Blue Eagle Consulting

Utilization Management Nurse

Posted on:

September 3, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Alabama

Blue Eagle Consulting (BEC) is known for providing “A-List” contract resources to help healthcare organizations maintain their core business applications – we solve temporary deficiencies in bandwidth and expertise. In addition, we deliver the best in the business when it comes to resources with the practical knowledge and expertise that industry leaders depend on. Since our beginnings in 2004, we have worked with dozens of integrated delivery networks, health plans, physician organization and hospital organizations in the United States and Puerto Rico. We primarily focus on providing Subject Matter Expertise (SME) consulting resources for individual healthcare markets, particularly healthcare plans, hospitals and large physician organizations.

Blue Eagle is looking for Pre-Cert Nurse(s) to assist with inpatient and outpatient PA reviews.

Current Nursing License and in good standing Prior Authorization and UM expert NCQA and InterQual expertise preferred Facets experience preferred

The Care Company

Registered Nurse (RN)

Posted on:

September 3, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Texas

The Care Company was founded on a simple idea - to offer dependable whole-person home health and personal care services to all who need it. Our approach is guided by a set of core values, including compassion, respect, integrity, professionalism, and excellence. These values are crucial to providing the best possible care, and we aim to uphold them in everything we do.

A professional who provides professional nursing services within the scope of nursing practice standards in collaboration with primary care physicians, teaches and educates clients and their families. Professional skilled nursing is performed under the supervision of the Administrator/Supervising Nurse. Note: This position pertains to in-home client services and telehealth in DFW, Texas.

An active license to practice professional nursing in Texas. Preferably completed a BA degree program. A minimum of two (2) years of experience as a professional nurse, with at least (1) year of experience, preferably in community/home healthcare. Will pass a criminal background check and any other required checks. Must have current CPR certification.

Furnishes those services requiring substantial and specialized nursing skill. Initiates appropriate preventative and rehab nursing procedures. Prepares & submits timely, clinical and progress notes. Oversees coordination of client services. Informs MD and other staff of changes in PT situation or needs. Completes medical history/home safety check/environmental assessments. Performs socio-psychological evaluation. Performs assessment visit and documents timely. (i.e., OASIS/ Skilled Nursing Note etc.). Performs physical examination and review of all body systems and documents accordingly. Develops individualized Plan of Care (POC) to be submitted to the physician for approval and implementation and performs necessary revisions based upon client needs. Determines medical necessity for other services. Regularly re-evaluates the client’s nursing needs. Evaluates the client’s ADL and iADL abilities and need for home health aide. Develops and implements the HHA plan of care when HHA services are ordered. Revises and signs this care plan at the beginning of each certification period. Supervises HHA in accordance with state/federal requirements and documents the supervision. Orders “other” professional services that may be appropriate to the needs. Reviews billing processes with client and/or family advising client and/or family when co-pay or Medicare is not likely to pay for services. Effectively communicates ongoing with client and family progression/changes in POC. Effectively communicates with Supervisor/Supervising nurse/other disciplines in the case. Communication with the client’s MD (verbally and/or in writing) to obtain effective treatment modalities and/or rehabilitative therapy modalities. Actively communicates in the case conferencing sessions to establish best practices. Submits requests for re-authorization of “more visits needed” to payers timely. Coordinates Community Services for the client to assist in safe home care needs. Participates in the QAPI Committee process. Performs timely CRR per Agency policy in collaboration with the Nursing Supervisor. Participates in ongoing staff meetings/in-services. Participates in the growth of office by being a willing preceptor for same discipline employees. Participates in the planning, operation, and evaluation of the nursing services of the organization. Maintains professional licensure per state requirements. Notifies the Agency of emergencies, sickness, and other imminent occurrences that may affect the client caseload as quickly as possible relative to the event’s occurrence. Submits written time requests 2 weeks or more in advance of planned time off. Other duties as assigned.

Vheda Health

Director, Health Services

Posted on:

September 3, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Maryland

Vheda Health is a leader in virtual health engagement, dedicated to improving health equity for underserved populations. With over 10 years of experience and a strong national presence, our turnkey chronic care coordination programs provide simple access to care coordination from anywhere, helping health plans deliver better outcomes for their members. 

As Vheda Health’s Director of Health Services, you will be a key leader responsible for the day-to-day operations and management of our Health Services team, ensuring delivery of the highest quality and impactful health outcomes for our clients and members. You will ensure the right operational processes and controls, people systems, and reporting are in place to deliver on the key performance indicators our clients expect from us every day. Our ideal Director of Health Services is a people motivator who inspires teamwork and will stop at nothing to ensure our members are receiving the best service. This role also demands an analytical mindset with the ability to execute ambitious organizational goals.

Master’s degree in healthcare administration, public health, or a related field. Clinical licensure and background as a Registered Nurse (RN) are required; additional clinical credentials are a plus. Basic knowledge about chronic health conditions, NCQA, HEDIS care gaps, case management and utilization management. 7+ years of leadership experience in healthcare services, with a focus on clinical operations, managed care, or population health. Proven track record of developing and scaling health services programs that deliver measurable outcomes. Possesses superior oral and written communication skills to clearly and effectively convey issues, reports, and other deliverables.

Providing day-to-day strategic and tactical leadership to health service operations teams, ensuring alignment with company goals related to engagement and outcomes. Collaborate cross-functionally with the Vice President of Operations as well as other key leaders to ensure seamless execution of health services resources to ensure the best health outcomes are delivered. Analyze and report key performance metrics to inform strategic decisions and improve program effectiveness. Build and maintain strong relationships with Vheda’s key clients. Mentor and lead a high-performing team of health service professionals.

Vheda Health

Clinical Coordinator

Posted on:

September 3, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

LPN/LVN

State License:

Maryland

Vheda Health is a leader in virtual health engagement, dedicated to improving health equity for underserved populations. With over 10 years of experience and a strong national presence, our turnkey chronic care programs provide simple access to care from anywhere, helping health plans deliver better outcomes for their members. We’re Hiring a Clinical Coordinator to Join Our Team!

This full-time position is an impactful role that directly influences the lives of underserved, vulnerable, and at-risk populations. We are seeking candidates who leverage their clinical knowledge and critical thinking skills to triage effectively, delegate tasks, identify risks, and close gaps in care. Your responsibilities will include contacting individuals with out-of-range vital signs or device readings, assessing their immediate health needs, reminding them of available resources, and documenting all interactions. As a Clinical Member Coordinator, you will receive real-time data through remote patient monitoring devices and be fully supported by our online platform, ensuring the highest adherence to care plans. This role is fully remote but may require travel to our offices in Columbia, MD, up to four times per year for companywide events and meetings.

Required Qualifications: Current and active medical certification such as MA, CNA, MedTech, LPN, Health Coach, Case Management, etc. Minimum of 1-3 years of experience in a medical care setting. General knowledge of chronic disease management and progression (e.g., Diabetes, Hypertension, Congestive Heart Failure, Asthma, COPD, Weight Management, Mental/Behavioral Health). Proficient with technology and web-based applications. Proven ability to work effectively in a remote setting, demonstrating strong communication and collaboration skills. Demonstrate effective communication skills with compassion and empathy. Possess exceptional interpersonal, organization, and communication skills. Additional Preferred Skills: Previous experience in Urgent, Emergent, and/ or front/back medical office care settings. Proven experience working with diverse populations. Understanding of Medicaid and/or Medicare Experience with telephonic provider and/or patient outreach. Experience with HEDIS and/or NCQA standards. Fluency in Spanish preferred, but not required. Location Preference: While this role is remote, candidates based in Florida, Illinois, and Kentucky will receive priority consideration.

Telephonic Consultation: Provide telephonic consultation to assigned patient cohorts to triage and assess for disposition. Non-Compliance Focus: Consult with individual members who are non-compliant, focusing on reengagement. Team Collaboration: Collaborate with clinical services, health coaching, and member support teams to coordinate services for assigned patient cohorts. Relationship Building: Develop, communicate, and maintain strong working relationships with the clinical services team, providing support and consultation as needed. Patient Education: Facilitate and/or delegate patient education in support of standards of care and best practices using the most appropriate modality for each member. Resource Maximization: Assist members with mobile care management devices and maximize their access to available resources.

Vheda Health

Bilingual Clinical Support Specialist

Posted on:

September 3, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Maryland

Vheda Health is a leader in virtual health engagement, dedicated to improving health equity for underserved populations. With over 10 years of experience and a strong national presence, our turnkey chronic care programs provide simple access to care from anywhere, helping health plans deliver better outcomes for their members. We’re Hiring a Bilingual Clinical Support Specialist to Join Our Team!

