writing, and follow up. Ability to manage your time effectively and efficiently. Driven, ambitious, and entrepreneurial spirited individuals. Ability to manage and follow multiple patients. Excellent technology skills: ability to navigate a platform consisting of health data

Guideway Care

Triage Nurse (Telehealth) [PRN] Weekends

Posted on:

February 11, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Minnesota

Sequence Health is working to provide superior patient conversion solutions to healthcare organizations. Our value system is centered around continuously improving the patient healthcare experience. We pride ourselves on hiring team members who can work independently but also enjoy being part of a team and like to continuously learn and grow. We believe you exemplify these qualities and are excited to have you join our team to continue to make a difference for patients and their families. Since 2004, Sequence Health has offered a wide breadth of innovative patient engagement and patient management solutions to help optimize operational efficiency, elevate brand awareness, and grow physician practices and healthcare businesses.

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

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

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

Guideway Care

Triage Nurse (Telehealth) [Part-time] Weekends

Posted on:

February 10, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

California

Sequence Health is working to provide superior patient conversion solutions to healthcare organizations. Our value system is centered around continuously improving the patient healthcare experience. We pride ourselves on hiring team members who can work independently but also enjoy being part of a team and like to continuously learn and grow. We believe you exemplify these qualities and are excited to have you join our team to continue to make a difference for patients and their families. Since 2004, Sequence Health has offered a wide breadth of innovative patient engagement and patient management solutions to help optimize operational efficiency, elevate brand awareness, and grow physician practices and healthcare businesses.

We are seeking a Registered Nurse to provide nursing and administrative support to practices across the country. Candidates should have strong computer skills and excellent phone skills to work with providers, patients, and administrators. The pay range is a $25-30 hourly rate. This position is Part-time, Saturday/Sunday 8 AM—8 PM CST being offered remotely.

Qualifications: Registered Nurse Current demonstration of clinical proficiency Excellent written and oral communication skills Excellent critical thinking and problem-solving skills Ability to work within approved procedure and clinical guidelines Electronic Medical Record Experience, i.e EPIC, Cerner, Greenway Ability to use windows-based computer software including ADOBE, MS Word, MS Excel, Fax and others Minimum Requirements: Registered Nurse with Unencumbered e-NCL Licensure. California licensure is required. Minimum of 5 years’ experience in working in a variety of direct patient care settings including Emergency Department, Labor and Delivery, Critical Care. Women's Health or Labor and Delivery experience preferred. Minimum of 3 years' of bedside experience Able to work remotely at home in a private HIPAA compliant workspace Able to house company equipment needed to perform job Broadband Internet Access Immigration or work visa sponsorship will not be provided Physical Demands: Ability to hear in normal range and wear a headset / earpiece Good visual acuity to read computer screens, scripts, forms etc. May sit 100% of the time when taking calls Internet download speed must be at least 24 mbps and upload speed at least 4 mbps Immigration or work visa sponsorship will not be provided

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

Guideway Care

Triage Nurse (Telehealth) [PRN] Overnights/Weekends

Posted on:

February 10, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Alabama

Sequence Health is working to provide superior patient conversion solutions to healthcare organizations. Our value system is centered around continuously improving the patient healthcare experience. We pride ourselves on hiring team members who can work independently but also enjoy being part of a team and like to continuously learn and grow. We believe you exemplify these qualities and are excited to have you join our team to continue to make a difference for patients and their families. Since 2004, Sequence Health has offered a wide breadth of innovative patient engagement and patient management solutions to help optimize operational efficiency, elevate brand awareness, and grow physician practices and healthcare businesses.

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

Qualifications: Registered Nurse Current demonstration of clinical proficiency Excellent written and oral communication skills Excellent critical thinking and problem-solving skills Ability to work within approved procedure and clinical guidelines Electronic Medical Record Experience, i.e EPIC, Cerner, Greenway Ability to use windows-based computer software including ADOBE, MS Word, MS Excel, Fax and others Minimum Requirements: Registered Nurse with Unencumbered e-NCL Licensure. Minnesota and California Licensure is required. Minimum of 5 years’ experience in working in a variety of direct patient care settings including Emergency Department, Labor and Delivery, Critical Care. Women's Health or Labor and Delivery experience preferred. Minimum of 3 years’ experience in Adult Nursing Oncology nursing experience preferred Able to work remotely at home in a private HIPAA compliant workspace Able to house company equipment needed to perform job Broadband Internet Access Immigration or work visa sponsorship will not be provided Physical Demands: Ability to hear in normal range and wear a headset / earpiece Good visual acuity to read computer screens, scripts, forms etc. May sit 100% of the time when taking calls Internet download speed must be at least 24 mbps and upload speed at least 4 mbps Immigration or work visa sponsorship will not be provided

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

Commonwealth of Pennsylvania

Medical Records Examiner

Posted on:

February 10, 2025

Job Type:

Full-Time

Role Type:

Behavioral Health

License:

RN

State License:

Pennsylvania

Are you a registered nurse with a passion for utilizing your skills and professional judgment to ensure the provision of medically necessary behavioral health services? Do you thrive on learning and implementing new software applications to increase efficiency and reporting? The Office of Mental Health and Substance Abuse Services is seeking a self-motivated individual to join our Clinical Review Division team. Do not miss out on this chance to make a difference - apply now and take the first step towards a rewarding career! Work Schedule and Additional Information: Full-time employment, 37.5 hours per week Work hours are 7:00 AM to 3:00 PM, Monday - Friday, with a 30-minute lunch. Telework: You may have the opportunity to work from home (telework) full-time with the exception of reporting to the office one day per month. In order to telework, you must have a securely configured high-speed internet connection and work from an approved location inside Pennsylvania. If you are unable to telework, you will have the option to report to the headquarters office in Harrisburg. FREE parking! Salary: In some cases, the starting salary may be non-negotiable. You will receive further communication regarding this position via email. Check your email, including spam/junk folders, for these notices.

Minimum Experience and Training Requirements: Three years of professional experience in the field of medical assistance, health care services, or human services; or An equivalent combination of experience and training. Special Requirements: This position requires active authorization to practice as a Registered Nurse in Pennsylvania. If you possess an active temporary practice permit, you must obtain licensure as a Registered Nurse within the one (1) year period defined by the Pennsylvania State Board of Nursing. Other Requirements: You must meet the PA residency requirement. For more information on ways to meet PA residency requirements, follow the link and click on Residency. You must be able to perform essential job functions.

This role requires a high level of attention to detail and the ability to make well-informed decisions based on federal regulations and specific PA Medicaid programs. While the nature of this work is highly independent, collaboration and communication with coworkers, the unit supervisor, and the department consultant physicians is necessary to ensure accuracy and compliance. Your main focus will be to determine the appropriateness of behavioral health services for individuals under the age of 21, and to complete federally mandated reviews of patients with mental illness who may require nursing facility care. In this position, you will play a crucial part in ensuring that the requested services are appropriate for reimbursement by the PA Medicaid Fee-for-Service Program.

CVS Health

Manager - Business Consultant

Posted on:

February 10, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

North Carolina

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.

Excellent opportunity for an experienced clinician with a passion for consulting and improving overall population health to leverage clinical, analytic, and consultative skills to join our team of Clinical Program Consultants (CPC) who offer clinical insights and solutions to help improve health plan performance for our group commercial plan sponsors. The CPC role is a highly collaborative position working proactively with the Aetna account team, Aetna’s Care management teams, and key Public and Labor partners to support our customers. ** This is a fully remote opportunity, Travel to Aetna office and customer locations as needed.**

Required Qualifications: Unrestricted active registered nurse license. Travel to Aetna office and customer locations as needed. (4-8 times per year) Comfortable presenting in front of executive level audience. Experience communicating for impact with large groups. Minimum of 3 years clinical experience (2 years in acute care, the other 1 year may be a combination of different sites of care including: hospital, clinic, and/or community health) Strong clinical analytic skills and demonstrated conceptual thinking. This includes utilizing Excel and other reporting mechanisms to support analysis. Strong problem-solving skills and attention to detail. Adept at communicating chronic conditions and impact on population health. Proficient consultative, communication and presentation skills (especially PowerPoint). Skilled at organizing and responding to multiple deliverables in a timely and professional manner. Ability to establish highly collaborative relationships within and outside the organization including at the executive level. Proficient with MS Office programs (Excel, PowerPoint, Word, and Outlook). Preferred Qualifications: 1+ years progressive leadership experience. Experience working with a Health Insurance Carrier. Experience with benefit plan design. Education BSN degree preferred/specialized training/relevant professional qualification, or equivalent work experience. Additional Candidate Information: This is a telework role with the expectation of time onsite with the plan sponsor in North Carolina or Virtually and travel as needed. Approximately 4-8 times per year.

Provide progressive consultative clinical insights based on analysis of clinical plan utilization and impact of member behavior on medical plan costs. Recommend clinical programs and services that align with the customer's strategy and help drive short- and long-term results. Analyze, synthesize, and present clinical content with recommended actions to drive member behavior change and help improve plan performance in customer facing meetings. Act as a trusted clinical resource educating constituents about population health, industry trends, and impact of health disparities. Collaborate across the enterprise to drive goal alignment with customer and health plan. Provide input to customer’s population health strategy across the clinical spectrum. Create and propose solutions to improve member health including leveraging community opportunities and resources. This is a customer-facing role with some travel to meet with customers and review plan performance, discuss recommendations, etc. In this role, the consultant will: Provide consultative clinical insights based on analysis and identification of key drivers of results; includes analysis of high-cost claimants, transplants, etc. Recommend clinical programs and services that align with the customer's strategy and help drive short- and long-term results. Develop and present clinical content and recommendations in customer facing meetings e.g. present findings and recommended actions to help improve plan performance and clinical outcomes, and work collaboratively to help track and resolve issues Act as a trusted clinical resource; share current information about population health trends. Collaborate across the enterprise and with care management to understand gaps and identify opportunities. Provide input to customer’s population health strategy across the clinical spectrum.

Gallagher Bassett

Nurse Consultant

Posted on:

February 10, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Illinois

Join our growing team of dedicated professionals at Gallagher Bassett, who guide those in need to the best possible outcomes for their health and wellbeing. You'll be part of a resilient team that works together to redefine the boundaries of excellence. At our organization, we value collaboration and making a positive impact in the lives of our clients and claimants, offering you the opportunity to join a team where your skills and dedication can truly make a difference. GUIDE. GUARD. GO BEYOND. We believe that every candidate brings something special to the table, including you! So, even if you feel that you’re close but not an exact match, we encourage you to apply.

Provides medical management to workers compensation injured employees, performing case management through telephonic and in-person contact with injured workers and medical providers. Coordinates with employers and claims professionals to manage medical care in order to return injured employee to work. This position will cover the Chicagoland area with a travel radius of up to 2 hours.

Required: Nursing or medical degree from an accredited institution with an active Registered Nursing license or medical license within the state of practice or states in which case management is performed. 2-4 years of work experience. Responsible for completing required and applicable training, in order to maintain proficiency and licensing requirements. Able to travel to appointments within approximately a 2 hour radius. Intermediate to advanced computer skills; Microsoft Office, Outlook, etc. WCCM Desired: Bachelor's degree preferred. Worker's Compensation experience is preferred. Certification in related field preferred. 1-3 years of clinical experience preferred. Work Traits: Demonstrates adequate knowledge of managed care with emphasis on use of criteria, guidelines and national standards of practice. Advanced written and oral communication skills, along with organizational and leadership skills. Self-directed and proactively manage assigned case files. Demonstrates strong time management skills.

Coordinating medical evaluation and treatment Meeting with physician and injured worker to collaborate on treatment plan and to discuss goals for return to work Keeping employer and referral source updated regarding medical treatment and work status Coordinating ancillary services, e.g. home health, durable medical equipment, and physical therapy. Communicates with employers to determine job requirements and to explore modified or alternate employment. Discusses and evaluates results of treatment plan with physician and injured worker using Evidence Based Guidelines to ensure effective outcome. Documents case management observations, assessment, and plan. Generates reports for referral source to communicate case status and recommendations. Generates ongoing correspondence to referral source, employer, medical providers, injured worker, and other participants involved in the injured worker's treatment plan. May participate in telephonic case conferences. Maintains a minimum caseload of 35 files, and 145 monthly billable hours, with minimum 95% quality compliance.

UF Health

Clinical Documentation Specialist Lead (RN) | Medical Records | Full Time

Posted on:

February 10, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Florida

The Clinical Documentation Specialist Team Lead reviews the progress of the CDI program, through interpretation of reports and quality rating reports. Able to identify areas of focus and necessary process refinements through report analysis. Leads CDI team in enacting process changes and measuring efficacy and impact of results. Serves as a resource to physicians and administration regarding issues related to the appropriateness of inpatient DRG assignment. This position is fully remote within the State of Florida.

Education Requirements: RN or Unlicensed physician who has graduated from a medical school that is listed in the World Directory of Medical Schools (World Directory) as meeting eligibility requirements for its graduates to apply to the Educational Commission for Foreign Medical Graduates (ECFMG) for ECFMG Certification and examination at the time of graduation. Experience Requirements: 5 years nursing experience in an acute care setting to include inpatient bedside nursing and Case Management or CDI experience Licensing/Certifications Required: Current FL RN License or ECFMG Registry Certified Clinical Documentation Specialist (CCDS)

Perform concurrent and retrospective second level reviews on specific types of opportunities Strategic approach and process refinements to capture opportunity within the CDS team Track progress of CDI team in capturing opportunities and prioritizing workload effectively Develop and oversee new hire training and orientation program for new CDSs Track query escalation process and DRG mismatches Provide feedback and educational growth opportunities to the CDI team Provide feedback to physician champion(s) on provider engagement/response Create and present targeted physician education Serve as main point of contact for external and internal CDI data requests Track technology issues with process tools and coordinate with IT on updates Perform all other duties as assigned by management within job scope

Molina Healthcare

Uniform System Assessor-RN Remote in New York

Posted on:

February 10, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

New York

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

Responsible for the completion Community Health Assessment (CHA) formerly the UAS (Uniform Assessment System) Initial Assessments and Reassessments based on New York State requirements, guidelines, and training provided by the company and/or outside resources; enrollment paperwork materials required to appropriately process members’ application for enrollment, and CHA Tasking Tool based on guidelines and training provided by the company and/or outside resources. Responsible for corrections and revision of CHA paperwork and tasking tool documentation based on review and feedback provided through quality and associated review process.