This full-time position is an impactful role that directly influences the lives of underserved, vulnerable, and at-risk populations. We are seeking candidates who leverage their clinical knowledge and critical thinking skills to triage effectively, delegate tasks, identify risks, and close gaps in care. Your responsibilities will include contacting individuals with out-of-range vital signs or device readings, assessing their immediate health needs, reminding them of available resources, and documenting all interactions. As a Remote Clinical Support Specialist, you will receive real-time data through remote patient monitoring devices and be fully supported by our online platform, ensuring the highest adherence to care plans. This role is fully remote but may require travel to our offices in Columbia, MD, up to four times per year for companywide events and meetings.

Required Qualifications: Fluent in Spanish Current and active RN license. Minimum of 1-3 years of experience in a critical care setting. Understand chronic disease management and progression (e.g., Diabetes, Hypertension, Congestive Heart Failure, Asthma, COPD, Weight Management, Mental/Behavioral Health). Proficient with technology and web-based applications. Proven ability to work effectively in a remote setting, demonstrating strong communication and collaboration skills. Demonstrate effective communication skills with compassion and empathy. Proven ability to work effectively in a remote setting, ensuring seamless communication and collaboration with the care team. Additional Preferred Skills: Previous experience in an emergency room setting. Experience working with diverse populations. Understanding of Medicaid and/or Medicare. Experience with telephonic patient outreach. Familiarity with Motivational Interviewing techniques. Experience in care coordination or case management roles. Experience with HEDIS and/or NCQA standards. Fluency in Spanish preferred, but not required. Location Preference: While this role is remote, candidates based in Florida, Illinois, and Kentucky will receive priority consideration.

Immediate Outreach: Contact members promptly regarding out-of-range vital signs or device readings. Mobile Care Management: Assist members with the use of mobile care management devices. Risk Identification: Communicate with members to identify risks and educate them on recommended device ranges. Health Education: Educate members about concerning symptoms and options for outreach, including when to refer to the ER or alternatives. Resource Maximization: Maximize members' access to available resources for optimal care. Team Collaboration: Assist health coaches, customer service, and tech support teams as needed and collaborate with the entire care team to support members effectively.

Vheda Health

Health Coach

Posted on:

September 3, 2025

Job Type:

Full-Time

Role Type:

Coaching

License:

None Required

State License:

Maryland

Vheda Health is a leader in virtual health engagement, dedicated to improving health equity for underserved populations. With over 10 years of experience and a strong national presence, our turnkey chronic care programs provide simple access to care from anywhere, helping health plans deliver better outcomes for their members.

Vheda Health is humanizing healthcare, through technology. We continue leading the field of digital medicine with effective and innovative health programs providing the right mix of human touch and technology that address the growing epidemic of chronic disease. We are hiring health coaches for an independent contractor, position. Our preference are candidates who are charismatic, kind, and intelligent. As part of Vheda Health’s health coaching team, your role will be guiding participants through our program focused on overcoming their barriers to change. You will be fully supported by our online platform, including data and technology that ensures the highest care plan adherence. Your primary role is listening openly to their challenges while keeping them motivated, focused, and energized. Our ideal health coach is someone who has: Compassion and empathy (“people person”) Effective communication skills Worked with diverse populations Comfort in leading one-on-one conversations Knowledge and experience in behavior change strategies Comfort in motivational interviewing Ability to identify risks and gaps in care

Required: Bachelors Degree in Community Health, Public Health, Health Promotion, Behavioral Health, Health Education, Nursing, Dietetics, or similar Health coaching certification with accreditation (i.e. CHES, ACE, ICF, or similar) Minimum 2-3 years of health coaching experience 1-3 year(s) of experience in chronic disease management (diabetes, hypertension, congestive health failure, asthma, COPD, weight management, behavioral health) Must possess valid Business License (e.g. LLC, etc.) Must possess valid & current Worker Compensation insurance policy Must possess valid & current Business Liability insurance policy Proficiency with technology/computers in web based applications Ability to work closely with member and care team Exceptional interpersonal, organization and communication skills required Preferred: Masters degree Proficiency in conversational Spanish or other languages Certified Diabetes Educator (CDE) certification Medicaid and/or Medicare knowledge 1-3 year(s) of experience in public health, community health, behavioral health, health education or similar

Motivate, focus, and energize participants with our mobile care management platform Establish goals and create an achievable care plan with participants Work with participants to mitigate impacts of social factors on health and functional status Engage participants in collaborative relationships, empowering them to manage their psycho-social, physical and environmental health to improve and maintain their well-being Develop collaborative relationships with participants care team Maximize access to available resources Provide education to participants, leading to life-long healthy changes. It will help if your availability is flexible, with occasional time required on evenings.

Vheda Health

Clinical Support Specialist

Posted on:

September 3, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Maryland

Vheda Health is a leader in virtual health engagement, dedicated to improving health equity for underserved populations. With over 10 years of experience and a strong national presence, our turnkey chronic care programs provide simple access to care from anywhere, helping health plans deliver better outcomes for their members. We’re Hiring a Clinical Support Specialist to Join Our Team!

This full-time position is an impactful role that directly influences the lives of underserved, vulnerable, and at-risk populations. We are seeking candidates who leverage their clinical knowledge and critical thinking skills to triage effectively, delegate tasks, identify risks, and close gaps in care. Your responsibilities will include contacting individuals with out-of-range vital signs or device readings, assessing their immediate health needs, reminding them of available resources, and documenting all interactions. As a Remote Clinical Support Specialist, you will receive real-time data through remote patient monitoring devices and be fully supported by our online platform, ensuring the highest adherence to care plans. This role is fully remote but may require travel to our offices in Columbia, MD, up to four times per year for companywide events and meetings.

Required Qualifications: Current and active RN license. Minimum of 1-3 years of experience in a critical care setting. Understand chronic disease management and progression (e.g., Diabetes, Hypertension, Congestive Heart Failure, Asthma, COPD, Weight Management, Mental/Behavioral Health). Proficient with technology and web-based applications. Proven ability to work effectively in a remote setting, demonstrating strong communication and collaboration skills. Demonstrate effective communication skills with compassion and empathy. Proven ability to work effectively in a remote setting, ensuring seamless communication and collaboration with the care team. Additional Preferred Skills: Previous experience in an emergency room setting. Experience working with diverse populations. Understanding of Medicaid and/or Medicare. Experience with telephonic patient outreach. Familiarity with Motivational Interviewing techniques. Experience in care coordination or case management roles. Experience with HEDIS and/or NCQA standards. Fluency in Spanish preferred, but not required. Location Preference: While this role is remote, candidates based in Florida, Illinois, and Kentucky will receive priority consideration.

Immediate Outreach: Contact members promptly regarding out-of-range vital signs or device readings. Mobile Care Management: Assist members with the use of mobile care management devices. Risk Identification: Communicate with members to identify risks and educate them on recommended device ranges. Health Education: Educate members about concerning symptoms and options for outreach, including when to refer to the ER or alternatives. Resource Maximization: Maximize members' access to available resources for optimal care. Team Collaboration: Assist health coaches, customer service, and tech support teams as needed and collaborate with the entire care team to support members effectively.

Texas Organ Sharing Alliance

Remote Administrator on Call

Posted on:

September 3, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Texas

Texas Organ Sharing Alliance (TOSA), founded in 1975, is one of 57 federally-designated Organ Procurement Organizations (OPOs) in the United States. TOSA is committed to a mission of saving lives through the power of organ donation by providing organ donation and recovery services to Central and South Texans wishing to donate, and to those waiting for a life-saving organ transplant. Recognized as a Top Workplace in San Antonio since 2014. TOSA has staff members in Austin, San Antonio, and McAllen.

JOB SUMMARY: The full-time Administrator-On-Call responsible for the clinical assessment of potential organ donors for medical suitability and pertinent risk factors that may impact recipients. In collaboration with the daily clinical call team, the AOC determines patient eligibility for organ donation, guides family interaction timing, clinical management of organ donor patients, oversees the plan for each donor while on call and works to overcome logistical barriers that may present throughout the donation process. This position will have access to confidential material and needs to use discretion with this information while strictly adhering to the Texas Organ Sharing Alliance confidentiality policy. WORK SCHEDULE: The Administrator-on-Call position is a full-time position that is supported within a strong team environment with periods of high stress and extended on-call rotation responsibility with M-F business hours as needed.

5+ years’ experience as an Organ Recovery Coordinator with donor management oversight Bachelor’s degree and/or RN/PA/RT/Paramedic certification Demonstrates teamwork, clinical, analytical, organizational, and communication skills in a high stress environment. BLS, ACLS, and PALS certification recommended CPTC certification Working knowledge of standard office equipment (computer/fax/copier). A valid driver's license and proof of automobile insurance. Possession of a reliable personal automobile. A physical requirement for the ability to lift at least 50lbs. Ability to travel by company or personal automobile, or commercial aircraft. Maintains confidentiality regarding all donor information.

Coaches frontline team members by providing consistent, evidenced based critical thinking and decision support while considering appropriate resource management decisions. Provides thorough, in-depth guidance utilizing highly developed clinical expertise and advanced knowledge of the organ donation process. Interprets hospital policies for determination of neurological death and guides staff to ensure potential donor patients are declared appropriately (where applicable). Collaborates with Medical Director(s) and other physician consults in evaluating donor suitability and setting appropriate donor case plans. Ensures appropriate and timely family interactions based upon TOSA’s Family Readiness Assessment Tool. Presents complex clinical information and determines a clear and cohesive plan for assessing donor risk factors and effectively communicates to transplant centers. Identifies potential anomalies appropriately. Provides resource management and direction to the clinical teams for the day-to-day operations. Provides real-time direction and guidance to staff for donor identification, evaluation, approach, authorization, clinical management, donor transfers, organ allocation, and surgical recovery directed towards maximizing every organ donation opportunity. Collaborates with Clinical Practice Specialist to optimize donor management. Problem solves with onsite organ team members and provides clinical and logistical expertise in all areas of the donation process. Advises staff when working through operational challenges by providing mentoring, talking points, coaching and on-site support. Communicates deviations from standard behavior and/or practices to appropriate manager for follow-up. Maintains an awareness of all active referrals and pending activity to ensure optimal use of available resources. Ensures consistent application and compliance with regulatory standards/requirements as well as organizational policies and procedures. Participates in performance improvement initiatives, identifying trends and supporting formal staff education needs including involvement in regular case activity review process. Assists with data collection, analysis, and shares best-practices for presentation and education during TOSA Interdepartmental Performance Improvement Team meetings. Provides regulatory oversight and verification of critical aspects of the donation process such as death notes, ABO verification, hemodilution, increased risk status, serology results, allocation variances, etc. Ensures compliance with JP/Medical Examiner donor related case requests and/or restrictions. Offers remote mentoring, education, guidance, and support of clinical staff. Works closely with clinical leadership and the Education Department to identify training needs and employee development. Serves as subject matter expert in clinical processes and procedures. Attend and presents donor case reviews with TOSA’s Medical Director monthly. Facilitates pre-OR and post-OR donor huddles as well as coordination of NRP related case responsibilities. Leads the daily Administrator on Call meeting (including Clinical Leadership, Hospital Development, DSC Leadership, Family Aftercare, AOCs) in meeting daily operational needs to facilitate organ donation. In coordination with Hospital Services escalates referral and donor case related challenges to the appropriate hospital administrator. Assists in facilitating timely root cause analysis, CAPA and follow up of variances, complaints, and audit findings when applicable Maintains positive working relationships with the internal staff, tissue agencies, transplant centers, research entities, and the general public. Collaborates with the Chief Clinical Officer and the Associate Director of Clinical Services in assessing the function and operation of the clinical department and develops plan to facilitate the achievement of organizational goals and objectives Engages in review, education, and required organizational meetings to promote best practice sharing and interdepartmental collaboration. Computer & Application Literacy: Proficiency in iTransplant, DonorNet, and Microsoft Office Suite. Ability to learn additional systems as needed.

Somatus, Inc.

Case Manager RN

Posted on:

September 3, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Arizona

As the largest and leading value-based kidney care company, Somatus is empowering patients across the country living with chronic kidney disease to experience more days out of the hospital and healthier at home. It takes a village of passionate and tenacious innovators to revolutionize an industry and support individuals living with a chronic disease to fulfill our purpose of creating More Lives, Better Lived. Does this sound like you? Showing Up Somatus Strong We foster an inclusive work environment that promotes collaboration and innovation at every level. Our values bring our mission to life and serve as the DNA for every decision we make: Authenticity: We believe in real dialogue. In any interaction, with patients, partners, vendors, or our teammates, we are true to who we are, say what we mean, and mean what we say. Collaboration: We appreciate what every person at Somatus brings to the table and believe that together we can do and achieve more. Empowerment: We make sure every voice gets heard and all ideas are considered, especially when it comes to our patients’ lives or our partners’ best interests. Innovation: We relentlessly look for ways to improve upon the status quo to continuously deliver new solutions. Tenacity: We see challenges as opportunities for growth and improvement — especially when new solutions will make a difference for our patients and partners.

This position is responsible for ensuring the continuity of care in both the inpatient and outpatient setting utilizing the appropriate resources within the parameters of established contracts and patients’ health plan benefits. Facilitates continuum of patients’ care utilizing basic nursing knowledge, experience and skills to ensure appropriate utilization of resources and patient quality outcomes. Performs care management functions on-site or telephonically as the need arises. This is a fully remote role where compact licensure is strongly preferred. **The schedule for this position includes some evening hours where you will be expected to work until approximately 8pm, based on member availability. For example: 11am-8pm OR a split shift 8am-12pm and then 4pm-8pm**

Required Qualifications: Active RN license in current state of residence with the ability to qualify for additional state licenses as requested 2+ years of nursing experience in a hospital, acute care, or direct care setting Renal, Chronic Kidney Disease or Dialysis Care experience as a main focus of your job Computer proficiency utilizing MS Office (Word, Excel, PowerPoint and Outlook), including the ability to type and talk at the same time while navigating a Windows environment Access to dedicated workspace from home for in home office set up Ability to work schedule listed Reside in a location that can receive a high speed internet connection or can leverage existing high-speed internet service Preferred Qualifications: BSN Certified Case Manager (CCM) Diabetic educator experience ICU, Cardiology or Critical Care experience Telephonic case management experience Experience with discharge planning Solid working knowledge of hypertension and/or diabetes

Consistently exhibits behavior and communication skills that demonstrate our company's commitment to superior customer service, including quality, care and concern with each and every internal and external customer. Prioritizes patient care needs upon initial visit and addresses emerging issues. Virtually meets with patients, patients’ family and caregivers as needed to discuss care and treatment plan telephonically. Virtually identifies and assists with the follow-up of high-risk patients in acute care settings, skilled nursing facilities, custodial and ambulatory settings. Consults with physician and other team members to ensure that care plan is successfully implemented. Coordinates treatment plans with the care team and triages interventions appropriate to the skill set of the team members. Uses protocols and pathways in line with established disease management and care management programs and approved by medical management in order to optimize clinical outcomes. Monitors and coaches patients using techniques of motivational interviewing and behavioral change to maximize self-management. Oversees provisions for discharge from facilities including follow-up appointments, home health, social services, transportation, etc., in order to maintain continuity of care. Works in coordination with the care team and demonstrates accountability with patient management and outcome. Maintains effective communication with the physicians, hospitalists, extended care facilities, patients and families. Assist member to maximize benefits according to health plan. Participates actively in assigned Care Management Coordination Committee (CMCC) meetings. Documents pertinent patient information and Care Management Plan in Electronic Health Record and Care Management Systems as appropriate. Coordinates care with larger interdisciplinary team on assigned patient caseload or panel. Adheres to departmental policies and procedures.

Cambia Health Solutions

Remote Care Management Nurse

Posted on:

September 3, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Idaho

Cambia Health Solutions, headquartered in Portland, Oregon, is a health solutions company dedicated to transforming health care by creating a person-focused and economically sustainable system. Cambia’s growing family of companies range from software and mobile applications, health care marketplaces, non-traditional health care delivery models, health insurance, life insurance, pharmacy benefit management, wellness and overall consumer engagement. Through bold thinking and innovative technology, we are delivering solutions that make quality health care more available, affordable and personally relevant for everyone.

Care Management Nurse Remote within WA, OR, ID, UT. Candidates outside of these states will not be considered. Primary Job Purpose The Care Management Nurse provides clinical care management (such as case management, disease management, and/or care coordination) to best meet the member’s specific healthcare needs and to promote quality and cost-effective outcomes. Oversees a collaborative process with the member and those involved in the member’s care to assess, plan, implement, coordinate, monitor and evaluate care as needed.

Minimum Requirements: Knowledge of health insurance industry trends, technology and contractual arrangements. General computer skills (including use of Microsoft Office, Outlook, internet search). Familiarity with health care documentation systems. Strong oral, written and interpersonal communication and customer service skills. Ability to interpret policies and procedures, make decisions, and communicate complex topics effectively. Strong organization and time management skills with the ability to manage workload independently. Ability to think critically and make decision within individual role and responsibility. Normally to be proficient in the competencies listed above Care Management Nurse would have a/an Associate or Bachelor’s Degree in Nursing or related field and 3 years of case management, utilization management, disease management, or behavioral health case management experience or equivalent combination of education and experience. Required Licenses, Certifications, Registration, Etc. Must have licensure or certification, in a state or territory of the United States, in a health or human services discipline that allows the professional to conduct an assessment independently as permitted within the scope of practice for the discipline (e.g. medical vs. behavioral health) and at least 3 years (or full time equivalent) of direct clinical care Must have at least one of the following: Certification as a case manager from the URAC-approved list of certifications; or Bachelor’s degree (or higher) in a health or human services-related field (psychiatric RN or Master’s degree in Behavioral Health preferred for behavioral health care management); or Registered nurse (RN) license (must have a current unrestricted RN license for medical care management)

Responsible for essential activities of case management including assessment, planning, implementation, coordination, monitoring and evaluation. Assessment: collection of in-depth information about a member’s situation and functioning to identify individual needs. Planning: identification of specific objectives, goals, and actions designed to meet the member’s needs as identified in the assessment. Implementation: execution of the specific case management activities that will lead to accomplishing the goals set forth in the plan. Coordination: organization, securing, integrating and modifying resources. Monitoring: gathering sufficient information to determine the plan’s effectiveness and the evaluation phase should determine the effectiveness of reaching the desired outcomes. Applies clinical expertise and judgment to ensure compliance with medical policy, medical necessity guidelines, and accepted standards of care. Utilizes evidence-based criteria that incorporates current and validated clinical research findings. Practices within the scope of their license. Consults with physician advisors to ensure clinically appropriate determinations. Serves as a resource to internal and external customers. Collaborates with other departments to resolve claims, quality of care, member or provider issues. Identifies problems or needed changes, recommends resolution, and participates in quality improvement efforts. Responds in writing or by phone to members, providers and regulatory organizations in a professional manner while protecting confidentiality of sensitive documents and issues. Provides consistent and accurate documentation. Plans, organizes and prioritizes assignments to comply with performance standards, corporate goals, and established timelines.