Required Education: Associates degree in Nursing Required Experience: Minimum two years clinical experience with focus in managed care, including disease or case management UAS experience Experience conducting home visits Required Licensure or Certification: Registered Nurse (RN) State Specific Requirements: Must reside in the state of NY or neighboring states (NJ, CT, parts of PA). Must have a NY state government ID Preferred Qualifications: Provide any preferred education, experience, licensure or Knowledge, Skills and Abilities Preferred Qualifications: Bachelor’s degree in Nursing CCM- Certified Case Manager, CCP – Chronic Care Professional. Home Care, Long-Term Care, MLTC experience, including appropriate support services in the community and accessing and using durable medical equipment (DME). Experience in utilization review, concurrent review and/or risk management a plus. Bilingual or multi-lingual. Health Commerce User Role 40 Travel Requirements: Driving: 50%

Completes approved New York State Comprehensive Health Initial Assessment Tool and/or Clinical Reassessment used to define eligibility for community based long term care services; develops plan of care for members Completes enrollment paperwork, progress notes and tasking tool in members’ home to assist in determining eligibility for services; reviews all data collected for accuracy and completion prior to submission Charts all contacts and findings within appropriate tool and form per policy and procedure within deadlines Attends training and continuing education sessions focused on the proper completion of Comprehensive Health Assessment documentation, enrollment paperwork, and tasking tool. Focuses on continuous improvement and quality excellence in the completion of all material associated with the initial enrollment/continued enrollment of members in the plan Supports initiatives of the Quality Assessment and Performance Improvement Committee Trained and knowledgeable in the NY UAS. Ability to understand and apply principles of Care Management and Person-Centered Planning Solid assessment skills Ability to understand and apply coverage guidelines and benefit limitations Familiar with clinical needs and disease processes for chronic physical and behavioral illnesses Understands and adapts appropriately to issues related to communication, cognitive or other barriers Strong organizational skills and the ability to prioritize and follow through on multiple projects in a timely manner Must be able to travel to multiple boroughs via car or commuting via public transportation Basic computer skills

The University of Iowa

Nurse Clinician - Utilization Management - 100% - Evening Hours

Posted on:

February 10, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Iowa

The University of Iowa Healthcare University Campus, within the Continuum of Care Division, Utilization Management Team is looking for a Nurse Clinician to functions as a clinical nurse expert and clinical coordinator acting as nurse liaison to physicians, patients and administration. The role will partner with the health care team to ensure reimbursement of hospital admissions is based on medical necessity and documentation is sufficient to support the level of care being billed. This role will conduct concurrent reviews as directed in the hospital’s Utilization Review Plan and review of medical records to ensure criteria for admission and continued stay are met and documented. Along with other health care team members, monitors the use of hospital resources and identifies delays. This role is approved for hybrid or remote work following the completion of probationary period and successful orientation. Percent of Time: 100% Schedule: Monday - Friday. Shifts to range between the hours of 07:00 - 23:00. Potential Holiday and weekend coverage rotation. This position is eligible for remote work within Iowa and will require a work arrangement form to be completed upon the start of your employment. Per policy, work arrangements will be reviewed annually, and must comply with the remote work program and related policies and employee travel policy when working at a remote location.

Required Qualifications: A Baccalaureate degree in Nursing is required. Current license to practice nursing in Iowa is required by date of hire. 3 - 5 years of RN clinical nursing experience Excellent written and verbal communication skills Desired Qualifications: Professional Masters of Nursing and Healthcare Practice (MNHP), MSN/Clinical Nurse Leader, or a Master’s Degree in Nursing (MSN, MA) Previous experience performing Utilization Reviews in an RN capacity. Previous experience involving high-volume public contact customer service. Previous experience working in an electronic medical record. Previous case management or utilization management experience. Certification in case management (i.e. ACM, CCM, or CMAC). Previous experience with EPIC. Position and Application details: In order to be considered for an interview, applicants must upload the following documents and mark them as a “Relevant File” to the submission: Resume Cover Letter

Perform a variety of admission, concurrent and retrospective utilization management-related reviews and functions to ensure that appropriate data are tracked, evaluated, and reported. Utilize an evidenced-based clinical review screening criteria as a guide to support medical necessity determinations and refers cases with failed criteria to the Physician Advisor or appeal as necessary in accordance with the UM plan. Collaborate with the health care team to determine the appropriate hospital setting (inpatient vs. outpatient) based on medical necessity. Actively seek additional clinical documentation from the physician to optimize hospital reimbursement when appropriate. Validate commercial payer authorization within the contractual time frame at time of presentation, every third day or as needed (e.g., ED, Direct Admit, Transfers). Manage concurrent cases to resolution care that may impact payer approval to authorize care as medically necessary. Participate in the resolution of retrospective reimbursement issues, including appeals, third-party payer certification, and denied cases. Provide clinical information to relevant clinical team members regarding patient needs and/or newly identified issues, specifically working with the Utilization Management team. Serve as clinical resource to social services and other providers/nurse navigators, specifically regarding the compliance portion of the level of care. Review data specific to utilization management functions and reports as requested. Monitor effectiveness/outcomes of the utilization management program, identifying and applying appropriate metrics, supporting the evaluation of the data, reporting results to various audiences, and implementing process improvement projects as needed. Participate in analyzing, updating, and modifying procedures and processes to continually improve utilization review operations. Work collaboratively with Nurse Navigators and Social Workers to expedite patient discharge. Participate in Care Coordination Division - Utilization Management initiatives or other projects according to departmental and organizational monitors. Perform basic administrative tasks related to the job as required by the Care Coordination Division to maintain accurate records and to ensure worker accountability/productivity. Maintain a highly acceptable level of professional conduct and respect for medical staff, coworkers, and hospital staff to foster a desirable image for the institution. Denote relevant clinical information to proactively communicate to payers for authorizations for treatments, procedures, and Length of Stay – send clinical information as required by the payer. Maintain current knowledge and understanding of hospital utilization review processes third party coverage with respect to Medicare, Commercial and Medicaid policies and procedures. Maintain compliance with all hospital/departmental policies/procedures assigned by the department manager, including work hours, scheduling, and other criteria for the expected daily operations of the department. Comply with the Code of Ethics and Guide for Professional Conduct. Maintain strict confidentiality in dealing with all patient-related activities and other sensitive physician and/or hospital issues by strictly adhering to hospital confidentiality of information policies. Facilitate open communication and good working relationships with Bed Management and/or Transfer Center to promote and enhance efficient operations within the Care Coordination Division.\ Acknowledge budgetary constraints in department operations and strives to perform duties cost-effectively and efficiently. Demonstrate ability to prioritize multiple work assignments to accomplish the assigned workload. Assist in the orientation and precepting of professional staff and colleagues as assigned. Maintain professional and technical knowledge by attending educational workshops; reviewing professional publications, establishing personal networks; participating in professional societies. Comply with federal, state, and local legal and certification requirements by studying existing and new legislation, anticipating future legislation; enforcing adherence to requirements; advising management on needed actions. Perform other duties as may be assigned to ensure that departmental objectives are fulfilled.

Molina Healthcare

Manager, Healthcare Services (Remote)

Posted on:

February 10, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Arizona

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

Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service. KNOWLEDGE/SKILLS/ABILITIES The Manager, Healthcare Services provides operational management and oversight of integrated Healthcare Services (HCS) teams responsible for providing Molina Healthcare members with the right care at the right place at the right time and assisting them to achieve optimal clinical, financial, and quality of life outcomes.

Required Education: Registered Nurse or equivalent combination of Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) with experience in lieu of RN license. OR Bachelor's or master’s degree in Nursing, Gerontology, Public Health, Social Work, or related field. Required Experience: 5+ years of managed healthcare experience, including 3 or more years in one or more of the following areas: utilization management, case management, care transition and/or disease management. Minimum 2 years of healthcare or health plan supervisory or managerial experience, including oversight of clinical staff. Experience working within applicable state, federal, and third-party regulations. Required License, Certification, Association: If licensed, license must be active, unrestricted and in good standing. Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation. Preferred Education: Master's Degree preferred. Preferred Experience: 3+ years supervisory/management experience in a managed healthcare environment. Medicaid/Medicare Population experience with increasing responsibility. 3+ years of clinical nursing experience. Preferred License, Certification, Association Any of the following: Certified Case Manager (CCM), Certified Professional in Healthcare Management Certification (CPHM), Certified Professional in Health Care Quality (CPHQ), or other healthcare or management certification.

Responsible for clinical teams (including operational teams, where integrated) performing one or more of the following activities: care review/utilization management (prior authorizations, inpatient/outpatient medical necessity, etc.), case management, transition of care, health management and/or member assessment. Typically, through one or more direct report supervisors, facilitates integrated, proactive HCS management, ensuring compliance with state and federal regulatory and accrediting standards and implementation of the Molina Clinical Model. Manages and evaluates team member performance; provides coaching, counseling, employee development, and recognition; ensures ongoing, appropriate staff training; and has responsibility for the selection, orientation and mentoring of new staff. Performs and promotes interdepartmental/ multidisciplinary integration and collaboration to enhance the continuity of care including Behavioral Health and Long-Term Services & Supports for Molina members. Oversees Interdisciplinary Care Team meetings. Functions as hands-on manager responsible for supervision and coordination of daily integrated healthcare service activities. Ensures adequate staffing and service levels and maintains customer satisfaction by implementing and monitoring staff productivity and other performance indicators. Collates and reports on Care Access and Monitoring statistics including plan utilization, staff productivity, cost effective utilization of services, management of targeted member population, and triage activities. Ensures completion of staff quality audit reviews. Evaluates services provided and outcomes achieved and recommends enhancements/improvements for programs and staff development to ensure consistent cost effectiveness and compliance with all state and federal regulations and guidelines. Maintains professional relationships with provider community, internal and external customers, and state agencies as appropriate, while identifying opportunities for improvement.

TriWest Healthcare Alliance

Manager, Utilization Management

Posted on:

February 10, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Arizona

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

We offer remote work opportunities (AK, AR, AZ, CA, *CO, FL, *HI, IA, ID, *IL, KS, LA, MD, *MN, MO, MT, NE, NV, NM, NC, ND, OK, OR, SC, SD, TN, TX, UT, VA/DC, *WA, WI & WY only). Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position. Veterans, Reservists, Guardsmen and military family members are encouraged to apply! Job Summary Manages prospective and concurrent Utilization Management (UM) programs including prior authorization, concurrent inpatient and continued stay reviews including authorization and management of selected post inpatient care. This position reports to the Director of UM and coordinates with Case Management (CM) and Care Coordination (CC) Managers. The position is responsible for providing assistance with the development of UM desk procedures, training, auditing and implementing UM program policies consistent with contractual and performance management goals.

Required: Registered Nurse with current, unrestricted license for appropriate state (RN) 5 years’ experience in a clinical setting 2 year experience with a managed care program 3 years supervisory or management leadership experience in a healthcare environment Preferred: Commercial Managed Care experience Master's Degree in Nursing or related field Veterans Healthcare or TRICARE Program experience Experience with policy development and technical writing Experience in budgeting, strategic program management and staff development Competencies: Communication / People Skills: Ability to influence or persuade others under positive or negative circumstances; adapt to different styles; listen critically; collaborate. Computer Literacy: Ability to function in a multi-system Microsoft environment using Word, Outlook, TriWest Intranet, the Internet, and department software applications. Delegation Skills: Provide clear performance expectations for projects and ensure adequate access to resources for completion. Independent Thinking / Self-Initiative: Critical thinkers with ability to focus on things which matter most to achieving outcomes; commitment to task to produce outcomes without direction and to find necessary resources. Information Management: Ability to manage large amounts of complex information easily, communicate clearly, and draw sound conclusions. Leadership: Successfully manage different styles of employees; provide clear direction and effective coaching. Multi-Tasking / Time Management: Prioritize and manage actions to meet changing deadlines and requirements within a high volume, high stress environment. Organizational Skills: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented. Team-Building / Team Player: Influence the actions and opinions of others in a positive direction and build group commitment. Technical Skills: Thorough knowledge of health care delivery, clinical quality assurance program metrics, UM, CM,CC, managed care concepts, management reporting tools, and medical management systems; ability to perform critical, in-depth analysis of medical records for appropriateness and level-of-care determinations. Working Conditions: Works non-regular hours, as required Works remotely, with 10% travel Extensive computer work with prolonged sitting Department of Defense security clearance required

Provides leadership to ensure operational effectiveness and efficiency of prospective and concurrent UM including discharge planning activities to meet and exceed production and service-level goals. Provides coaching and oversight to staff to ensure staff success and development. Oversees the program quality assurance and quality improvement processes related to UM programs. Generates reports to identify trends and opportunities for process improvement. Facilitates efforts to enhance UM programs by working collaboratively with the UM Director and other Medical Management leaders to effectively manage contract and internal performance standards. Provides assistance with Desk Procedures (DP) development monitors and provides assistance with application use and training programs in support of DPs. Collaborates with Data Management staff for data compilation and statistical analysis regarding program outcomes. Develops audit reports to identify quality issues and to identify areas for enhanced staff training. Develops new training programs, training documents, and flow diagrams to address targeted operational issues. Collaborates with clinical leadership to implement new processes for enhancing service levels. Assists the UM Director with staffing projections for contract management and budgets. Performs other duties as assigned. Regular and reliable attendance is required.

TriWest Healthcare Alliance

Manager, Case Management

Posted on:

February 9, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Arizona

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

We offer remote work opportunities (AK, AR, AZ, CA, *CO, FL, *HI, IA, ID, *IL, KS, LA, MD, *MN, MO, MT, NE, NV, NM, NC, ND, OK, OR, SC, SD, TN, TX, UT, VA/DC, *WA, WI & WY only). Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position. Veterans, Reservists, Guardsmen and military family members are encouraged to apply! Job Summary Responsible for leading all Case Management and Care Coordination programs and staff that provide integrated, whole health services in conjunction with corporate goals and objectives under the direction of the Director of Case Management. The Manager develops and implements clinical program components to optimize CM strategies, goals, policies and procedures to ensure compliance with contract and accreditation standards.