Salem Solutions

Telehealth RN

Posted on:

September 3, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

Texas

Payrate: $26.75/hour and $4.93/hour (40 hours/week) towards 401k. Job Type: Temp to Hire Location: Remote Are you ready to transform patient care from the comfort of your home? We’re looking for a compassionate and skilled Telehealth Registered Nurse to join our dynamic virtual team! In this role, you’ll provide essential nursing support, guiding patients to the care they need with empathy and expertise.

A licensed RN with a Bachelor’s degree in nursing and a minimum of 5 years of experience in acute care, ambulatory care, or home care. BLS certified with the ability to obtain US Security Clearance. A dedicated professional with a passion for patient advocacy and care excellence. #SES2

Deliver expert nursing triage and advice, ensuring compliance with nursing regulations and federal guidelines. Communicate effectively with patients, families, and healthcare providers to achieve outstanding outcomes. Advocate for patients and involve them in their care plans. Navigate cultural differences and tailor your approach to meet diverse patient needs. Thrive under pressure and respond efficiently to medical emergencies. Mentor new staff, fostering a collaborative and supportive environment. Monitor quality and productivity, consistently exceeding project goals. Handle complaints professionally, resolving issues or escalating as necessary.

Walker Healthforce, LLC

Utilization Inpatient Case Manager RN | Remote | Contract

Posted on:

September 2, 2025

Job Type:

Contract

Role Type:

Case Management

License:

RN

State License:

New Jersey

Walker Healthforce is known as the dominant force of performance, precision, expertise, and integrity in the healthcare consulting community! As a certified WMBE, we provide end-to-end healthcare IT and clinical solutions to hospitals, health systems, and payer organizations, including Fortune 100 firms nationwide. We are healthcare experts, we’re custom not commodity and we’ve been exceeding expectations for nearly 20 years. Join forces with us to experience unparalleled results today!

Utilization Inpatient Case Manager RN | 2+ years’ experience | Remote | Remote | Contract Walker Healthforce is seeking a Utilization Inpatient Case Manager RN with 2+ years’ experience to support a healthcare client based out of New Jersey. This is a 3-month contract opportunity. #IND1 START DATE: 9/15/2025 WORKER TYPE: W2

CORE REQUIREMENTS: Minimum of two (2) years clinical experience Associate or bachelor’s degree (or higher) in nursing and/or a health-related field OR accredited diploma nursing school. Active New Jersey Registered Nurse License ADDITIONAL REQUIREMENTS: Must be located in New Jersey, New York, Delaware, Pennsylvania, or Connecticut WE CONSIDER IT A BONUS IF YOU ALSO HAVE: Prefers proficiency in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint) and Lotus Notes; prefers knowledge in the use of intranet and internet applications. Prefers working knowledge of case/care management principles. Prefers working knowledge of principles of utilization management. Prefers basic knowledge of health care contracts and benefit eligibility requirements. Prefers knowledge of hospital structures and payment systems.

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

Walker Healthforce, LLC

Registered Nurse | Review Analyst I Remote | Contract

Posted on:

September 2, 2025

Job Type:

Contract

Role Type:

Triage

License:

RN

State License:

Michigan

Walker Healthforce is known as the dominant force of performance, precision, expertise, and integrity in the healthcare consulting community! As a certified WMBE, we provide end-to-end healthcare IT and clinical solutions to hospitals, health systems, and payer organizations, including Fortune 100 firms nationwide. We are healthcare experts, we’re custom not commodity and we’ve been exceeding expectations for nearly 20 years. Join forces with us to experience unparalleled results today!

Walker Healthforce is seeking a Registered Nurse (RN) Review Analyst with 2+ years of experience located in Michigan. This is a 6-month contract opportunity.

Must be a RN with an unrestricted Registered Nurse Michigan license Two (2) to four (4) years of clinical experience which may include acute patient care, discharge planning, case management, and utilization review, etc. Demonstrated clinical knowledge and experience relative to patient care and health care delivery processes- 2 years acute care experience ICU/ER preferred *should not just be 2 years in a specialized field such as NICU/OB/BH/Substance Abuse* InterQual/MCG or other utilization review experience Triage, case management or utilization review experience Associate Degree or nursing diploma required WE CONSIDER IT A BONUS IF YOU ALSO HAVE: Utilization Review experience at a previous insurance company (medical, surgical admissions) Utilization Review experience in an acute care setting One (1) year health insurance plan experience or managed care environment

Responsible for the review of precertification, admissions approvals, telephone triage, and/or benefit interpretation. May be required to enter or reference data via PC. Other related skills may be required to perform this job. The maximum hourly rate reflects budget estimates only and does not reflect the final negotiated rate.

CorroHealth

Manager, Clinical Operations

Posted on:

September 2, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

None Required

State License:

Texas

Our purpose is to help clients exceed their financial health goals. Across the reimbursement cycle, our scalable solutions and clinical expertise help solve programmatic needs. Enabling our teams with leading technology allows analytics to guide our solutions and keeps us accountable achieving goals. We build long-term careers by investing in YOU. We seek to create an environment that cultivates your professional development and personal growth, as we believe your success is our success.

The Manager, Clinical Operations will support the Senior Director in overseeing the Clinical Documentation team's workflow operations and participating in reviews of organizational and functional activities. They will assist in managing a comprehensive and practical schedule of daily production coverage, financial expectations, and client success. Additionally, they will collaborate with the Senior Director to ensure that all client expectations are met to the highest degree of quality. The Manager, Clinical Operations will contribute to producing and presenting reports to leadership to trend and track the success and gaps of the division. Furthermore, they will play a role in achieving operational excellence by assisting in the construction of plans and strategies to overcome challenges.

Knowledge, Skills & Abilities: AHIMA or AAPC accreditation preferred. Minimum of three years' experience in Revenue Cycle Management. Six Sigma or related LEAN/OPEX/Process Excellence experience desirable. Proficient in Microsoft Word, Excel, and PowerBI. Strong verbal and written communication skills. Ability to work independently, exercise good judgment, and make confident decisions. Proficiency in generating, interpreting, and analyzing reports. Effective team player with the ability to collaborate and communicate effectively across departments.

Note: The essential duties and responsibilities below are intended to describe the general duties and responsibilities of this position and are not intended to be an exhaustive statement of duties. This position may perform all or most of the primary duties listed below. Specific tasks, responsibilities or competencies may be documented in the Team Member’s performance objectives as outlined by the Team Member’s immediate Leadership Team Member. Essential Functions: Note: The essential duties and primary accountabilities below are intended to describe the general content of and requirements of this position and are not intended to be an exhaustive statement of duties. Incumbents may perform all or most of the primary accountabilities listed below. Specific tasks, responsibilities or competencies may be documented in the incumbent’s performance objectives as outlined by the incumbent’s immediate supervisor or manager. Role & Responsibilities: Report directly to the Senior Director of Clinical Documentation. Assist the Senior Director in overseeing the Clinical Documentation team's workflow operations and contribute to reviews of organizational and functional activities. Manage a comprehensive and practical schedule of daily production coverage, financial expectations, and client success in alignment with the company directives. Ensure that all client expectations are met to the highest degree of quality. Produce and present reports to the Clinical Documentation team and other leadership members to trend and track the success and gaps of the division. Collaborate with the Clinical Documentation team to achieve operational excellence by implementing plans and strategies to overcome challenges. Organize, prioritize, and delegate workload within the Clinical Documentation team in line with the company's vision and objectives. Implement Performance Improvement Programs to drive continuous quality and productivity improvements. Assist in the preparation and documentation of policies and procedures. Identify opportunities for process and product improvements to enhance the department's competitive market position and outcomes for clients. Participate in cross-functional projects and process improvement initiatives. Facilitate departmental and client meetings, ensuring effective communication and collaboration. Produce and facilitate monthly or quarterly executive report outs to clients. Provide timely and accurate reporting regarding department performance, financial goals, and objectives. Collaborate with stakeholders to address operational risks and mitigate their impact on cost, schedule, and quality factors. Develop and maintain manuals and training aids to support ongoing staff training and development initiatives. Accumulates data, maintains records, and prepares reports on the administration of production projects and other assigned activities. Works with client management coding, CDI and technical support services to ensure client expectations are met.

CorroHealth

CDI Specialist, RN/BSN, CCDS (FT/REMOTE) (CDI experience req'd)

Posted on:

September 2, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Texas

Our purpose is to help clients exceed their financial health goals. Across the reimbursement cycle, our scalable solutions and clinical expertise help solve programmatic needs. Enabling our teams with leading technology allows analytics to guide our solutions and keeps us accountable achieving goals. We build long-term careers by investing in YOU. We seek to create an environment that cultivates your professional development and personal growth, as we believe your success is our success.

CDI Specialists will collaborate extensively with physicians, nursing staff, other patient caregivers, and medical records coding staff to improve the quality, specificity, accuracy and completeness of the documentation of care provided and coded. CDI Specialist will review medical records for opportunities for diagnosis clarification and validity as it pertains to DRG assignment, severity of illness, risk of mortality, and case mix data as well as timely, accurate and complete documentation of clinical information used for measuring and reporting physician and facility outcomes. These goals will be accomplished by chart review and query placement when appropriate following AHIMA guidelines and CorroHealth policies and procedures.

Qualifications and Requirements: Experience with telecommuting, working with EMRs and other electronic tools. Strong analytical skills. Strong Microsoft Office skills. Works well with numbers. Strong team player. Ability to work with multiple and diverse clients and projects. Ability to work with minimal supervision. Ability to maintain and access multiple files. Assure that work product is completed with high levels of accuracy and attention to detail. Education & Experience: CCDS or CDIP certification required. **Or be willing to get CCDS certification within 6 months of employment. Current RN license. Three years CDI experience. Two years or more clinical experience in an acute care setting preferred.

Note: The essential duties and responsibilities below are intended to describe the general duties and responsibilities of this position and are not intended to be an exhaustive statement of duties. This position may perform all or most of the primary duties listed below. Specific tasks, responsibilities or competencies may be documented in the Team Member’s performance objectives as outlined by the Team Member’s immediate Leadership Team Member. Conduct clinical documentation tasks, meeting productivity and quality standards as set for each project. Adhere to all coding and clinical documentation improvement guidelines as endorsed by AHIMA and ACDIS. Perform review on clinical documentation and issue queries when appropriate. Review medical records for completeness and accuracy for severity of illness and risk of mortality. Accurate and timely record review. Demonstrate knowledge of DRG payer issues, documentation opportunities, and clinical documentation requirements. Analyze findings and identify potential root causes of produced errors.

Integrated Home Care Services

Sr. Clinical Review Manager, Registered Nurse RN

Posted on:

September 2, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Florida

IHCS provides an Integrated Delivery System in the home setting, which includes, DME, Respiratory, Home Health and Home Infusion services. IHCS has a select network of Medicare and/or Medicaid Certified and Accredited providers to respond to the needs of our patients – 24/7. We operate with the sole intent of providing the highest quality in-home care services that improve and enhance the daily living for our patients, where our patients are #1 With over 30 years of experience, we are the trusted market leader in Home Health, Durable Medical Equipment, and Home Infusion Services. If you are passionate about inspiring, motivating, and leading teams this opportunity could be for you and we want to hear from you! Join our team as we strive for excellence through teamwork. We are committed to delivering high quality care to our patients through Exceptional Customer Service, Proven Outcomes, and Seamless Care.

State licensure as RN Bachelor's degree in Nursing (BSN), Healthcare Administration, or a related field (Master’s degree preferred). Registered Nurse (RN), or equivalent clinical license required. Minimum of 3–5 years of experience in utilization management, case management, or a related healthcare setting. Prior experience in UM review management, denials, appeals, and payer relations preferred At least 3 years of leadership or supervisory experience in a healthcare environment Strong understanding of utilization management, medical necessity criteria, and regulatory compliance (e.g., CMS, NCQA, URAC). Required to uphold compliance principles as outlined in the Code of Conduct and related policies. Actively supports and participates in mandatory Corporate Compliance Program training initiatives annually or as required.

The Senior Clinical Review Manager is responsible for overseeing the clinical review and management of utilization management (UM) program related to home health and durable medical equipment (DME) services. This role ensures compliance with regulatory requirements, payer guidelines, and internal policies while driving process improvements to optimize review efficiency and ensure accuracy of medical necessity decisions. The Senior Clinical Review Manager will lead a team of clinicians, collaborate with internal and external stakeholders, and provide strategic oversight to ensure high-quality and timely review of UM determinations.

Thyme Care

Oncology Nurse Case Manager (8:30AM - 5PM EST Shift)

Posted on:

September 2, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Tennessee

Imagine building a better healthcare journey for patients with cancer, where individuals and their loved ones feel seen, supported, and heard by their care team – both in and out of the clinic. Where fast access to high-quality care is the norm, not the exception. Where patients have access to a care navigator to guide them through their diagnosis and trusted support all along the way. At Thyme Care, we share a passion for transforming the cancer care experience – not just for patients but also for their caregivers and loved ones, as well as those delivering and paying for their care. Today, Thyme Care is known predominantly as a cancer care navigation company enabling value-based cancer care; in the next few years, we will become a nationally recognized technology-driven and provider-centric care delivery model, reshaping the landscape of cancer care access, delivery, and experience. Our commitment runs deep—we're not satisfied with the status quo but determined to redefine it. To make this happen, we’re building a diverse team of problem solvers and critical thinkers to drive innovation and shape the future of healthcare. If you share our vision and want to be part of something truly meaningful, we want to hear from you. Together, we can revolutionize cancer care and make a difference that lasts a lifetime.

Thyme Care Inc., the management company to Thyme Care Medical PLLC, is the employing entity with your duties to be performed for Thyme Care Medical PLLC, a medical practice, and its patients. As an Oncology Nurse - Transitions of Care, you will be on the frontlines serving our members diagnosed with cancer. This role reports to our RN Care Team Lead. In it, you will conduct clinical assessments, monitor for changes in health, coordinate care, including transitions, and educate members and caregivers about their diagnosis and treatment over the phone to support our members as they move through the oncology care continuum. You will demonstrate a strong clinical focus, supporting the need for culturally competent care. Additionally, you will help improve Thyme Care’s service offerings by communicating feedback from members and providers to our clinical leadership. You will also assist with other administrative projects as needed. This role can be remote or hybrid based in our Nashville office. Most of your day will be dedicated to speaking with members and handling clinical escalations and tasks. We maintain a schedule that includes your lunch and breaks to ensure sufficient clinical coverage.

A member-first approach. You’re personally motivated by our mission and by what we are building. You seek to understand problems and help people solve them, especially this one. A BSN. You must have a Bachelor of Science Degree in Nursing, an unrestricted Registered Nurse (RN) license, and a willingness to obtain additional state licenses as needed. Experience. You have at least 5 years of nursing experience with 3 years of oncology nursing or case management experience and are a Certified Case Manager (CCM). Organized. You’re skilled in juggling multiple tasks and working under pressure without sacrificing organization in your communications and documentation. Effective listener and communicator. You are winsome and articulate, but you always start with listening and hearing what may not be voiced because you listen intently to others. You build rapport and great working relationships with members and colleagues. Comfort with ambiguity. Start-ups are fast-paced environments, and you understand that rapid changes to the business, strategy, organization, and priorities are par for the course… and part of the adventure. A desire to learn how to use new technologies. We are a technology company focused on interacting with folks during the season when they need it most. Experience with video chatting, Google Suite, Slack, electronic health records, or comfort in learning new technology is important. Identify priorities and take action. You know how to identify and prioritize a member's needs and do what it takes to address urgent and important needs immediately.

Have completed training and are up to speed on Thyme Care systems, tools, technology, partners, and expectations. Have built strong, trusting relationships with your members, where listening and empathy are the foundation for every interaction. Be comfortable following Care Team policies and procedures, escalation pathways, communications best practices, and documentation standards. Your ability to effectively engage and support our members is reflected in our efficiency metrics and quality standards. Identify and prioritize a member's needs and help them remain safe in the community. Assist members with care coordination and care management following admissions. Coordinate discharge plans with hospital case managers and follow-up care with providers. Monitor member progress, provide regular updates, and establish targeted support plans with the healthcare team in case conferences. Build strong, trusting relationships with payers and providers to optimize care and prevent readmissions for our members. Partner with non-clinical Care Team members to support the member’s social determinants of health needs, such as food resources, transportation access, and support at home. Conducting telephonic assessments, including pain assessments and medication reconciliation. Ensure members have access to medications and appointments, providing referrals and support as appropriate. Perform virtual home safety evaluations and assess the need for DME/supplies. Provide referrals to PT, OT, skilled nursing, palliative care, hospice care, etc., as appropriate. Be available for urgent clinical escalations and clinical consult support.