Bachelor's degree in Nursing or related field or equivalent experience Current unrestricted RN license in the appropriate state or territory of the United States Must obtain a URAC-recognized Case Management certification within 2 years of hire If supporting TRICARE contract, must be a U.S. Citizen If supporting TRICARE contract, must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation Minimum of five years clinical experience with progressively responsible management experience in CM or DM operations and program development Preferred: Master's degree in Nursing or related field Military or Veteran Health experience URAC-recognized Case Management Certification upon hire 2 years’ experience providing direct clinical care to patients Competencies: Coaching / Training / Mentoring: Actively foster actions required for desired business outcomes through ongoing constructive feedback. Computer Literacy: Ability to function in a multi-system Microsoft environment using Word, Outlook, TriWest Intranet, the Internet, and department software applications. Coping / Flexibility: Resiliency in adapting to a variety of situations and individuals while maintaining a sense of purpose and mature problem-solving approach is required. Empathy / Customer Service: Customer-focused behavior; Helping approach, including listening skills, patience, respect, and empathy for another's position. Independent Thinking / Self-Initiative: Critical thinkers with ability to focus on things which matter most to achieving outcomes; Commitment to task to produce outcomes without direction and to find necessary resources. Leadership: Successfully manage different styles of employees; Provide clear direction and effective coaching. Multi-Tasking / Time Management: Prioritize and manage actions to meet changing deadlines and requirements within a high volume, high stress environment. Organizational Skills: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; Detail-oriented. Problem Solving / Analysis: Ability to solve problems through systematic analysis of processes with sound judgment; Has a realistic understanding of relevant issues. Team-Building / Team Player: Influence the actions and opinions of others in a positive direction and build group commitment. Technical Skills: Knowledge of TRICARE programs and benefits; managed care, and healthcare principles and delivery systems; case management interventions; psychosocial and community support systems and crisis intervention strategies; collaboration skills; legal, regulatory requirements and HIPAA privacy regulations. Working knowledge of workers’ compensation principles; Proficient with the Microsoft Office suite of applications. Working Conditions: Remote/virtual environment Regular and reliable attendance is required. Availability to cover any work shift Ability to travel as needed Extensive computer work with long periods of sitting

Direct operational leadership of Case Management functions and staff to ensure compliance with contract requirements and adherence to contract deliverables. Monitors day-to-day operations of the Case Management team to identify barriers to providing excellent service to beneficiaries. Systematically evaluates the quality and effectiveness of staff performance, analyzing appropriate data and information to identify areas of improvement; advises and coaches when appropriate and completes annual performance appraisals. Manage activities necessary to ensure appropriate utilization of resources while maintaining optimal achievable standards of care. Participates in the development of measureable outcomes, ensures measures are in place to monitor the impact of programs and services on the health status of beneficiaries being managed. Plans and implements orientation and training strategies for new-hire employees. Ensure adherence to accreditation standards, contract policy, contractual requirements, and nationally recognized practice standards. Participates in development of desk procedures, education and auditing to support uniform application of programs and compliance with program policy and standards. Participates in interdepartmental committees and/or workgroups that are pertinent to areas of responsibility. Participates in cross-functional teams for corporate projects. Performs other duties as assigned.

Molina Healthcare

Clinical Appeals Nurse (RN): Texas and New Mexico REMOTE

Posted on:

February 9, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

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

Clinical Appeals is responsible for making appropriate and correct clinical decisions for appeals outcomes within compliance standards.

Required Education: Graduate from an Accredited School of Nursing. Bachelor's degree in Nursing preferred. Required Experience: 3-5 years clinical nursing experience, with 1-3 years Managed Care Experience in the specific programs supported by the plan such as Utilization Review, Medical Claims Review, Long Term Service and Support, or other specific program experience as needed or equivalent experience (such as specialties in: surgical, Ob/Gyn, home health, pharmacy, etc.). Experience demonstrating knowledge of ICD-9, CPT coding and HCPC. Experience demonstrating knowledge of CMS Guidelines, MCG, InterQual or other medically appropriate clinical guidelines, Medicaid, Medicare, CHIP and Marketplace, applicable State regulatory requirements, including the ability to easily access and interpret these guidelines. Required License, Certification, Association: Active, unrestricted State Registered Nursing (RN) license in good standing. Compact / multi state licensure Preferred Education: Bachelor's Degree in Nursing Preferred Experience: 5+ years Clinical Nursing experience, including hospital acute care/medical experience. Preferred License, Certification, Association: Active and unrestricted Certified Clinical Coder Certified Medical Audit Specialist Certified Case Manager Certified Professional Healthcare Management Certified Professional in Healthcare Quality other healthcare certification ALTERNATE WORK SCHEDULE: Must work CENTRAL DAYTIME BUSINESS HOURS. 4 days a week - 10hrs a day. Schedule will be alternating every 4 weeks Monday-Thursday and Wed - Saturday.

The Clinical Appeals Nurse (RN) performs clinical/medical reviews of previously denied cases in which a formal appeals request has been made or upon request by another Molina department to reduce the likelihood of a formal appeal being submitted. Independently re-evaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of all relevant and applicable Federal and State regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of service provided, length of stay and level of care. Applies appropriate criteria on PAR and Non-PAR (contracted and non-contracted) cases and with Marketplace EOCs (Evidence of Coverage). Reviews medically appropriate clinical guidelines and other appropriate criteria with Chief Medical Officer on denial decisions. Resolves escalated complaints regarding Utilization Management and Long-Term Services & Supports issues. Identifies and reports quality of care issues. Prepares and presents cases in conjunction with the Chief Medical Officer for Administrative Law Judge pre-hearings, State Insurance Commission, and Meet and Confers. Represents Molina and presents cases effectively to Judicial Fair Hearing Officer during Fair Hearings as may be required. Serves as a clinical resource for Utilization Management, Chief Medical Officer, Physicians, and Member/Provider Inquiries/Appeals. Provides training, leadership and mentoring for less experienced appeal LVN, RN and administrative staff.

Point32Health

SCO RN Care Manager - Springwell areas

Posted on:

February 9, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Massachusetts

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

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

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

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

Point32Health

RN Outpatient Reviewer, Precertification Operations

Posted on:

February 9, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Massachusetts

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

The Clinical Reviewer is a licensed Registered Nurse that is expected to function independently in her / his role and is responsible for managing a clinically complex caseload of varied requests for services. The Clinical Reviewer is responsible for making the determination of medical necessity and, therefore, benefit coverage for Commercial members. The Clinical Reviewer ensures consistent and timely disposition of coverage decisions as required by product specific compliance and regulatory time frames. The Clinical Reviewer functions as a member of the Precert / Outpatient UM team and works under the general direction of the Precertification Team Manager or department Manager. The Clinical Reviewer is expected to demonstrate the ability to work independently as well as collaboratively within a team environment. The Clinical Reviewer will be expected to demonstrate sound clinical and health plan business knowledge in their decision-making processes, on behalf of the health plan.

Bachelor’s degree in Nursing preferred Registered Nurse with a current and unrestricted Massachusetts license required

Provides all aspects of clinical decision making and support needed to perform utilization management, medical necessity determinations and benefit determinations using applicable coverage documents, purchased clinical guidelines or Medical Necessity Guidelines for clinically complex services / coverage requests in a consistent manner and within established, product specific time frames. Collaborates with Medical Directors when determination to deny a request is indicated, advising the Medical Directors on standard business processes, ensuring those processes are followed or variances to the process are escalated, if needed, and agreed to and well documented. Coaches letter writers to assure that appropriate medical necessity language is clearly defined in the denial letter. Communicates frequently through the day with physicians, practices, facilities and/or allied health providers. Communicates frequently through the day with external customers (agents acting on behalf of the provider or member or both) regarding the rational for a determination, as well as the status and disposition of cases. Orients new staff to role as needed. Interfaces between Precertification staff and providers when issues arise regarding policy interpretation, potential access availability or other quality assurance issues to ensure that members receive coverage decisions timely within all accrediting and regulatory guidelines. Facilitates communication between Precertification and other internal departments by acting as a liaison or committee member on the development or implementation of new programs. Provides input to the Medical Policy Department regarding the development of Medical Necessity Guidelines and adding input to purchased criteria through participation in the IMPAC. Proactively identifies trends in Utilization Management applicable to the precertification and outpatient UM processes. Assists in the screening of appeal cases to provide clinical input as needed or requested. Models professionalism and leadership in all capacities of the position to all audiences.

Included Health

Nurse Care Manager, Adult

Posted on:

February 9, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Compact / Multi-State

Included Health is a new kind of healthcare company, delivering integrated virtual care and navigation. We’re on a mission to raise the standard of healthcare for everyone. We break down barriers to provide high-quality care for every person in every community — no matter where they are in their health journey or what type of care they need, from acute to chronic, behavioral to physical. We offer our members care guidance, advocacy, and access to personalized virtual and in-person care for everyday and urgent care, primary care, behavioral health, and specialty care. It’s all included. Learn more at includedhealth.com.

We're looking for Nurse Care Managers for our Care and Case Management team, who are passionate about caring for members holistically through their healthcare journey and ensuring needs are met with industry-leading interventions. As a telephonic Nurse Care Manager you will report to the Manager, Care and Case Management and will guide members through complex medical and behavioral Health situations, partnering with a diverse clinical team that includes a variety of healthcare professionals, care coordinators, and records specialists, to deliver integrated remote care in a creative way. The Nurse Care Manager should enjoy spending time on the phone, listening to members' needs, answering questions, and serving as an advocate. You will excel at creating cohesive care plans, and have the clinical skills to guide members clinically and navigate available benefits and resources. Nurse Care Managers will support members through complex care management, disease management, and acute case management, ensuring they receive longitudinal care that results in excellent health outcomes. #LI-Remote

Bachelor of Science in Nursing (BSN). 5+ years of experience in nursing 2+ years experience working in care management Must reside in a compact NLC state. Active Compact RN license in good standing with the nursing board of their state. Willingness to become (and maintain) licensure in multiple states. Work until 9-6PM Local Time Be comfortable discussing several medical conditions and experience with populations across the age ranges Spanish speaking desirable Experience working remotely, and strong competence and ability to use multiple computer/medical record systems. Be empathetic. We work with patients and their families who are going through challenging times. You practice empathy and reassure patients that we are available to help them. We are a fast-growing company and we are busy. Our team will meet volume goals without sacrificing quality. Strictly follow security and HIPAA regulations to protect our patients' medical information. Be pleasant, responsive, and willing to work with and learn from our team. A lot of time is spent on the phone with patients and families, and a lot of time communicating with colleagues. Therefore, the ability to gather a clinical history, answer questions at a patient level, and summarize findings is critical. Efficient at writing medical information in easy-to-understand, patient-centric language. Physical/Cognitive Requirements: Prompt and regular attendance at assigned work location. Capability to remain seated in a stationary position for prolonged periods. Eye-hand coordination and manual dexterity to operate keyboard, computer and other office-related equipment. No heavy lifting is expected, though occasional exertion of about 20 lbs of force (e.g., lifting a computer \/ laptop) may be required. Capability to work with leadership, employees, and members in an appropriate manner.

Deliver coordinated, patient-centered virtual Care Management by telephone or video that improves members' health outcomes. Create impactful care plans together with members and our diverse care team, and help members achieve the desired goals. Help members navigate complex medical conditions, treatment pathways, benefits, and the healthcare system in general. Partner with the members' local providers to ensure coordinated care. Provide compassionate, longitudinal follow-up care, building supportive relationships. Assist throughout acute healthcare episodes, such as hospitalizations and rehabilitation stays, providing coordinated Case Management to support the member and their family. Coordinate necessary resources that holistically address members' problems, whether clinical or social

Included Health

CA Licensed- Nurse Care Manager, CCM

Posted on:

February 9, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Compact / Multi-State

Included Health is a new kind of healthcare company, delivering integrated virtual care and navigation. We're on a mission to raise the standard of healthcare for everyone. We break down barriers to provide high-quality care for every person in every community — no matter where they are in their health journey or what type of care they need, from acute to chronic, behavioral to physical. We offer our members care guidance, advocacy, and access to personalized virtual and in-person care for everyday and urgent care, primary care, behavioral health, and specialty care. It's all included. Learn more at includedhealth.com.

Are you a passionate Nurse Care Manager with oncology experience and a background in care and case management? Do you have experience working with a health plan, health navigator, or third-party administrator (TPA)? If so, we'd love to have you on our Care and Case Management team! As a telephonic Nurse Care Manager, you will report to the Manager, Care and Case Management; you'll be at the heart of our integrated care model, helping members navigate complex medical and behavioral health situations. You'll collaborate with a diverse clinical team—including healthcare professionals, care coordinators, and records specialists—to ensure members receive seamless, integrated support. You'll spend your time on the phone, listening to members, answering their questions, and advocating for their needs. Your expertise in care planning and clinical navigation will help members make informed decisions about their health, access benefits, and connect with essential resources. Through complex care management, disease management, and acute case management, you'll provide longitudinal care that leads to outstanding health outcomes. If you're looking for a meaningful role where you can make a real difference in members' lives—while working in a virtual healthcare environment—this is the opportunity for you!

Bachelor of Science in Nursing (BSN). CCM Certification (or eligible to sit for exam within 6 months of hire) 3 years of experience in nursing Must reside in a compact NLC state. Active Compact RN license in good standing with the nursing board of their state. Active California Nursing License Willingness to become (and maintain) licensure in multiple states. Work until 6pm PST (Preference for those based in MST/PST time zones) Experience with technology and an understanding of digital tools and EMR platforms Strong empathy and commitment to patient-centered care. Meet volume goals while maintaining quality standards. Flexibility and comfort in an evolving environment. Strictly follow security and HIPAA regulations to protect our patients' medical information. Ability to translate medical information into clear, accessible, and patient-friendly language. Physical/Cognitive Requirements: Prompt and regular attendance at assigned work location. Capability to remain seated in a stationary position for prolonged periods. Eye-hand coordination and manual dexterity to operate keyboard, computer and other office-related equipment. No heavy lifting is expected, though occasional exertion of about 20 lbs of force (e.g., lifting a computer / laptop) may be required. Capability to work with leadership, employees, and members in an appropriate manner.

Deliver coordinated, patient-centered virtual Care Management by telephone or video that improves members' health outcomes. Create impactful care plans together with members and our diverse care team, and help members achieve the desired goals. Help members navigate complex medical conditions, treatment pathways, benefits, and the healthcare system in general. Partner with the members' local providers to ensure coordinated care. Provide compassionate, longitudinal follow-up care, building supportive relationships. Assist throughout acute healthcare episodes, such as hospitalizations and rehabilitation stays, providing coordinated Case Management to support the member and their family. Coordinate necessary resources that holistically address members' problems, whether clinical or social

Included Health

CA Licensed Nurse Care Manager, Adult

Posted on:

February 9, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Compact / Multi-State

Included Health is a new kind of healthcare company, delivering integrated virtual care and navigation. We’re on a mission to raise the standard of healthcare for everyone. We break down barriers to provide high-quality care for every person in every community — no matter where they are in their health journey or what type of care they need, from acute to chronic, behavioral to physical. We offer our members care guidance, advocacy, and access to personalized virtual and in-person care for everyday and urgent care, primary care, behavioral health, and specialty care. It’s all included. Learn more at includedhealth.com.

We're looking for Nurse Care Managers for our Care and Case Management team, who hold a UT Compact RN license and also a CA RN license; have experience working with a health plan, health navigator or third-party administrator (TPA). Are passionate about caring for members holistically through their healthcare journey and ensuring needs are met with industry-leading interventions. As a telephonic Nurse Care Manager you will report to the Manager, Care and Case Management and will guide members through complex medical and behavioral Health situations, partnering with a diverse clinical team that includes a variety of healthcare professionals, care coordinators, and records specialists, to deliver integrated remote care in a creative way. The Nurse Care Manager should enjoy spending time on the phone, listening to members' needs, answering questions, and serving as an advocate. You will excel at creating cohesive care plans, and have the clinical skills to guide members clinically and navigate available benefits and resources. Nurse Care Managers will support members through complex care management, disease management, and acute case management, ensuring they receive longitudinal care that results in excellent health outcomes. #LI-Remote

Bachelor of Science in Nursing (BSN). Must have current CCM Certification 5+ years of experience in nursing 2+ years experience working in care management Must reside in a compact NLC state. Active Compact RN license in good standing with the nursing board of their state. Active California Nursing License Willingness to become (and maintain) licensure in multiple states. Work until 6pm PST (Preference for those based in MST/PST time zones) Be comfortable discussing several medical conditions and experience with populations across the age ranges Spanish speaking desirable Experience working remotely, and strong competence and ability to use multiple computer/medical record systems. Be empathetic. We work with patients and their families who are going through challenging times. You practice empathy and reassure patients that we are available to help them. We are a fast-growing company and we are busy. Our team will meet volume goals without sacrificing quality. Strictly follow security and HIPAA regulations to protect our patients' medical information. Be pleasant, responsive, and willing to work with and learn from our team. A lot of time is spent on the phone with patients and families, and a lot of time communicating with colleagues. Therefore, the ability to gather a clinical history, answer questions at a patient level, and summarize findings is critical. Efficient at writing medical information in easy-to-understand, patient-centric language. Physical/Cognitive Requirements: Prompt and regular attendance at assigned work location. Capability to remain seated in a stationary position for prolonged periods. Eye-hand coordination and manual dexterity to operate keyboard, computer and other office-related equipment. No heavy lifting is expected, though occasional exertion of about 20lbs of force (e.g., lifting a computer \/ laptop) may be required. Capability to work with leadership, employees, and members in an appropriate manner.

Deliver coordinated, patient-centered virtual Care Management by telephone or video that improves members' health outcomes. Create impactful care plans together with members and our diverse care team, and help members achieve the desired goals. Help members navigate complex medical conditions, treatment pathways, benefits, and the healthcare system in general. Partner with the members' local providers to ensure coordinated care. Provide compassionate, longitudinal follow-up care, building supportive relationships. Assist throughout acute healthcare episodes, such as hospitalizations and rehabilitation stays, providing coordinated Case Management to support the member and their family. Coordinate necessary resources that holistically address members' problems, whether clinical or social

Included Health

Infertility Maternity Nurse Care Manager, CCM

Posted on:

February 9, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Compact / Multi-State

Included Health is a new kind of healthcare company, delivering integrated virtual care and navigation. We're on a mission to raise the standard of healthcare for everyone. We break down barriers to provide high-quality care for every person in every community — no matter where they are in their health journey or what type of care they need, from acute to chronic, behavioral to physical. We offer our members care guidance, advocacy, and access to personalized virtual and in-person care for everyday and urgent care, primary care, behavioral health, and specialty care. It's all included. Learn more at includedhealth.com.

We are looking for an Infertility/Maternity Nurse Care Manager for our Care and Case Management team who also holds a CCM and a CA license. You must have case and disease management in a health plan, health navigator or third-party administrator (TPA) environment. You must be passionate about holistic, patient-centered care to support members through their healthcare journey and ensure needs are met with industry-leading interventions. As a telephonic Nurse Care Manager you will specialize in guiding members through both routine and complex infertility and maternity clinical scenarios. You will report to the Manager, Care and Case Management and partner with a diverse clinical team, including providers, care coordinators, and other supporting team members, to deliver integrated remote care and case management. You should enjoy spending time on the phone, listening to members' needs, answering questions, and serving as a member advocate. You will excel at creating personalized care plans and have the clinical skills to guide members through infertility and maternity journeys, while navigating available benefits and resources. As a CCM-certified nurse, you will be equipped with the expertise to navigate complex healthcare systems and ensure that each member receives the highest quality care. Nurse Care Managers will support members with education, advocacy, and care management through family-building/fertility journeys and prenatal/postpartum care, ensuring they receive comprehensive care that results in positive health outcomes for both them and their families.

Bachelor of Science in Nursing (BSN). Must reside in a compact NLC state. Active Compact RN license in good standing with the nursing board of their state. Active California Nursing License required Willingness to become licensed in multiple states. Must have current CCM Certification 3 years of experience in nursing 2+ years experience working in care, case and disease management 2+ years experience working in labor and delivery 2+ years experience working in infertility Be comfortable discussing different medical conditions Spanish speaking desirable Experience with technology and an understanding of digital tools and EMR platforms Strong empathy and commitment to patient-centered care. Meet volume goals while maintaining quality standards. Flexibility and comfort in an evolving environment. Strictly follow security and HIPAA regulations to protect our patients' medical information. Be pleasant, responsive, and willing to work with and learn from our team. Strong competence and ability to use multiple computer/medical record systems. Collaborate well across diverse teams with clinical and non-clinical members to deliver a seamless, top-quality care experience to patients. Understand cultural and socioeconomic issues affecting members and to coordinate all available resources to serve members. Translate medical information into clear, accessible, and patient-friendly language Strict adherence to security and HIPAA regulations. Physical/Cognitive Requirements: Prompt and regular attendance at assigned work location. Capability to remain seated in a stationary position for prolonged periods. Eye-hand coordination and manual dexterity to operate keyboard, computer and other office-related equipment. No heavy lifting is expected, though occasional exertion of about 20 lbs of force (e.g., lifting a computer / laptop) may be required. Capability to work with leadership, employees, and members in an appropriate manner.

Deliver coordinated, patient-centered virtual Care Management by telephone or messaging that improves members' health outcomes. Create impactful care plans together with members and our diverse care team, and help members achieve their desired goals. Help members navigate complex medical conditions, treatment pathways, benefits, and the healthcare system in general. Partner with the members' local providers to ensure coordinated care. Provide compassionate, longitudinal follow-up care, building supportive relationships.

Angels of Care Pediatric Home Health

Remote RN Health Home Service Coordinator

Posted on:

February 9, 2025

Job Type:

Full-Time

Role Type:

License:

RN

State License:

Texas

Proven customer support experience or experience as a client liaison. Strong phone contact handlingskills and active listening. Customer orientation and ability to adapt/respond to different types of characters. Excellent communication and presentation skills. Ability to multi-task, prioritize, and manage time effectively.

Education: High School Diploma Experience: 3+ years of Customer Service experience Other Requirements: Positive communication skills and ability to interact with people. Performance Requirements: Knowledge of organization policies, procedures, systems. Superior interpersonal skills. Skill in written and verbal communication. Ability to handle confidential information with discretion and adapts to competing demands. Ability to think strategically, solve problems and propose solutions. Ability to competently use Microsoft Office, including Word and Excel. Organized and detail-oriented self-starter. Strong sense of personal integrity Equipment Operated: Standard office equipment including computers, fax machines, copiers, printers, telephones, postal machines, etc. Work Environment: Position is in a well-lighted medical office environment. Occasional evening and weekend work.

Performs Outreach Activities for the purpose of enrollment for clients in the health home Assisting with Angel Link client queries and admissions procedures Managing the admissions and coordination for the health home population Maintaining relevant records and documentation as required. Demonstrates an ability to communicate effectively and express ideas clearly and actively listens. Maintains an excellent rapport with clients and clinicians and effectively promotes harmonious interpersonal relationships. Works the after-hours on call phone on some days after normal 9a-Sp office hours including weekend and holidays per business need. Performs other duties as assigned Performance Responsibilities: Although each position has its own unique duties and responsibilities, the following listing applies to every employee. Exercise necessary cost control measures. Strive to maintain positive internal and external customer service relationships. Demonstrate effective communication skills by conveying necessary information accurately, listening effectively and asking questions when clarification is needed. Must be able to be depended upon to plan and organize work effectively and ensure its completion. Must be able to demonstrate reliability by arriving to work on time and taking breaks in expected time frames. Expected to meet all productivity requirements. Must be able to demonstrate team behavior and must be willing to promote a team-oriented environment. Must always represent the organization professionally. Just be able to demonstrate initiative, strive to continually improve process and relationships.

TriWest Healthcare Alliance

Utilization Clinical Reviewer

Posted on:

February 9, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Arizona

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

We offer remote work opportunities (AK, AR, AZ, CA, *CO, FL, *HI, IA, ID, *IL, KS, LA, MD, *MN, MO, MT, NE, NV, NM, NC, ND, OK, OR, SC, SD, TN, TX, UT, VA/DC, *WA, WI & WY only). Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position. Veterans, Reservists, Guardsmen and military family members are encouraged to apply! Job Summary The Utilization Management Clinical Review nurse reviews and makes decisions about the appropriateness and level of beneficiary care being provided in an effort to provide cost effective care and ensure proper utilization of resources. Applies clinical knowledge to make determinations for preauthorization, inpatient and continued stay reviews for Behavioral Health and Medical/Surgical requests to establish medical necessity, benefit coverage, appropriateness of quality of care, and length of stay or care plan. Utilizes clinical criteria and policy keys to complete review. Documents in the medical management information system. Prepares and presents more complex cases for Medical Director Review. Refer cases to Case Management and Disease Management as appropriate. Advises non-clinical staff on clinical and coding questions. Conducts pre-admission screening and assessments.

Active, unrestricted RN license U.S. Citizen Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation 2+ years clinical experience 2+ years UM experience Proficient computer skills including Microsoft Office Suite (Teams, Word, Excel and outlook) Demonstrates effective verbal and written communication skills Preferred: 3+ years Medical / Surgical experience Behavioral Health experience 1 year TriWest or TRICARE experience Managed Care experience Competencies: Communication / People Skills: Ability to influence or persuade others under positive or negative circumstances; adapt to different styles; listen critically; collaborate. Computer Literacy: Ability to function in a multi-system Microsoft environment using Word, Outlook, TriWest Intranet, the Internet, and department software applications. Coping / Flexibility: Resiliency in adapting to a variety of situations and individuals while maintaining a sense of purpose and mature problem-solving approach is required. Empathy / Customer Service: Customer-focused behavior; Helping approach, including listening skills, patience, respect, and empathy for another's position. Independent Thinking / Self-Initiative: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented. High Intensity Environment: Ability to function in a fast-paced environment with multiple activities occurring simultaneously while maintaining focus and control of workflow. Organizational Skills: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented Team-Building / Team Player: Influence the actions and opinions of others in a positive direction and build group commitment Technical Skills: Knowledge of TRICARE policies and procedures, Utilization Management principles, Managed Care concepts, medical terminology, medical management system, InterQual criteria, working knowledge of medical coding Working Conditions: Ability to cover any work shift Ability to work overtime, if needed Onsite: Works within a standard office environment Remote: Private and secure work space and work station with high speed internet is required. Extensive computer work with prolonged sitting, wearing of headset, typing, speaking on a phone

Conducts prior authorization, continued stay, and referral management activities. Assesses medical necessity by screening available information against established criteria, using InterQual Clinical Guidelines Policy Keys and Behavioral Health criteria. Interprets information and makes decision whether authorizations align with the TriWest benefit program. Ensures timely reviews for requesting facilities and appropriate notification to parties. Contacts beneficiary and / or provider to obtain or clarify medical information as necessary. Refers cases to Case Management, Care Coordination, or Disease Management for review as necessary. Prepares cases for Medical Director and Peer Review according to established policy. Refers potential quality issues and complaints to Clinical Quality Management. Notifies Internal Audit & Corporate Compliance department of cases for review of potential fraud. Maintain compliance with Federal, State and accreditation organizations. Performs other duties as assigned. Regular and reliable attendance is required.

Sentara Healthcare

Integrated Nurse Case Manager

Posted on:

February 9, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

At Sentara, our differences are our strengths. The unique backgrounds, skills, and experiences that each Sentara colleague brings to work are what make Sentara special and what allows us to deliver excellent service and care to our patients, members, and communities.

Sentara Health Plans is hiring a Nurse Case Manager for the Health Care Services Department. This is a remote position however traveling to Nursing Facilities and Members Home is required in the TW area VA Beach/Norfolk or Richmond and its surroundings in Virginia. The Nurse Case Manager is responsible for case management services within the scope of licensure; develops, monitors, evaluates, and revises the member's care plan to meet the member's needs, with the goal of optimizing member health care across the care continuum.

RN License (Virginia/Compact) Associate or bachelor’s degree in nursing Nursing experience 3 years required Discharge planning experience preferred Managed Care experience preferred

Performs telephonic or face-to-face clinical assessments for the identification, evaluation, coordination and management of member's needs, including physical and behavioral health, social services and long-term services. Identifies members for high-risk complications and coordinates care in conjunction with the member and health care team. Nurse Case Managers manage chronic illnesses, co-morbidities, and/or disabilities ensuring cost effective and efficient utilization of health benefits; conducts gap in care management for quality programs. Assists with the implementation of member care plans by facilitating authorizations/referrals within benefits structure or extra-contractual arrangements, as permissible. Nurse Case Manager interfaces with Medical Directors, Physician Advisors and/or Inter-Disciplinary Teams on care management treatment plans. Presents cases at case conferences for multidisciplinary focus. Ensures compliance with regulatory, accrediting and company policies and procedures. May assist in problem solving with provider, claims or service issues.

Mass General Brigham

Lead Clinical Documentation Integrity Specialist

Posted on:

February 8, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Massachusetts

At Mass General Brigham, we know it takes a surprising range of talented professionals to advance our mission—from doctors, nurses, business people and tech experts, to dedicated researchers and systems analysts. As a not-for-profit organization, Mass General Brigham is committed to supporting patient care, research, teaching, and service to the community. We place great value on being a diverse, equitable and inclusive organization as we aim to reflect the diversity of the patients we serve. At Mass General Brigham, we believe a diverse set of backgrounds and lived experiences makes us stronger by challenging our assumptions with new perspectives that can drive revolutionary discoveries in medical innovations in research and patient care. Therefore, we invite and welcome applicants from traditionally underrepresented groups in healthcare — people of color, people with disabilities, LGBTQ community, and/or gender expansive, first and second-generation immigrants, veterans, and people from different socioeconomic backgrounds – to apply.