Axion Contact

Registered Nurse - Remote

Posted on:

September 2, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

Axion is a dynamic and innovative contact, staffing and integration organization determined to exceed our clients’ highest expectations. For over 40 years, we have been the preferred staffing solution for thousands of companies and job-seekers nationwide. Recently, we expanded our reach with new Partner Companies in Arizona, New Jersey, and Pennsylvania with new Partner Companies being scouted all the time. We attribute our success and longevity to our partnership building approach. Our strength derives from our three-way partnership teams, which include the Axion staff, our clients, and our superior talent pool of employees. We pride ourselves on our ability to nurture long-term partnerships with our clients who utilize us as an extension of their Human Resources function. With that focus, we have developed a highly successful team of experienced business development and recruiting professionals ready to help you with your most challenging staffing and business services needs.

AXION Contact is a fully customizable State of the Art call center. We are a preferred resource and known for our dynamic and innovative practices and are determined to exceed our client’s highest expectations. Axion Contact is currently seeking a Registered Nurse - to work in our state-of-the-art call center. This is a full-time remote position. We are looking for friendly, accessible, credible individuals to join a great team.

Promptly answers, screens, and processes medical service requests and telephone inquiries with strict adherence to confidentiality agreements and policies and procedures. Provides education to patients and patients' families. Ability to speak clearly in order to communicate effectively between patient and provider, provide pre-visit instructions/directions, and relay provider instructions. Follow up with patients regarding medication changes or questions Handle incoming and outbound calls as needed Provide health education to patients and caregivers Nursing License required, Multi-state nursing license a plus *2- 5 years’ experience as a registered nurse required Outstanding customer service and communication skills required Case Management experience preferred Bilingual (English/Spanish) a plus 40 Hours a week -9:00am-5:30pmJob Type: Full-time

Conflux Systems Inc

Registered Nurse Case Manager

Posted on:

September 2, 2025

Job Type:

Contract

Role Type:

Case Management

License:

RN

State License:

Georgia

Established in 2007, Conflux Systems provides unique staffing solutions that bridge the gap between high-end consulting services and offshore development. Conflux Systems originated as a software development and business intelligence firm. Conflux has experienced steady growth over the last fourteen years, outperforming its competitors with fast, cost-effective staffing solutions. Regardless of whether the requirements are onshore or offshore, we employ the same rigorous recruitment strategy to fulfill our client’s needs for software development and other IT staffing requirements.

Here are the job details for your review: Job Title: Nurse Case Manager II Job Location- Remote (Georgia) Duration: 6+ Months Contract (Potential for extension) Pay Rate: $37.14/HR on W2 Shift : Mon - Fri 8am to 5pm EST

Experience: 2-3 years Clinical practice experience, e.g., hospital setting, alternative care setting such as home health or ambulatory care required. 2 years Healthcare and/or managed care industry experience. Case Management experience required. Education: RN with current unrestricted compact state licensure. Case Management Certification preferred.

The Case Manager utilizes a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual's benefit plan and/or health needs through communication and available resources to promote optimal, cost-effective outcomes. Requires an RN with unrestricted active license in Georgia. Through the use of clinical tools and information/data review, conducts comprehensive assessments of referred member's needs/eligibility and determines approach to case resolution and/or meeting needs by evaluating member's benefit plan and available internal and external programs/services. Application and/or interpretation of applicable criteria and guidelines, standardized case management plans, policies, procedures, and regulatory standards while assessing benefits and/or member's needs to ensure appropriate administration of benefits. Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures.

OpTech LLC

Medical Review RN (State of FL)

Posted on:

September 2, 2025

Job Type:

Contract

Role Type:

Clinical Operations

License:

RN

State License:

Florida

OpTech is a leading Talent Management and Technology Services company with nearly two decades years of successful experience managing large, enterprise-wide solutions for our clients. We provide mission critical services to major commercial clients including well known institutions in financial services, healthcare /insurance , utilities and manufacturing. OpTech has contracts with the Federal Government supporting agencies such as the Department of Homeland Security, Department of Defense, and the Department of Labor. OpTech has been nationally recognized for “Excellence in Staffing”, National “Best and Brightest Companies to Work For”, and “Top 500 Woman Owned Businesses in the United States”. At OpTech we believe that “Talent” matters. We are committed to connecting great companies with great talent to creatively and effectively apply technology to solve important problems.

Great opportunity for a Register Nurse - Medical Review Nurse (State of FL license required) Remote opportunity: 3 month contract, high probability of extension Must have Active/Valid Register Nurse license with the State of Florida Compensation: $34/hour - $36.00/ hour; Ability to work weekend/holiday hours on rotation JOB SUMMARY The Medical Review Nurse RN reviews, authorizes, coordinates, and responds to requests for services for Florida Blue members. This position also communicates telephonically with providers and their offices, and occasionally with members. Makes decisions based on established policies and procedures, Florida Blue medical coverage guidelines, benefits, InterQual criteria, nursing knowledge. Refers cases to Florida Blue medical directors for potential denial.

Medicare Prior Authorization (Pre-Service) Understanding of CMS rules and regulations Ability to toggle between multiple systems Knowledge of medical terminology Experience with prior authorization Experience applying nationally recognized criteria, including InterQual Knowledge of Medicare regulations and guidelines Computer skills, including ability to use Microsoft Office suite Previous experience within a call-center environment Ability to navigate through multiple systems and screens to resolve authorization or medical review requests Talking and typing simultaneously Effective time management skills Effective interpersonal and communication skills Ability to use electronic medical record and claims systems Problem solving abilities Work cooperatively, positively, and collaboratively in an interdisciplinary team Work respectfully and positively with others Ability to manage multiple projects and prioritize work tasks to adhere to deadlines and identified time frames Ability to manage large workload Ability to think analytically and make decisions Required Experience: 1+ years related work experience Required Licenses and Certifications Registered Nurse - State of Florida Licensure

Review and authorize, as appropriate, phone/fax referral/authorization and clinical form requests per established criteria meeting compliance standards and timeframes Review all requests not approved by the non-clinical support rep to determine benefit coverage and medical necessity Review cases and potential denials with the Medical Directors Research requests not clearly meeting established criteria Assist the Prior Authorization non-clinical reps with the Prior Authorization process Coordinate and maintain complete written documentation on all prior authorizations requests. Collaborate with other Florida Blue departments, such as Claims, UM, Quality, Disputes/Appeals, and other external vendors. Log into phone queue to service providers Answer inbound calls regarding authorizations within established time frame Provide accurate prior authorization information to provider offices Handle calls professionally Document contact information in electronic medical record system Maintain productivity

AltaStaff, LLC

Remote RN Case Manager II

Posted on:

September 2, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

New Mexico

**Must have a valid RN License** Pay Rate: $42.00 - 44.00 hourly Shift: Monday-Friday, 8am-5pm PST **This role is fully remote, but candidates must work PST hours** Summary: Case Managers work with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum. This is a clinical role performing care management responsibilities. This individual will have responsibility for a caseload of members. This will mean completing health risk assessments (and other assessments if warranted based on the member’s situation), completing individual care plans, helping members connect with resources, coordinating care with member and providers, etc.

POSITION QUALIFICATIONS: Must have an active, valid RN License 3+ years of clinical experience required Must have 3-5+ years in case management, disease management, and/or managed care Experience with insurance case management preferred Verbal and written communication skills including discussing medical needs with members and interfacing with internal staff/management and external vendors and community resources. PC proficiency to include Word, Excel, and PowerPoint, database experience and Web based applications. Work Environment Requirements: Must be able to to lift at least 30lbs Must be able to stand or sit for prolonged periods (75% of the time) Private Secured Internet Connection Must confirm work environment is safe and secure for work in handling private and sensitive information. Constantly operates a computer and other office equipment Constantly works indoors in a secluded safe space Must have High-speed internet access 25 MBPS minimum; 50 MBPS minimum preferred

Completes comprehensive assessments of members per regulated timelines and determines who may qualify for case management based on clinical judgment, changes in member's health or psychosocial wellness, and triggers identified in the assessment. Develops and implements a case management plan in collaboration with the member, caregiver, physician and/or other appropriate healthcare professionals and member's support network to address the member needs and goals. Performs ongoing monitoring of the care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly. Maintains ongoing member case load for regular outreach and management. Promotes integration of services for members including behavioral health care and long term services and supports/home and community to enhance the continuity of care for Molina members. Facilitates interdisciplinary care team meetings and informal ICT collaboration. Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts. Assesses for barriers to care, provides care coordination and assistance to member to address concerns.