Summary: This role supports the clinical documentation by providing leadership, guidance, training, and problem resolution to less experienced staff. This position is responsible for ensuring accurate documentation of patient conditions to improve care quality, compliance, and reimbursement. As a leader in this space, the role plays a key role in driving documentation best practices, serving as a compliance resource, and mentoring team members on effective, regulatory-compliant documentation. Does this position require Patient Care? Essential Functions Reviews and analyzes patient records to identify opportunities for improving clinical documentation.

Education: Associate's Degree Nursing required and Bachelor's Degree Nursing preferred Can this role accept experience in lieu of a degree? No Licenses and Credentials: Registered Nurse [RN - State License] - Generic - HR Only preferred Experience: Experience in clinical documentation improvement, medical coding, or a related area 3-5 years required and Experience as a lead, coordinator, or supervisor in clinical documentation 1-2 years preferred Knowledge, Skills and Abilities: Strong knowledge of clinical documentation standards, coding guidelines, and regulatory requirements. Excellent analytical and problem-solving skills to assess and improve documentation practices. Effective communication and interpersonal skills to collaborate with physicians, coders, and other staff. Proficiency in health information systems and electronic medical record platforms. Ability to provide education and training to clinical and administrative teams. Detail-oriented with strong organizational skills to manage multiple tasks and meet deadlines.

Provides education and guidance to physicians and clinical staff on documentation best practices and standards. Collaborates with coding and billing teams to ensure alignment between clinical documentation and coding requirements. Mentors, trains, and assists junior team members with day-to-day inquiries. Develops and implements strategies to address documentation gaps and improve accuracy. Conducts audits of medical records to monitor compliance and identify trends or areas for improvement. Prepares reports and presentations on documentation quality and outcomes for leadership and stakeholders. Serves as a resource for clinical staff on documentation policies, regulatory requirements, and hospital procedures. Participates in multidisciplinary meetings and initiatives to support continuous improvement in clinical documentation

Molina Healthcare

Sr Specialist, Quality Improvement (RN) Remote in WA state

Posted on:

February 8, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Washington

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

Molina's Quality Improvement function oversees, plans, and implements new and existing healthcare quality improvement initiatives and education programs; ensures maintenance of programs for members in accordance with prescribed quality standards; conducts data collection, reporting and monitoring for key performance measurement activities; and provides direction and implementation of NCQA accreditation surveys and federal/state QI compliance activities. KNOWLEDGE/SKILLS/ABILITIES: The Senior Specialist, Quality Improvement (Registered Nurse) contributes to one or more of these quality improvements functions: Quality Interventions, Quality Improvement Compliance, HEDIS, and / or Quality Reporting. This position will be supporting our Washington State Plan. We are seeking a Registered Nurse with quality improvement experience. The Sr. Specialist will conduct Quality Intervention work, outbound calls to members, develop/deploy member educational materials, and support quality interventions efforts. Further details to be discussed during our interview process. Work hours: Monday – Friday 8:00am – 5:00pm PST. WA state RN licensure

Required Education: Bachelor's degree in nursing or higher Required Experience: Min. 3 years’ experience in healthcare with minimum 2 years’ experience in health plan quality improvement, managed care, or equivalent experience. Required License, Certification, Association: Active and unrestricted RN license for the State(s) of employment Preferred Education Preferred field: Clinical Quality, Public Health or Healthcare. Nursing: Master's or higher Preferred Experience: 2 years coding and medical record abstraction experience. 1-year managed care experience. Basic knowledge of HEDIS and NCQA. Preferred License, Certification, Association: Certified Professional in Health Quality (CPHQ) Certified HEDIS Compliance Auditor (CHCA) Registered Health Information Technician (RHIT), or Certified Medical Record Technician with training in coding procedures (as required by state/location only), or Certified Professional Coder (CPC)

Acts as a lead specialist to provide project-, program-, and / or initiative-related direction and guidance for other specialists within the department and/or collaboratively with other departments. Implements key quality strategies that require a component of near real-time clinical decision-making. These activities may include initiation and management of interventions (e.g., removing barriers to care); preparation for Quality Improvement Compliance surveys; preparation and review of potential quality of care and critical incident cases; review of medical record documentation for credentialing and model of care oversight; and any other federal and state required quality activities. Monitors and ensures that key quality activities that involve clinical decision-making are completed on time and accurately in order to present results to key departmental management and other Molina departments as needed. Writes narrative reports to interpret regulatory specifications, explain programs and results of programs, and document findings and limitations of department interventions. Creates, manages, and/or compiles the required documentation to maintain critical quality improvement functions that have a component of clinical decision-making. Leads quality improvement activities, meetings, and discussions with and between other departments within the organization. Often the Senior Specialist will be assigned activities where clinical expertise is important to the activity. Surfaces to Manager and Director any gaps in processes that may require remediation. In particular, the Senior Specialist may be asked to focus on parts of the process where a clinician's perspective would be valuable to uncover process gaps or limitations. HEDIS / Quality Reporting: Performs the lead role in the coordination and preparation of the HEDIS medical record review which includes ongoing review of records submitted by providers and the annual HEDIS medical record review. The Senior Specialist will be asked to perform duties where clinical decision-making may be necessary. Participates in meetings with vendors for the medical record collection process. Assists Manager and Supervisor(s) in training and takes the lead role in these activities Collects medical records and reports from provider offices, loads data into the HEDIS application, and compares the documentation in the medical record to specifications to determine if preventive and diagnostic services have been correctly performed. Works with the corporate HEDIS team to monitor accuracy of abstracted records as required by specifications. Participates in scheduled meetings with the corporate HEDIS team, vendors and HEDIS auditors. Assists the quality improvement staff with physician and member interventions and incentive efforts as needed through review of medical records documentation. Provides data collection and report development support for quality improvement studies and performance improvement projects. Assists as needed in support of accreditation activities such as NCQA reviews, CAHPS and state audits by reviewing clinical documentation.

Netsmart Technologies

QA Specialist

Posted on:

February 8, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Kansas

Responsible for monitoring, reviewing, and proposing measures to correct or improve staff capability and quality

Required: At least 4 years of experience in Inpatient/Outpatient Coding review Expert in ICD-10 coding and guidelines Proficient in Inpatient/Outpatient industry regulations and guidelines Excellent communication and presentation skills Working knowledge of Microsoft Office Preferred: Advanced clinical degree Active clinical license (e.g. RN, PT, OT, SP)

Accountable for internal competency of Inpatient/Outpatient Coding staff Develop content for and deliver orientation and training for new associates and ongoing skill-based training for all reviewers Complete quality assurance processes; document and report findings Lead client and reviewer quality communication and resolution Test McBee Clinical Review functionality Act as an expert resource for highly complex or first-of-a-kind reviewer questions; ensure knowledge management resources are available, updated and leveraged. Accountable to communicate quality concerns to all stakeholders

Franciscan Health

Part Time RN Utilization Review Coordinator

Posted on:

February 8, 2025

Job Type:

Part-Time

Role Type:

Utilization Review

License:

RN

State License:

Indiana

With 12 ministries and access points across Indiana and Illinois, Franciscan Health is one of the largest Catholic health care systems in the Midwest. Franciscan Health takes pride in hiring coworkers that provide compassionate, comprehensive care for our patients and the communities we serve.

Department : Utilization Management - EST Location : Work From Home, Indiana Scheduled Weekly Hours : 20 Shift : Day Schedule : Regular Part time Work From Home : Yes

Associate degree in nursing/patient care required Bachelor's Degree in nursing/patient care preferred Registered Nurse (RN - Indiana licensure) required 3 years of nursing/patient care experience required 2 years of Utilization or Case Management experience preferred

Schedule: 8am - 4:30 pm EST, Monday -Tuesday and then Wednesday - Friday the following week. Perform concurrent reviews for appropriateness of utilization to optimize clinical and financial outcomes. Communicate with physicians, patients, members of the Healthcare team, Coordinated Business Office staff, Denial Management staff, and third-party payors to justify the admission or continued stay. Notify appropriate staff members of any admission, service, length of stay, lack of medical necessity criteria, as well as denials/appeals and issuing of letters to patients. Provide Physician, Patient, Family, Staff and Student education. Act as a resource person for the case management department regarding payer rules, regulations, policies and procedures, and utilization issues. Perform admission necessity screening using criteria as established by the various federal, state and private sector programs.

Banner Health

Registered Nurse RN Population Health Remote

Posted on:

February 8, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Colorado

At Banner Medical Group, you'll have the opportunity to perform a critical role in the community where you practice. Banner Medical Group provides both primary and specialty care throughout the communities in which Banner Health operates. We do this in a variety of settings - from smaller group practices like our Banner Health Clinics in Colorado and Wyoming, to large multi-specialty Banner Health Centers in the metropolitan Phoenix area. We currently have more than 1,000 physicians and more than 3,500 total employees in our group and are seeking others to enhance our ability to deliver our nonprofit mission of providing excellent patient care.

This position provides clinical and operational coordination of all Risk Adjustment efforts in support of achieving organizational strategic initiatives related to the organization’s Risk Adjustment program goals. This position is also responsible for understanding and serving as an informative source on Medicare Advantage funding models (Risk adjustment, HCCs, HEDIS quality Rate, etc.) This includes collaborating with key stakeholders to implement the activities across BMG and to identify opportunities for optimization of RAF scores and capture of Hierarchical Condition Categories (HCCs).

MINIMUM QUALIFICATIONS: Must possess a strong knowledge of healthcare provider relations as normally obtained through 3-5 years of related healthcare experience. Must possess a current, valid RN license in the state of practice. Must demonstrate effective relationship development skills, and ability to effectively communicate in individual and group settings. Teamwork is critical. Attentive listening and polished presentation skills are needed to effectively educate providers and practices on Risk Adjustment tools. Requires critical thinking and project management capabilities. Position requires proficiency in personal software applications, including word processing, generating spreadsheets, claims adjudication and provider systems. PREFERRED QUALIFICATIONS: Additional related education and/or experience preferred.

Serves as a subject matter expert in support of Risk Adjustment Factor (RAF) tools for Banner Medical Group. Coordinates the business design, testing and implementation of web-based RAF tools and reports in areas of expertise. Monitors and ensures tools are available post implementation. Responsible for the development and implementation of Risk Adjustment education and training for network physicians and practices, including documentation and coding requirements, HCCs, HEDIS quality ratings. Establishes and promotes a collaborative relationship with physicians, third party vendors, and other members of the health care team. Collects and communicates pertinent, timely clinical information to third party vendors and others to fulfill utilization and regulatory requirements. Assess accuracy and comprehensiveness of HCC recapture to ensure that diagnosis opportunities are identified timely and appropriately, with a goal to optimize the program’s financial benefit to Banner Health. Partners with Risk Adjustment resources to provide guidance on utilization of Risk Adjustment tools. Provides formal training and supports physicians and practices in the day to day utilization of Risk Adjustment tools throughout Banner Medical Group. Serves as primary contact with external physicians and practices for escalated issue resolution related to Banner RAF tools. Identifies trends and escalates issues as required to ensure proper resource management, customer satisfaction and issue resolution. Develops and implements recommendations to improve business processes to support and/or optimize RAF scores. Works collaboratively with ambulatory care management to ensure quality performance criteria expectations are disseminated so physicians and practices are equipped to meet and/or exceed clinical targets. Accesses and interprets data from a variety of sources to gain full understanding of Risk Adjustment trends and educational opportunities. Meets regularly with BMG workforce team to review findings and develop an improvement plan to meet organizational goals. Partners with Risk Adjustment Quality Analysts and Educators to develop educational materials. Meets regularly with workforce teams to support communication and promote partnership. Participates in or leads Risk Adjustment projects designed to improve program offerings or address system limitations. This may include analysis of BMG Practice Management systems, clearinghouse routing, vendor routing and/or CMS submissions. Monitors data submission for attestation to CMS for Risk Adjustment. This position also analyzes and monitors clinical Risk Adjustment reports to and from CMS to ensure data accuracy and compliance. Reviews, prepares, analyzes, and presents reports and as needed. This subject matter expert role will interface on a regular basis with all levels at assigned facilities/entities. This position will also interact with both internal resources and external vendors.

AdventHealth PHSO Resources

Nurse Health Advisor

Posted on:

February 8, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Florida

Joining AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.

The Nurse Health Advisor coordinates care, educates clients, and provides interventions within the scope of case management practice that have direct influence on clinical and financial outcomes. It is a dynamic and systemic collaborative approach to providing and coordinating health care services to a defined population across the continuum. Responsibility includes identification of high-risk clients, assessment of healthcare needs, collaboration, and coordination with health care providers and development of plan of care with accurate documentation of these activities. Participates in the process to identify and facilitate options and services for meeting individuals' health care needs, while decreasing fragmentation and duplication of care and enhancing quality and cost-effective clinical outcomes. Actively participates in outstanding customer service and accept responsibility in maintaining relationships that are equally respectful to all.

Minimum qualifications: Graduate of a school of accredited nursing 5 years of clinical experience as a registered nurse Current registration with Florida State Board of Nursing Current, valid State of Florida license as a registered professional nurse (RN) Preferred qualifications: Bachelor's Degree of Science degree or advanced degree Previous experience with telecommuting, activity tracking, call-centers, and related metrics Experience in clinical nursing with a minimum of 5 years’ experience in the following job areas is highly preferred: case management, quality assurance, utilization management, insurance/managed care industry, hospice/home health care, ED/ICU and geriatric care 1 year of attending face-to-face meetings using WebEx, Skype, FaceTime, Go-To-Meeting, Zoom, or a similar 2-way webcam enabled technology CCM - Certified Case Manager

Identify high-risk clients, monitor, assess, and evaluate health care /psychosocial needs, collaborate and coordinate care and services between healthcare providers Develop plans of care with immediate and long-term goals, organize and implement care management activities, and document interventions and activities consistent with individualized and care management goals. Adhere to case management standards of practice for case management and follows evidence-based clinical guidelines, incorporates whole person care with CREATION Health model promoting quality care and cost-effective outcomes that enhance physical, psychosocial and vocational health of individuals Assesses clients/caregiver(s) activation stage, literacy level, and self-management capabilities. Identifies and refers client to appropriate interdisciplinary care team member and/or community resources for identified needs in these areas. Incorporates the assessments and referrals into plan of care. Facilitates advanced care planning and collaboration with behavioral health services to prevent/avoid unnecessary hospitalizations and/or readmissions. Educates client and family/caregiver(s) on diagnosis, medications, medication reconciliation, nutrition and moves client toward self-management. Monitor and document response to interventions and client progress utilizing motivational interviewing to facilitate positive behavior change and meeting goal driven outcomes. Collaborate with the interdisciplinary care team to develop person-centered care plans that prevent avoidable hospitalizations and ED visits

Sunshine State Health Plan

Manager, Quality Improvement

Posted on:

February 8, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Florida

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.

Oversee and manage the functions of the quality improvement program. Providing support to staff and communicate with departments and staff to facilitate daily quality improvement (QI) functions. Including Accreditation, Trilogy Documents and State Deliverables. This is a fully remote position but must reside/sit in Florida.

Education/Experience: Bachelor’s degree in related field or equivalent experience. 3+ years clinical, quality management or healthcare related experience and 1 year of recent quality improvement and supervisory experience in a healthcare environment, preferably managed care. License/Certification: Current state registered nursing license preferred. Certain states may require a formal certification in quality improvement, risk management, or another parallel field. Certified Professional in Healthcare or other licensed clinical experience preferred. This is a fully remote position but must reside/sit in Florida.

Review and analyze reports, records and directives. Confer with staff to obtain data such as new projects, status of work in progress, and problems encountered, required for planning work function activities. Verify data to be submitted in accordance with government program requirements and ensure compliance with state, federal and certification requirements. Prepare reports and records on work function activities for management. Oversee the review and analysis of reports. Evaluate current procedures and practices for accomplishing the assigned work functions objectives to develop and implement improved procedures and practices and to ensure compliance with required standards. Collaborate with appropriate departments to document, investigate and resolve formal or informal complaints and appeals in accordance with Company and State policies, procedures and requirements. Monitor and analyze costs and participate in the preparation of the budget.

CVS Health

Utilization Management Review Consultant (Weekend)

Posted on:

February 8, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

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.

Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours. This is a full-time remote Utilization Review opportunity. Working hours are four 10hr days including every Weekend, both Saturday and Sunday, and two weekday shifts of 10hrs each (Monday, Tuesday, Wednesday,Thursday or Friday). Also includes holiday and late rotations. 12.5% Shift Premium applies once M-F training schedule completed and UM Nurse Consultant participating in non-traditional, weekend shift rotation. As a Utilization Management Nurse Consultant, you will utilize clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. You would be responsible for ensuring the member is receiving the appropriate care at the appropriate time and at the appropriate location, while adhering to federal and state regulated turn-around times. This includes reviewing written clinical records.

Required Qualifications: Must have active current and unrestricted RN licensure in state of residence Willing and able to obtain additional Nursing Licenses as business needs require 3+ years of experience as a Registered Nurse 1+ years of clinical experience in acute or post-acute setting Must be willing and able to work four 10hr days including every Weekend, both Saturday and Sunday, and two weekday shifts of 10hrs each in time zone of residence; Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours. 12.5% Shift Premium applies once Monday through Friday training schedule completed and UM Nurse Consultant participating in non-traditional, weekend shift rotation Preferred Qualifications: Critical care experience i.e. ICU, CCU, NICU, ER Utilization review experience Managed Care experience Experience working with MS office applications such as Teams, Outlook, Excel, and Word Education: Associates Degree or Nursing Diploma Required BSN Preferred

Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function. Typical office working environment with productivity and quality expectations. Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor. Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment. Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding. Effective communication skills, both verbal and written

Point32Health

Per Diem Care Manager – SCO

Posted on:

February 8, 2025

Job Type:

Part-Time

Role Type:

Care Management

License:

RN

State License:

Massachusetts

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

Under the administrative direction of the Clinical Manager, the Nurse Case Manager (NCM) for Senior Care Options (SCO) is responsible to conduct assessments for frail elderly population, while working within a healthcare team. The RNCM directly interfaces with physicians, other members of the primary care team, members, and their caregivers in identifying risk factors, conducting assessments, and developing and implementing care plans to comprehensively manage members’ care.

EDUCATION: (Minimum education & certifications required) Bachelors of Science in Nursing (BSN) and Registered Nurse with current, unrestricted state license is required. EXPERIENCE: (Years of experience) Minimum 3 years clinical nursing experience required Experience in case management managing geriatric/chronic illness populations required Experience within a SCO program highly preferred Experience in Medicare and/or Medicaid managed care preferred Proficient in computer use, the Internet, and health information technology required Case management certification a plus SKILL REQUIREMENTS: (Include interpersonal skills) Work cooperatively as a team member across multiple levels within the organization Demonstrate initiative in achieving individual, team, and organizational goals and objectives Must be able to prioritize work and develop strategies for adapting to constantly changing priorities and urgencies. Regard for confidential data and adherence to corporate compliance policy Demonstrate cultural competency and sensitivity Demonstrate the ability to work autonomously WORKING CONDITIONS AND ADDITIONAL REQUIREMENTS: (include special requirements, e.g., lifting, travel, overtime) Ability to travel frequently to member’s homes, hospitals, skilled nursing facilities, PCP office practices and other sites where patients receive care.

Timely completion of all types of geriatric assessments Development and communication (with member, caregiver and primary care physician/primary care team) of an individualized plan of care Completion of the Minimum Data Set-Home Care (MDS-HC) Facilitation of member and caregiver access to community resources relevant to the member’s needs, including referrals to Adult Day Health, Adult Foster Care and the Personal Care Attendant Program. Pro-active management and follow-up (via home visits and by telephone) according to the member’s care plan Direct caregiver support Serves as a member advocate and facilitator to resolve issues that may be barriers to care Provide education and coaching to the member, family, and/or caregiver about health status, treatment options, goals of care, and health insurance benefits to assist members in making the most informed decisions and help promote self-management SCO RN Care Manager per diem positions are required to meet a minimum productivity of 25 face to face assessments per month, which would be a mix of initial assessments, annual assessments and ongoing assessments not to exceed 25 assessments/month. This includes the entire process of each assessment to be considered complete.

CVS Health

Case Manager RN - Remote

Posted on:

February 8, 2025

Job Type:

Full-Time

Role Type:

Case Management

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.

Fully remote role with requirement to reside within a compact state. Preference for those residing in Arizona. Required schedule: Monday-Friday 8a-5pm MST , with some flexibility required to accommodate member's needs.

Required Qualifications: 3+ years clinical practice experience as an RN required Compact RN with active and unrestricted licensure in state of residence required Willingness to obtain additional state licensure as needed Preferred Qualifications: Bilingual English/Spanish Med/Surg experience Managed care experience Case management experience Education: Associate degree required BSN preferred

Nurse Case Manager is responsible for telephonically assessing, planning, implementing and coordinating all case management activities with members to evaluate the medical needs of the member to facilitate the member’s overall wellness. Develops a proactive 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. 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 to benefit overall medical 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.

Ciba Health Inc.

Registered Nurse Care Manager

Posted on:

February 8, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

New York

We are currently looking for a full-time Registered Nurse Care Manager to join our dynamic multi-disciplinary team who is flipping healthcare on its head and shifting the paradigm of the “sick-care model” to the “well-care model” of the future. As a nurse, we are looking for someone excited about an exciting role within a digital health startup. The candidate must be professional, efficient and organized, very reliable, clinically well-versed, independent, have an excellent team work ethic and of course, be a compassionate patient advocate.

Qualifications: RN with a minimum of 3 years of experience in case management 3+ years of clinical experience in primary care, acute care, or related fields Ability to work effectively with a multidisciplinary team Strong communication skills with patients, providers, and external stakeholders Experience in office management and operations Proficiency in technology and willingness to learn new systems What You Bring: Passion for root-cause/functional medicine Startup mentality with a willingness to contribute to building a growing healthcare company Excellent organizational skills and ability to work in a fast-paced environment

Provide key support in engaging patients in their care Serve as a liaison in coordinating patients' care Develop and implement best practice workflows Manage lab and prescription orders Generate appointments for patients Collaborate with other healthcare professionals to coordinate patient care effectively

Pager Health

Bilingual Nurse Navigator

Posted on:

February 8, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

Pager Health is a connected health platform company that enables healthcare enterprises to deliver high-engagement, intelligent health experiences for their patients, members and teams through integrated technology, AI and concierge services. Our solutions help people get the right care at the right time in the right place and stay healthy, while simultaneously reducing system friction and fragmentation, powering engagement, and orchestrating the enterprise. Pager Health partners with leading payers, providers and employers representing more than 28 million individuals across the United States and Latin America. We believe that healthcare should work for everyone. We believe that it’s too important to be as cumbersome and difficult as it is. And we believe that there is a better way to deliver a simplified, more meaningful healthcare experience for all – one that we’re determined to enable.

This position is for a full-time, remote Bilingual Registered Nurse who is willing to think creatively and utilize their clinical skills in the field of Telehealth! We are seeking motivated Registered Nurses with 2+ years of clinical hospital experience to work in Pager Health's Command Center. An active compact unencumbered RN license is required for this position. This position entails working 11am-8pm EST, five days per week, including rotating (every other) weekend and some holidays. The core objective of the Triage RN, Nurse Navigator is to use technology to build trust and triage patients to the right care at the right time while providing an exceptional virtual care experience through empathic communication.

2+ years of clinical hospital experience; within the ICU or ER highly preferred An active compact unencumbered RN license Minimum of Associates Degree in Nursing (ADN) Bilingual and able to communicate in both English and Spanish fluently Ability to give and receive actionable feedback Passionate about patient care and triage Enjoy helping others Ability to use critical thinking when presented with new and challenging situations Relish solving problems, seeking out answers, and trying new things Kind, empathetic and possess a strong social perceptiveness Positive, energetic, and fun! Outstanding multitasking skills Enthusiasm and savviness for new technology Mastery of oral and written language along with strong typing skills Ability to assess and communicate with patients via a text-based platform Flexible and fast learner, comfortable in a fast-paced and changing environment Eager to challenge the status quo of traditional healthcare Detail oriented and an organized self-starter with outstanding interpersonal skills

Provide exceptional customer service and virtual care by communicating with patients via live messaging, video, phone, and/or email Document within EMR Follow and apply clinically validated triage protocols Ensure the highest quality customer service for patients and providers Complete basic nursing responsibilities, outpatient testing, medications, etc… Troubleshoot technology with patients Work to ensure a seamless patient call center experience Coordinate lab orders, prescription orders, radiology tests, and any aspect of patient care Work on projects that will optimize operational efficiency and improve the patient’s telemedicine experience Assist in identifying technology needs that improve patient experience Additional projects as assigned

Pager Health

Per Diem Nurse Navigator

Posted on:

February 8, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

Pager Health is a connected health platform company that enables healthcare enterprises to deliver high-engagement, intelligent health experiences for their patients, members and teams through integrated technology, AI and concierge services. Our solutions help people get the right care at the right time in the right place and stay healthy, while simultaneously reducing system friction and fragmentation, powering engagement, and orchestrating the enterprise. Pager Health partners with leading payers, providers and employers representing more than 28 million individuals across the United States and Latin America. We believe that healthcare should work for everyone. We believe that it’s too important to be as cumbersome and difficult as it is. And we believe that there is a better way to deliver a simplified, more meaningful healthcare experience for all – one that we’re determined to enable.

We are looking for a Per Diem (As Needed) Nurse who can commit to 13-24 hours per week. Candidates must be available for some weekends and holidays. Shifts range from 4 to 12 hours, with scheduling based on business needs. Candidates must also be able to complete a 4 week, full-time (M-F 9am-5pm) onboarding period. If you have a flexible schedule and are comfortable picking up both last-minute shifts and pre-planned hours, this role is a great fit for you! An active, unencumbered, compact RN license is required for this position, as well as 2+ years of clinical hospital experience. The core objective of the Triage RN, Nurse Navigator is to use technology to build trust and triage patients to the right care at the right time while providing an exceptional virtual care experience through empathic communication.

2+ years of clinical hospital experience; within the ICU or ER highly preferred An active compact unencumbered RN license Minimum of Associates Degree in Nursing (ADN) Ability to give and receive actionable feedback Fluent writing/speaking in Spanish is a plus Passionate about patient care and triage Enjoy helping others Ability to use critical thinking when presented with new and challenging situations Relish solving problems, seeking out answers, and trying new things Kind, empathetic and possess a strong social perceptiveness Positive, energetic, and fun! Outstanding multitasking skills Enthusiasm and savviness for new technology Mastery of oral and written language along with strong typing skills Ability to assess and communicate with patients via a text-based platform Flexible and fast learner, comfortable in a fast-paced and changing environment Eager to challenge the status quo of traditional healthcare Detail oriented and an organized self-starter with outstanding interpersonal skills

Provide exceptional customer service and virtual care by communicating with patients via live messaging, video, phone, and/or email Document within EMR Follow and apply clinically validated triage protocols Ensure the highest quality customer service for patients and providers Complete basic nursing responsibilities, outpatient testing, medications, etc… Troubleshoot technology with patients Work to ensure a seamless patient call center experience Coordinate lab orders, prescription orders, radiology tests, and any aspect of patient care Work on projects that will optimize operational efficiency and improve the patient’s telemedicine experience Assist in identifying technology needs that improve patient experience Additional projects as assigned

UCB

Mito Case Manager (MCM)

Posted on:

February 8, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

None Required

State License:

California

UCB is a global biopharmaceutical company, focusing on neurology and immunology. We are around 8,500 people in all four corners of the globe, inspired by patients and driven by science.

We are looking for a Mitochondrial (Mito) Case Manager (MCM) who is empathic, collaborative and patient-focused when assisting patients' HCPs with the reimbursement journey to access to join our Onward Patient Services team, based in the U.S. as a remote/virtual role is designed to support the entire U.S. About the role The Mitochondrial (Mito) Case Manager is a nonpromotional role that serves as the primary point of contact for prescribers for market access and reimbursement related questions and support in navigating insurance and access-related barriers. They understand market access and the reimbursement journey encompassing procurement, payer policies, and coverage, benefit design, prior authorizations (PAs), appeals, exceptions, denials, coding and payer payment guidelines, understanding of coding guidelines (CPT/J-Code/ICD-10), with demonstrated knowledge of the complex payer environment as it pertains to insurance benefit structures, with strong ability to relay detailed benefits information to help patients. This individual will share insights and collaboratively coordinate support with internal and external program partners. The MCM will have strong communication skills to relay detailed benefit information and is expected to demonstrate market expertise in communicating payer criteria/terms and practices, as these relate to UCB Products. Who you’ll work with The work of an MCM is to help patients gain access to prescribed UCB rare disease medicines by working with: Onward Care Coordinators Mito Regional Leads (MRLs) Legal, compliance, Market access strategy Specialty Pharmacies, Payers, HCPs, Office staff

8-10 years of experience in pharma, biotech, or healthcare space 5+ years of case manager experience supporting market access, biologics claims and appeals manager, hospital social work, pharma, specialty pharmacy, biotech, or relevant healthcare space Excellent working knowledge of the evolving reimbursement landscape and the practice management environment Ability to understand health care insurance including CHIP, and Medicaid Demonstrated knowledge of the complex regulatory environment Above-average skills with technology, including the ability to quickly learn and accurately utilize contact center systems, CRM, and virtual platforms Preferred: Bachelors/Masters Preferred, or extensive relevant experience Pediatric experience Rare Disease or Ultra Rare disease experience Experience in managing access complexities associated with a new-to-market medication Experience with specialty pharmacy products/products acquired through specialty pharmacy networks

Serve as expert on challenging market access patient cases specific to benefit verifications, product procurement processes, reimbursement information, billing, coding, and coverage details after the clinical prescribing decision has been made by the HCP Provides support to accounts specific to benefit verifications, product procurement processes, reimbursement information, billing, coding, and coverage details, after the clinical prescribing decision has been made by the HCP & keep team updated Provide appropriate PA, Appeals, and Claims support Establish yourself as a national and regional expert on payer trends, product access, and reporting reimbursement trends and/or delays (i.e., denials, underpayment, access delays, etc.) Coordinate and collaborate with UCB Care Coordinators, specialty pharmacies, HCPs and their office staff, infusion providers, and other key personnel on complex cases that require strategic intervention Manage and facilitate specialty pharmacy relationships, responsible for dispersing updates to team members and ensuring forward patient momentum Demonstrate a strong compliance mindset, demonstrating a clear understanding of applicable laws and regulations, including patient privacy laws Advise HCPs on patient-specific reimbursement issues in compliance with policies and well-defined ways of working Provides strategic coverage/reimbursement support and marketplace feedback to internal colleagues aligned to their geographies Develops state-level key access stakeholder relationships with healthcare professionals who will advocate with Medicare Part A/B, Commercial and State Payers for medical and pharmacy benefit access to UCB rare disease products for patients · Expected to demonstrate market expertise in communicating payer criteria/terms and practices, as these relate to assigned products Provides strategic coverage/reimbursement support and marketplace feedback to internal colleagues aligned to their geographies

UCB

Care Coordinator GMG

Posted on:

February 8, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

California

UCB is a global biopharmaceutical company, focusing on neurology and immunology. We are around 8,500 people in all four corners of the globe, inspired by patients and driven by science.

We are seeking a Care Coordinator for the Western Region of the US who is a compassionate, patient-centric healthcare professional (e.g., nurse or pharmacist) for this remote/virtual opportunity that will support the Western time Zones standard hours of operations are 8:00 am PST to 5:00 pm PST. The role may require up to 20% face-to-face interactions and travel to existing UCB sites. About the role The Care Coordinator is a healthcare professional who offers individualized support and serves as the primary point of contact for patients, families, and caregivers enrolled in the UCB Rare Disease Patient Support Program. The UCB Rare Disease Patient Support Programs are designed to help patients gain access to, and support the appropriate use of, a prescribed treatment by offering support along the patient’s treatment journey. You will assume case management responsibilities and focus on supporting patients with access, affordability, administration, and adherence-related care. You’ll identify and alleviate stressors and barriers to treatment through appropriate educational solutions with the aim of delivering an individualized model of care that benefits patients, families, and caregivers. Who you’ll work with Patients and Caregivers Internal and external stakeholders Rare Case Manager Specialists Customer Operations Representatives Access Specialists Specialty Pharmacies, and other key personnel as applicable

Current RN license, bachelor’s degree in pharmacy or Pharm.D., or relevant experience within a healthcare setting  At least two (2) years’ clinical experience required Above-average skills with technology, including ability to quickly learn and accurately utilize contact center systems, CRM, and virtual platforms One to two years' experience in remote/virtual Call Center providing patient education and support required Excellent virtual interaction and customer communication skills – both written and verbal Provide world class Customer service. Flexibility to work evenings Preferred: Clinical education experience  Experience with Industry Patient Support Programs   Extensive call center experience   Rare disease experience Previous experience working remotely

Serve as patient primary point of contact for UCB’s Rare Disease Patient Support Services Program Supports patients through education and setting of proper expectations of treatment Understand and communicate patient-specific insurance coverage along with access and affordability options to support appropriate patients Understand patient-specific perceptions regarding treatment and support to meet the unique patient’s needs and preferences Understand patient-specific knowledge and beliefs about their illness (severity, treatability, controllability), and help the patient see their progress, where applicable Identify ways to enhance patient and provider-specific communication, to equip the patient with questions to consider when discussing their treatment regimen with their HCP Understand how the patient lives with the condition, and offer tools and resources to address financial, social, and emotional needs, where possible/applicable Execute the Patient Support Program in compliance with UCB Standard Operating Procedures and report safety information accordingly.

CVS Health

Case Manager RN - Tarrant County and Dallas County

Posted on:

February 7, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

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.

This is a work from home flexible position with expected travel up to 50% that will require home visits. Schedule is Monday-Friday, standard business hours, 8:00am-5:00pm CST.

Required Qualifications: Active and unrestricted RN license in the state of TX 2+ years of clinical experience Must reside in Tarrant County or Dallas County of TX Willing and able to travel up to 50% of their time to meet members face to face Tarrant County, Dallas County, or surrounding counties Reliable transportation required; mileage is reimbursed as per company policy Preferred Qualifications: Case Management and/or home health care experience Managed care organization (MCO) experience Pediatric experience Education: Minimum of an Associate degree in Nursing required BSN preferred

Develop, implement, support, and promote health service strategies, tactics, policies, and programs that drive the delivery of quality healthcare to our members. Health service strategies, policies, and programs are comprised of utilization management, quality management, network management, clinical coverage, and policies. The position requires advanced clinical judgment and critical thinking skills to facilitate appropriate physical, behavioral health, psychosocial wrap around services. The care manager will be responsible for, care planning, direct provider collaboration, and effective utilization of available resources in a cost-effective manner. Strong assessment, writing and communication skills are required. The Case Manager is responsible for conducting face to face visits in the members home utilizing comprehensive assessment tools for members enrolled in Long-Term Services and Support programs. The case manager is responsible for coordinating and collaborating care with the member/authorized representative, PCP, and any other care team participants. The case manager schedules and attends interdisciplinary meetings and advocates on the members behalf to ensure proper and safe discharge with appropriate services in place. The case manager works with the member and care team to develop a care plan and authorizes services in a cost-effective manner within the LTSS benefit. The care manager is responsible for documenting accurately and timely in the member’s electronic health record. This position requires the case manager to use critical thinking skills and the ability to problem solve. Assessment of Members: Through the use of care management tools and information/data review, the Case Manager conducts comprehensive evaluation of referred member’s needs/eligibility and recommends an approach to case resolution and/or meeting needs by evaluating member’s benefit plan and available internal and external programs/services. Identifies high risk factors and service needs that may impact members outcome and care planning components with appropriate referrals. Coordinates and implements assigned care plan activities and monitors care plan progress. Enhancement of Medical Appropriateness and Quality of Care: Uses a holistic approach to overcome barriers to meet goals and objectives; presents cases at case conferences to obtain multidisciplinary review in order to achieve optimal outcomes. Identifies and escalates quality of care issues through established channels. Utilizes negotiation skills to secure appropriate options and services necessary to meet the member’s benefits and/or healthcare needs. 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 support to empower the member to make ongoing independent medical and/or healthy lifestyle choices. Helps member actively and knowledgeably participate with their provider in healthcare decision-making.

Suncoast Behavioral Health Center

Remote Referral Management Specialist: Nights

Posted on:

February 7, 2025

Job Type:

Full-Time

Role Type:

Behavioral Health

License:

RN

State License:

Florida

One of the Nation’s largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. has built an impressive record of achievement and performance. Growing steadily since its inception into an esteemed Fortune 500 corporation, our annual revenues were $10.77 billion in 2018. In 2020, UHS was again recognized as one of the World’s Most Admired Companies by Fortune; in 2019, ranked #293 on the Fortune 500; and in 2017, listed #275 in Forbes inaugural ranking of America’s Top 500 Public Companies. Headquartered in King of Prussia, PA, UHS has more than 87,000 employees and through its subsidiaries operates 26 acute care hospitals, 327 behavioral health facilities, 40 outpatient facilities and ambulatory care access points, an insurance offering, a physician network and various related services located in 37 U.S. states, Washington, D.C., Puerto Rico and the United Kingdom.

Suncoast Behavioral Health Center opened its doors in 2014 and provides the highest quality of behavioral healthcare for patients in a safe, secure and nurturing environment. Suncoast Behavioral Health Center is a 60-bed free-standing psychiatric hospital. We offer diverse inpatient and residential programs for children and adolescents. In a highly specialized field of psychiatry, our goal is to promote cognitive, social, physical and emotional development to provide individuals with the knowledge and skills to help our patients succeed. The Hospital is looking for a Remote Referral Management Specialist (Monday - Friday Nights 11P – 7:30A). The Referral Management Specialist is the initial contact with referral sources and potential patients, coordinates the referral and intake process, facilitates the admission process and maintains communication with referral sources, families, patients and unit staff.

Licensed RN or LPN preferred; Master’s Degree in a Behavioral Health related field (QMHP). Current license to practice nursing in Florida. 1-3 years of experience preferred in psychiatric health care. Experience in Behavioral Health Intake/Admissions preferred. Excellent customer service and communication skills (i.e., verbal and written). Ability to prioritize; work well under periods of high stress and pressure. Ability to multi-task and demonstrate critical thinking skills. Thorough knowledge of psychiatric services and medical capabilities provided by the hospital. Ability to work flexible hours. Requires knowledge of computers and ability to utilize Department specific electronic applications; and accurate data entry skills. Experience reviewing medical and clinical information to staff appropriately with physician is preferred.

Performs all aspects of the hospital’s assessment and referral process Ensures expedient processing of E-Fax and Concord referrals Monitors Electronic Bed Board Reviews Medical Records Verifies Medical Insurance Enters data in MedSeries IV Exhibits excellent customer relations skills as evidenced by supportive and constructive communication with all contacts including coworkers, physicians, patients, visitors, families and referral sources.

HonorHealth

RN Specialist Clinical Documentation

Posted on:

February 7, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

HonorHealth is one of Arizona’s largest nonprofit healthcare systems, serving a population of five million people in the greater Phoenix metropolitan area. The comprehensive network encompasses nine acute-care hospitals, an extensive medical group with primary, specialty and urgent care services, a cancer care network, outpatient surgery centers, clinical research, medical education, a foundation, an accountable care organization, community services and more. With more than 16,000 team members, 3,700 affiliated providers and over 1,100 volunteers dedicated to providing high quality care, HonorHealth strives to go beyond the expectations of a traditional healthcare system to improve the health and well-being of communities across Arizona. Learn more at HonorHealth.com.

**Remote in the greater Phoenix, NW Valley/Anthem, Scottsdale, Mesa, Tempe metro area** Training requires being on-site at least one (1) day per week. Looking to be part of something more meaningful? At HonorHealth, you’ll be part of a team, creating a multi-dimensional care experience for our patients. You’ll have opportunities to make a difference. From our Ambassador Movement to our robust training and development programs, you can select where and how you want to make an impact. HonorHealth offers a diverse benefits portfolio for our full-time and part-time team members designed to help you and your family live your best lives. Visit honorhealth.com/benefits to learn more. Join us. Let’s go beyond expectations and transform healthcare together.

Education: Associate's Degree in Nursing or Foreign Medical (MD) Graduate with extensive clinical background and current CDI or coding experience. Required Experience: 5 years patient care in hospital setting Required Licenses and Certifications: Nursing\RN - Registered Nurse - State Licensure And/Or Compact State Licensure or Foreign Medical (MD) Graduate Required

Improves the overall quality and completeness of clinical documentation through the application of evidence-based knowledge, analysis, in-depth review, interpretation, identification of opportunities, communication and consistent follow-up and evaluation of concurrent and retrospective (as required) medical record documentation. Interacts primarily with, but not limited to, physicians, nursing staff, other patient caregivers and health information coding staff to capture appropriate reimbursement and clinical severity for the level of service rendered to all patients, with a focus on DRG-based payers. Facilitates timely, accurate and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes in compliance with regulatory standards. Educates all members of the patient care team on issues relating to clinical documentation. Works with Clinical Data Analyst – ICCM to quantify complete and accurate clinical documentation and utilization, focusing on DRG payers. Demonstrates knowledge of DRG payer issues for documentation opportunities, clinical documentation requirements, coding standards as applied to medical record documentation and compliance requirements. Demonstrates working knowledge of APR DRG's and intensity of service criteria. Applies teaching/learning principles in establishing an overall educational program related to effective clinical documentation for, and in collaboration with, physicians and the health care team. Develops and maintains close working relationships with physicians and the departments of coding, nursing, health information management, quality and managed care, as well as ancillary departments responsible for clinical documentation. Position requires self-directed, independent decision-making, analytical teaching and articulate communication skills, both verbal and written. Assumes responsibility and accountability for incorporating the mission, vision, values and critical goals of the organization into job performance. Demonstrates enhanced knowledge of anatomy and pathophysiology to facilitate the increased need for granularity and specificity in the clinical documentation with the transition to new coding systems. Demonstrates the ability to accurately utilize coding guidelines, software and resource material. Provides informal and formal education on required documentation and acts as a resource to physicians and other members of the health care team. Performs concurrent and retrospective (as required) medical record review utilizing evidence-based knowledge, protocols, and criteria. Facilitates modifications to support clinical documentation of health team members to ensure that appropriate reimbursement is received for the level of service rendered to all patients with a focus on physician documentation, inpatients and DRG payors. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and Hospital outcomes. Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient’s chart. Communicates and interacts with physicians and clinical staff, verbally and through the use of written communication tools, observations and recommendations to improve the overall quality and completeness of clinical documentation. Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient’s chart. Tracks response to clinical documentation and trends completion of the process, e.g. DRG worksheets. Establishes cooperative and multidisciplinary relationships with physicians and health team members including successful problem resolution and acts as a resource to the health team members related to optimal documentation. Develops and implements formal and informal educational programs related to documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies for internal customers and physicians. Designs, generates and evaluates the effectiveness of reports and evaluation tools, in conjunction with the Clinical Analyst- ICCM, utilizing multiple data systems in order to analyze impact of the documentation improvement process. Analyzes and compiles accurate and complete data for statistical reporting and educational presentations. Analyzes, summarizes and documents outcomes of documentation improvement process for re-evaluation of ongoing program revisions. Participates as a member of work groups related to clinical documentation, utilization and compliance, if required. Assumes responsibility and accountability for incorporating the vision, values, mission and critical goals of the organization into job performance. Perform other duties as assigned.

Acentra Health, LLC

Case Management Triage Nurse - RN (Remote U.S.)

Posted on:

February 7, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

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

Acentra seeks a Case Management Triage Nurse - RN to join our growing team. Outreach to health plan members to assess and determine if they have intervenable needs that can be addressed through Case Management, Disease Management, Health Coaching, Care Navigation, or Care Coordination. Using independent judgment, knowledge, expertise, and excellent communication skills to assess the members’ needs and engage them in enrollment into the appropriate program to meet their needs. Working collaboratively with all healthcare team members, internally and externally. ** The hours of coverage required by the contract/client for the Case Management Triage Nurse - RN roles are: Monday-Friday, 9:00 AM – 6:00 PM Eastern OR 8:00 AM – 5:00 PM Central. The specific hours worked between those times will be determined by the selected candidate's availability along with approval from your Leader. This will be agreed upon during the interviewing process, and the selected candidate must maintain the set schedule once started. **

Required Qualifications/Experience: Active, unrestricted Registered Nurse (RN) compact license. Associate’s degree (or Diploma) in Nursing. 3+ years of clinical experience performing case management services in a medical or behavioral health environment. Ability to multitask and prioritize with variable and sometimes conflicting deadlines; superior attention to detail and demonstrated decision-making ability. Demonstrated initiative and judgment in performing job responsibilities while maintaining professionalism, flexibility, and dependability under pressure. Strong communication (written/verbal), interpersonal, organizational, and time management skills with a strong focus on customer service, including building and maintaining relationships with internal/external customers. Ability to work independently and as part of a team. Ability to research/identify and apply appropriate standards of care. Interest in continuous learning and a commitment to staying informed on regulatory changes. Motivational interviewing skills and ability to positively motivate members to participate in programs during outreach. Proven track record of excellent engagement skills in case management programs. Experience in triaging and prioritizing cases based on risk and identified needs. Strong clinical acumen and ability to identify issues that may warrant enrollment in a case management program. Ability to evaluate reports, claims, and medication profiles and identify those who may benefit from case management intervention. Experience with utilizing Microsoft Word, Excel, and Outlook. Proficient in navigating multiple computer programs at the same time. Excellent documentation skills utilizing proper terminology, spelling, and grammar. Preferred Qualifications/Experience: Bachelor’s degree in Nursing. Certified Case Manager (CCM).

Utilizes predictive modeling and risk tool reports to determine the priority of outreach to members based on risk score, claims history, medications, and referral task reason(s). Opens case in electronic medical record system, creates a triage program, and begins member outreach. Using motivational interviewing, complete a screening assessment to identify intervenable needs. Review needs with a member, discuss how the program can help meet their needs, and get their consent to enroll. Assign members who consent to the applicable program; provide members with the name of their assigned case manager and generate a welcome packet. Assign a "new case" task to the applicable case manager. Provide short-term interventions for members who declined CM program enrollment but have immediate needs. Complete screening assessment outcomes and document any interventions discussed with members. Educates members about community resources/options, if needed. Maintains strict standards for client confidentiality and client-related information. Complies with all organizational, state, and federal regulations and policies on confidentiality. Prepares member documentation and coordination summaries in accordance with regulatory requirements and company policies and procedures. Pursues ongoing education, certification, and self-development to remain current with case management standards and licensure requirements. The above list of accountabilities is not intended to be all-inclusive and may be expanded to include other duties that management may deem necessary from time to time.

Wellstar Health System, Inc.

Clinical Documentation Specialist PRN

Posted on:

February 7, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

The Remote Clinical Documentation Specialist (CDS) demonstrates strong clinical knowledge and understanding of coding/DRG requirements to improve overall quality and completeness of clinical documentation in the patient medical record on a concurrent, and potentially a prospective and retrospective basis, using a multi-disciplinary team process. The CDS works collaboratively with physicians, other healthcare professionals and coding team to ensure that clinical information in the medical record is present and accurate so that the appropriate utilization, clinical severity, outcomes and quality is captured for the level of service rendered to all patients, as well as ensuring compliant reimbursement of patient care services.

Required Minimum Education: Bachelor's Degree in nursing or other health-related field Preferred Required Minimum License(s) and Certification(s): All certifications are required upon hire unless otherwise stated. Cert Clin Document Specialist or Cert Coding Spec or Cert Document Improvement Prac or Reg Nurse (Single State) or RN - Multi-state Compact Additional License(s) and Certification(s): Required Minimum Experience: Minimum 5 years of healthcare experience Preferred Strong medical surgical and/or critical care background Preferred Minimum 2 years clinical documentation improvement experience Preferred Experience with care coordination/utilization management, coding/DRG, billing, auditing and various healthcare payers Preferred Clinician preferred and/or CDIP/CCDS credential Preferred It is expected that all RN’s are licensed, knowledgeable and uphold the practice of nursing as outlined by the Scope of Practice and Code of Ethics Standards put forth by the American Nurses Association Required and EPIC Electronic Medical Record and CDI Software experience Preferred Required Minimum Skills: Self-directed with good written communication skills necessary to effectively communicate with physicians and other healthcare providers. Minimum MS Office (Word, Outlook, Excel and PowerPoint) knowledge and expertise is expected. Chart review experience required. Regulatory background and DRG reimbursement knowledge and strong understanding of coding methodologies and guidelines preferred.

Reviews clinical documentation during patient admissions and possibly prospectively or retrospectively, to determine opportunities to improve physician documentation and communicates identified opportunities to the physician. Facilitates appropriate modifications to clinical documentation to accurately reflect patient severity of illness and risk of mortality through extensive interaction with physicians, mid-level providers, case management team, nursing team, other patient caregivers, and HIM coding team. Reviews medical records concurrent and/or prospective/retrospective to the patient visit to determine opportunities to query physicians regarding essential clinical documentation. Conducts timely follow-up reviews to ensure appropriate clinical documentation is recorded in patient's chart. Performs concurrent hospital-wide medical record reviews facilitating improvement in the quality, completeness and accuracy of medical record documentation to ensure coding compliance, accurate reporting, appropriate reimbursement, and improved patient outcomes. Performs prospective and/or retrospective reviews as assigned. Submits electronic queries as appropriate, to clinicians to ensure documentation of complete and accurate records to allow coding assignments post discharge that will accurately reflect the severity and risk of mortality of the patient population. Ensure queries are compliant, grammatically correct, concise and free of typographical errors. Provides appropriate follow up on all queries. Notifies onsite Regional CDI Manager immediately when queries are not answered. Provides all data necessary for onsite Regional CDI Manager to assist. Reconciles all appropriate records daily in CDI software tool to ensure appropriate reporting is generated. Maintains required daily/weekly/monthly metrics. Meets productivity standards. Participates in required onsite meetings, conference calls and Skype presentations. Adheres to departmental Policies and Procedures. Participates in assuring hospital compliance with Federal and State regulatory requirements. Submit ideas to improve work flow and increase productivity of his/her team to the CDI Regional Manager/Executive Director and perform any other duties as assigned. 80% Maintains knowledge of coding and billing rules and regulations to ensure that the documentation in the medical record supports appropriate reimbursement. Maintain knowledge base of current medical terminology, procedures, medications and diseases to provide accurate patient record analysis. Reviews quarterly Coding Clinic changes/summaries and follows appropriate required changes to their process. 5% Ensures the accuracy and completeness of clinical information used for measuring and reporting physician, hospital and regulatory outcomes. Reviews data and trends to identify additional areas of opportunity. Provides input to core measure and other quality data initiatives regarding areas for investigation and education (PSI’s and HAC’s). Identify and participate in opportunities to improve documentation, EPIC, and quality of care initiatives. 15%

Amedisys

Care Transitions Coordinator - Remote

Posted on:

February 7, 2025

Job Type:

Part-Time

Role Type:

Care Management

License:

RN

State License:

Georgia

This position is part time and fully remote! Are you looking for a rewarding career as a care transitions coordinator? If so, we invite you to join our team at Amedisys, one of the largest and most trusted home health and hospice companies in the U.S. This role requires an RN, LPN or other clinical license, plus previous outside sales/business development experience in the healthcare industry. A background in cold calling customers in pharmaceuticals, medical device sales, hospital, home health, hospice or long-term care is ideal.

At least one year of experience in a healthcare related business development/outreach role. A bachelors degree is preferred, but not required. Current RN or LPN license, specific to the state(s) you are assigned to work.

Educates health care professionals, patients, and families about home care services. Develops and maintains relationships with key referral sources, such as hospitals, nursing homes and physician offices to generate leads. Coordinates patient admissions with the team, including obtaining all required documentation to complete referral to admission process. Keeps accurate records of patient interactions and referrals. Maintains a complete, up-to-date record of targeted referral sources in territory in CRM. Responds to customer complaints in timely manner. Performs other duties as assigned.

Amedisys

Hospice Afterhours Triage Nurse - Saturday and Sunday

Posted on:

February 7, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Texas

Amedisys is a leading provider of home health, hospice, and high-acuity care, dedicated to helping patients and families navigate the complex healthcare system. With a focus on compassionate, patient-centered care, you would be joining a team of professionals committed to improving the lives of those they serve.

10-hour shift on Saturdays and Sundays Are you a highly skilled and compassionate registered nurse (RN) looking for a rewarding career as an afterhours triage nurse? If so, we invite you to join our team at Amedisys, one of the largest and most trusted home health and hospice companies in the U.S.

Current, unencumbered license to practice as a registered nurse in the state you are assigned to work. One year of experience as a registered nurse. Current CPR certification. Knowledge of physical, psychosocial, and spiritual needs of terminally ill patients and their caregivers. Must be comfortable with technology. Must be willing and eligible to obtain additional RN licenses in other states (reimbursed). Preferred: Previous hospice experience. Telephone triage experience. Spanish speaking.

Assesses physical, environmental, and emotional factors telephonically to determine hospice needs. Utilizes EHR, including the patient's plan of care to develop recommendations. Provides recommendations, patient/caregiver education/instructions and hospice support telephonically based on the situation and the plan of care. Collaborates with pharmacies, DME vendors and other agencies for effective patient management. Facilitates delivery or maintenance of provided medical equipment to meet patient needs. Assigns all visits, admissions and follow-up calls to on-call field staff (RN, LPN, HA, CH, SW) as needed. Submits accurate and detailed documentation in real-time to promote continuity of care. Utilizes a combination of agency resources and nationally recognized standards of practice to achieve excellent pain and symptom management and high-quality end-of-life care. Participates in agency performance improvement initiatives. Performs other duties as assigned.

Atrium Health

Utilization Management Registered Nurse - Lake Norman PT Days (Remote)

Posted on:

February 7, 2025

Job Type:

Part-Time

Role Type:

Utilization Review

License:

RN

State License:

Compact / Multi-State

Atrium Health is one of the nation’s leading healthcare organizations, connecting patients with on-demand care, world-class specialists and the region’s largest primary care network. A recognized leader in healthcare delivery, quality and innovation, our foundation rests on providing clinically excellent and compassionate care. We’ve been serving our community since 1940, when we opened our doors as Charlotte Memorial Hospital. Since then, our network has grown to include more than 40 hospitals and 900 care locations ranging from doctors’ offices to behavioral health centers to nursing homes. Our focus: Delivering the highest quality patient care, supporting medical research and education, and joining with partners outside our walls to keep our community healthy.

Utilization Management RN supports medical necessity, revenue integrity and denial prevention while coordinating with members of the healthcare team and payors for authorization of appropriate level of care and length of stay for medically necessary services. Accurately conducts medical necessity reviews, utilizing the electronic medical record, in accordance with all state and federal regulations and the Utilization Management Plan. Advocates for the patient while balancing the responsibility of stewardship for their organization, and in general, the judicious management of resources.

Physical Requirements: Works in an office type setting, extensive walking throughout the facility. Prolonged periods of sitting reviewing medical records and documentation. Repetitive wrist motion and occasional lifting of 10-20 pounds. Intact sight and hearing with or without assistive devices are required. Must speak English fluently and write English in understandable terms Education, Experience and Certifications: Bachelor’s in Nursing from an accredited school of nursing, required. Master's degree in business or healthcare related field, preferred. Previous utilization review experience preferred. Current RN license or temporary license as a Registered Nurse Petitioner in the state in which you work and reside or if declaring a National License Compact (NLC) state as your primary state of residency, meet the licensure requirements in your home state; or for Non-National License Compact states, current RN license or temporary license as a Registered Nurse Petitioner required in the state where the RN works. 5 years of related nursing experience preferred. Clinical experience within the assigned population. Extensive knowledge of disease processes and clinical outcomes. Case Management experience or background preferred. Strong financial and analytical skills preferred. Appropriate Professional certification required within 3 years of hire and per Clinical Care Management Certification Guidelines. Additional education, training, certifications, or experience may be required within the department by the department leader.

Coordination with members of the healthcare team and payors to facilitate placement of patients in the appropriate level of care related to medical necessity. Promotes an open communication between utilization management and the health care team concerning level of care. Responsible for timely provision/flow of specific clinical information to third-party payors to ensure authorization of stay. Maintaining compliance with professional standards, national and local coverage determinations, the Centers for Medicare, and Medicaid Services (CMS) as well as state and federal regulatory requirements, as applicable. Performs admission and continued stay utilization reviews to assure the medical necessity of hospital admissions, appropriate level of care, continued stay and supportive services, and to examine delays in the provision of services, in accordance with the utilization management plan. Demonstrates proficiency in applying nationally accepted evidence-based criteria to assure appropriate hospital level of service. Maintains timely and appropriate documentation of all utilization management activities. Utilizes critical thinking skills based upon extensive knowledge of disease processes and clinical outcomes to identify the need for further clarification of physician documentation within the medical record. Prioritize work to facilitate timely accurate utilization management activities for each evidence-based product type. Collaborates to improve quality throughput coordination of care impacting length of stay with minimizing cost and ensuring optimum outcomes. Identification and documentation of potentially avoidable delays. Demonstrates the ability to utilize the licensed software tool to perform and record daily medical reviews. Communicates information effectively, including comprehensive clinical information, to third-party payors, to secure timely authorization for the appropriate level of service. Provides payor feedback to case managers, social workers, and providers. Escalates and resolves denials to secure payment for the necessary care and services provided to the patient. Collaborates with payor, physician advisor, attending provider and multi-disciplinary team to reconcile payor-issued denials. Demonstrates proficiency and knowledge of various reimbursement criteria, including documentation necessary for reimbursement from regulatory bodies. Assist in process improvement of various committees, interdepartmental and departmental as assigned by the VP, AVP, Director, Medical Director, Manager or Team Supervisor. Supports and contributes to the Patient Centered Care Philosophy by understanding that every staff member is a Caregiver whose role is to meet the needs of the patient. Performs other duties and responsibilities as assigned and within the time frame specified.