AltaStaff, LLC

Medical Claims Review Nurse

Posted on:

September 2, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Florida

AltaStaff is a staffing agency currently looking for a Medical Claims Review Nurse to work with our Managed Care Client! Location: Remote (Candidates must reside in NY (outside greater NYC), FL, GA, MI, OH, WI, IA, NM, TX or KY) Pay Rate: $41 - $43.00 hourly Shift: 8-hour shifts within 6am-6pm local time after training Description: Remote (RN License Required) Position Purpose: This position will be reviewing medical patient records against standard medical criteria. Responsible for administering claims payments, maintaining claim records, and providing counsel to claimants regarding coverage amount and benefit interpretation. Monitors and controls backlog and workflow of claims.

Active, unrestricted State Registered Nursing (RN) license in good standing. 3+ years of clinical appeals review experience required. 1+ year of Utilization Review experience required. Data entry and/or typing experience. Interpersonal, analytical, organizational and independent decision-making skills. Clear and concise verbal and written communication skills.

Performs clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases, in which an appeal has been submitted, to ensure medical necessity and appropriate/accurate billing and claims processing. Identifies and reports quality of care issues. Identifies and refers members with special needs to the appropriate Healthcare program per policy/protocol. Assists with Complex Claim review; requires decision making pertinent to clinical experience Documents clinical review summaries, bill audit findings and audit details in the database Provides supporting documentation for denial and modification of payment decisions 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 policies and procedures, and individual judgment and experience to assess the appropriateness of service provided, length of stay and level of care.

Pyramid Consulting, Inc

Patient Care Advocate (HEDIS)

Posted on:

September 2, 2025

Job Type:

Contract

Role Type:

License:

LPN/LVN

State License:

Georgia

Pyramid specializes in Talent, Technology and Transformation Pyramid Consulting, Inc. provides Staffing and Technology Solution services to enterprise customers. Headquartered in Atlanta, GA with offices across the United States, Canada, Europe and India, we serve companies ranging from innovative startups to Fortune 500 and 1000 companies. Pyramid is the career partner-for-life for top talent. Through successive engagements, we help them develop the best path to achieve their career goals. We place top talent through our four divisions: Technology Staffing, Professionals, Healthcare and Search and Placement. Our flexible staffing options include contract, contract-to-hire, direct hire and SOW/Statement of Work.

Immediate need for a talented Patient Care Advocate (HEDIS). This is a 06+months contract opportunity with long-term potential and is located in Roseburg, OR (Remote). Please review the job description below and contact me ASAP if you are interested.

Key Requirements and Technology Experience: Key skills; LPN HEDIS Outreach Bachelor’s degree in healthcare, Public Health, Nursing, Psychology, Social Work, Health Administration, or related health field or equivalent work experience required (a total of 4 years of experience required for the position) Licensure Required: RN, BSN, or LPN

Works with members and providers to close care gaps, ensure barriers to care are removed, and improve the overall member and provider experience through outreach and face-to-face interaction with members and providers at large IPA and/or group practices. Serves to collaborate with providers in the field, to improve HEDIS measures and provides education for HEDIS measures and coding. Supports the implementation of quality improvement interventions and audits in relation to plan providers. Assists in resolving deficiencies impacting plan compliance to meeting State and Federal standards for HEDIS. Conducts telephonic outreach, while embedded in the providers' offices, to members who are identified as needing preventive services in support of quality initiatives and regulatory/contractual requirements. Provides education to members regarding the care gaps they have when in the providers office for medical appointments. Schedules doctor appointments on behalf of the practitioner and assists member with wraparound services such as arranging transportation, connecting them with community-based resources and other affinity programs as available. Maintains confidentiality of business and protected health information.

Prosser Memorial Health

RN Nurse Navigator GI - FT (Remote)

Posted on:

September 2, 2025

Job Type:

Full-Time

Role Type:

License:

RN

State License:

Compact / Multi-State

The Nurse Navigator (NN) is a professional RN with service line specific clinical knowledge who offers individualized assistance across the care continuum to patients, families, and caregivers to expedite and coordinate care, and address health system barriers.

Education and/or Experience Requirements: Excellent written, oral, and conversational communication skills to effectively work with diverse groups. Ability to analyze, evaluate multiple solutions and solve complex problems using well developed critical & analytical thinking skills. Excellent time management skills needed to prioritize among many competing priorities. Mastery of Microsoft Office, especially Word and Excel, and use of health record for documentation and/or reporting. EPIC preferred. Demonstrated skills in verbal and written communication. Ability to maintain strict confidentiality. Ability to promote and build teamwork and multidisciplinary care concept. Metric tracking skills. Preferred: Experience in nurse navigation. Completion of national nurse navigation training. Licensure & Certifications Requirements: Current WA State RN licensure or qualifying multi-state licensure (MLC). BLS upon date of hire or within 30 days.

The NN assumes responsibility for the coordination of patient care through interdisciplinary and multidisciplinary collaboration to achieve optimal patient outcomes with a focus on high-risk patients or those with complex care needs (including multidisciplinary care). The NN has a particular focus on improving transitions in care and adherence to care. Additionally, the NN functions as a clinical advocate and educator for patients. The NN assists to build and maintain community relationships to provide expedient and reliable access to quality care. The NN identifies and alleviates stressors during transitions and barriers to care with the aim to deliver a seamless model of care that benefits patients, family members, providers, and the healthcare team.

Health Information Alliance Inc

GWTG Abstractor, Stroke, Heart Failure, CAD, Afib and Resuscitation (PRN)

Posted on:

September 2, 2025

Job Type:

Part-Time

Role Type:

Clinical Operations

License:

RN

State License:

Pennsylvania

Since 1992 Health Information Alliance, Inc., “HIA” has serviced its acute care clients in optimizing reimbursement. HIA has provided and continues to provide Core Measure Abstraction Services, (since the inception of Core Measures), Registry Services, (General Surgery - for example ACS/NSQIP, Thoracic Surgery - for example STS, and Cancer), Meaningful Use Attestations (VTE & STK) and Consulting for Core Measure, Meaningful Use and Value Based Purchasing outcomes. HIA also offers Coding Services to include IP, OP, ED, Pro-Fee, & Wound Care as well as Coding Quality Audits. HIA is composed of more than 70 credentialed professionals now offering these professional performance improvement services throughout the country.

Get With The Guidelines Abstractor: Stroke, Heart Failure, CAD, Afib and Resuscitation – (PRN) Fully Remote Subcontractor Position Description: Health Information Alliance is Seeking a GWTG CAD and/or CHF – Fully Remote Subcontractor Get With The Guidelines Stroke, Heart Failure, Coronary Artery Disease, Atrial Fibrillation and Resuscitation is much more than a data registry. It’s a broad program for supporting quality care, which includes a collection of tools and resources to help improve processes and maximize effectiveness. The ideal Candidate must be able to go into any hospital system, look up specific patients that meet the criteria, and be able to enter what they collected into the preferred system, which is then reported to Medicare. Requirements: 100% Remote Work Reliable, high-speed internet connection is required Must be able to work a Minimum of 15-20 hours a week or more.

Qualifications and Education Requirements: Graduate of approved accredited nursing program, BSN and RN Current license to practice as a Registered Professional Nurse Broad clinical training and work experience sufficient to provide background in clinical management, continuing care and transitions of care Familiarity with health care insurances and regulations desirable Preferred Skills: Electronic Health Record experience Abstract crucial medical data for reporting key quality measures Knowledge of computer hardware and software, including applications and programming Must be reliable, responsible, and dependable, and fulfilling obligations General Requirements: The ideal candidate must possess the following characteristics: Commitment and reliability; be able to dedicate consistent time to HIA Superb communication and responsiveness Computer literacy Must be comfortable with, but not limited to: Excel, web-browsers, email, electronic health records (non-specific) Must be familiar with various technologies such as, but not limited to: security (e.g., Citrix), data collection/abstraction, encoders, web-based applications Self-maintenance of skillset Maintaining credentials Staying current with abstraction/coding rules, manuals, and guidelines Prior experience in position applying for Motivation; remote work can be team-based, but requires the ability to work independently Strong interpersonal skills and tactfulness to be able to effectively communicate with team members and client contacts May require Covid Vaccination May require Background and Drug Screening

Fonemed

Telehealth Triage Nurse (Part Time)

Posted on:

September 1, 2025

Job Type:

Part-Time

Role Type:

Telehealth

License:

RN

State License:

California

Telehealth Triage Nurse (Remote) Weekend work required - either every weekend or 2 weekends on/1 weekend off Must have compact nursing license + CA licensure preferred Fonemed is recruiting part time remote Registered Nurses to join our team! We are looking for experienced and dependable Registered Nurse who are dedicated to providing quality nursing care to patients. If you are a Registered Nurse who is looking for a challenge and a company who values you, apply today! Position Overview: Our nurses provide telephone triage and health advice to callers across the United States remotely from the comfort of their own home using world renowned Schmitt-Thompson protocols and provide nursing care advice virtually to patients. Calls received can vary greatly in subject matter and complexity. In addition to triage calls, we receive questions requesting information on medical conditions, medications, diagnostic tests, etc., and provide patient support through addressing their medical questions and concerns. Registered Nurses must be attentive and engaged listeners who have strong critical thinking and clinical assessment abilities and are able to make decisions independently and document clear clinical data. All calls are documented electronically, and all telephone encounters are recorded. Scheduling and Licensure: Part time work with a commitment of 20 hours per week and the opportunity to pick up additional shifts when available at your own discretion Shift work type schedule that could include mornings, days, evenings, nights, weekends, holidays and occasional split shifts Our current major hiring need is for shifts that would fall between 06:00am ET and 22:00pm ET daily. Please note that we are not able to offer a set schedule at this time, your schedule would vary week to week Work either every weekend or a weekend rotation of 2 weekends on/1 weekend off. We offer after hours services to clients, therefore more weekend coverage is required Must possess a compact nursing license and a California license

Completion of a recognized Nursing program Minimum 3 years of recent clinical experience as a Registered Nurse, preferably in areas such as ER/Urgent Care, Adult, Pediatric, OB/GYN, Orthopedic, Ambulatory Care, Home Health, or ICU An active license in CA is required, along with active compact license in your home state. Active licensure in all 50 states would be an asset or the willingness to obtain licenses at the company’s request Previous telephone triage experience using electronic triage software and computerized medical protocols will be considered an asset Experience using the Barton Schmitt/David Thompson guidelines will be considered an asset Strong communication skills Strong clinical assessment skills Strong computer skills within a Windows environment and keyboarding ability Bilingual English/Spanish will be considered an asset

Provide telephone triage and advice to callers to assist them in making timely medical decisions Exercise clinical judgement in combination with utilization of protocols to arrive at the appropriate disposition to provide timely and accurate level of care to patients Promptly complete confidential medical records as per company documentation standards Provide clear and concise information and direction during patient encounters

Fairfax Radiological Consultants

Physician Assistant (PA) / Nurse Practitioner (NP) – Overnight Clinical Liaison (100% Remote)

Posted on:

September 1, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

NP/APP

State License:

Virginia

Fairfax Radiology Centers, LLC (FRC), is the largest radiology practice in the Washington, DC metropolitan area. FRC provides leading-edge medical imaging at 20 outpatient locations throughout Northern Virginia, with more than 110 subspecialty trained radiologists and over 700 employees. FRC also works with local hospitals and health care providers to deliver an excellent patient experience and top quality, specialized care.

Title: Physician Assistant (PA) / Nurse Practitioner (NP) – Overnight Clinical Liaison (100% Remote) Location/Department: Remote/ Overnight team of Radiologists Reports to: Section Chief for Overnight/Emergency Dept Team Job Summary: The Advanced Practice Professional (Nurse Practitioner or Physician Assistant) will function as a Clinical Liaison of the diagnostic Overnight/Emergency radiology team, providing specialized support between the Hospital’s ER departments and our Radiologists. This role focuses on ensuring accurate clinical context for imaging studies, streamlining communication, and supporting the efficiency and quality of radiology services delivered overnight. The role is 100% remote and will be supporting Inova Fairfax Medical Campus (IFMC), INOVA Fair Oaks (IFOH), INOVA Alexandria (IAH), INOVA Mt. Vernon & INOVA Loudoun (ILH).

Requirements: Minimum of 2 years of clinical experience, preferably in Emergency Medicine, Hospital Medicine, or Radiology preferred. Must be a licensed Physician Assistant/Nurse Practitioner within the Commonwealth of Virginia. Must have Prescriptive authority for the Commonwealth of Virginia. Current ACLS/AED required/ PALs certification preferred. Must meet hospital and insurance credentialing requirements. Requires knowledge of business and an excellent command of the English language. Must be able to communicate effectively and efficiently, both verbally and in writing. Skills & Competencies: Strong knowledge of anatomy, physiology, and radiologic imaging protocols. Excellent communication and interpersonal skills. Ability to work independently and collaboratively in a fast-paced clinical environment. Proficiency in EMR systems and relevant documentation standards. Work Schedule & Environment: Shift Structure: 4 shifts per week, each 10 hours in length (10:00 PM – 8:00 AM). Location: 100% remote; must have secure, HIPAA-compliant internet and workspace

The PA/NP Clinical Liaison will support Fairfax Radiological Consultants’ overnight emergency radiology team by serving as the primary point of clinical communication between radiologists, emergency department providers, and hospital staff. This role involves obtaining and clarifying patient histories, reviewing imaging orders for appropriateness, and performing initial patient triage by quickly assessing clinical information and imaging findings to ensure timely referral to the correct department or physician. The clinician will also be responsible for communicating urgent findings, coordinating care and follow-up recommendations, and maintaining accurate documentation in alignment with FRC and hospital standards. In addition, the Clinical Liaison will play a key role in optimizing workflow efficiency for radiologists, participating in case discussions, and contributing to quality improvement initiatives. Essential Functions: Serve as the clinical liaison between emergency department providers, hospital staff, and FRC radiologists. Conduct patient triage and preliminary case assessments to direct cases to the appropriate specialty team. Obtain, clarify, and document clinical histories relevant to imaging studies. Communicate urgent findings and critical results as directed by radiologists. Review imaging orders for completeness and appropriateness; escalate concerns when necessary. Assist with coordination of care, follow-up recommendations, and provider-to-provider communication. Maintain thorough and accurate documentation in accordance with FRC and hospital protocols. Support radiologists with workflow optimization to ensure timely turnaround of emergency department imaging. Participate in virtual team huddles, case discussions, and quality improvement initiatives.

Optum

RN Call Center Nurse – CA Remote

Posted on:

September 1, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

California

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

Optum CA is seeking a RN Call Center Nurse to join our team in Torrance, CA. Optum is a clinician-led care organization that is changing the way clinicians work and live. As a member of the Optum Care Delivery team, you’ll be an integral part of our vision to make healthcare better for everyone. Optum’s Pacific West region is redefining health care with a focus on health equity, affordability, quality, and convenience. From California to Oregon and Washington, we are focused on helping more than 2.5 million patients live healthier lives and helping the health system work better for everyone. At Optum Pacific West, we care. We care for our team members, our patients, and our communities. Join our culture of caring and make a positive and lasting impact on health care for millions. Position in this function is responsible for providing moderately complex telephonic nursing assessment, evaluation, and advice to patients through established and approved telehealth protocols with physician oversight. If you are located within a commutable distance to Torrance, CA, you will have the flexibility to work remotely* as you take on some tough challenges.

Required Qualifications: Graduation from an accredited school of nursing Active, unrestricted Registered Nurse license through the State of California Basic Life Support for Healthcare Providers (AHA) ESI (Emergency Severity Index) Certification within 30 days of hire Preferred Qualifications: BSN ACLS and PALS certification 2+ years of experience working as a Registered Nurse ER/critical care/Pediatrics/Med/Surg

Consistently exhibits behavior and communication skills demonstrating Optum’s commitment to superior customer service, including quality, care, and concern with every internal and external customer Performs comprehensive telephonic patient assessment, evaluation, and advice while meeting production standards Follows established clinical protocols/guidelines and provides appropriate patient instructions Directs patient to appropriate levels of care based on assessment within Optum’s guidelines Documents authorizations for vendors and/or outside services as appropriate Instructs patients on procedural preparations Documents and maintains records of telephonic interactions Completes medical documentation of telephonic assessment and disposition in Telehealth Record Notifies pharmacies of new prescriptions and authorizations of refills as ordered by the clinician or via pharmacy protocols Translates oral information into concise and accurate written documentation using standard medical guidelines and abbreviations Manages own work queues Recognizes financial, medical, and legal risks based on data collected during customer interactions and follows appropriate procedures Expedites emergency calls as needed Accesses Language Line for non-English patients as needed

Optum

Call Center Nurse RN

Posted on:

September 1, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

Compact / Multi-State

Opportunities at Change Healthcare, part of the Optum family of businesses. We are transforming the health care system through innovative technology and analytics. Find opportunities to make a difference in a variety of career areas as we all play a role in accelerating health care transformation. Help us deliver cutting-edge solutions for patients, hospitals and insurance companies, resulting in healthier communities. Use your talents to improve the health outcomes of millions of people and discover the meaning behind: Caring. Connecting. Growing together.

The Call Center Nurse RN position is in a Managed Services organization (does not reside on Client/Practice Sites). The RN telephonically assists and guides patients towards self-management and behavior modifications that result in improved patient outcome. The RN is the primary point of contact, coordination with schedulers, pharmacists, providers of medical and behavioral health care and social services. Success is measured in terms of improved patient outcomes, prevention of patient adverse events and unnecessary inpatient readmissions, satisfied customers, meeting or exceeding quality measures, producing consistent and high-quality work ad collaboration with other care team members. Schedule: Monday to Friday 10:30 am to 7:00pm CST (8-hour shifts), with the ability to work a rotation of being on call for one weekend day every 4-6 weeks. You will enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.

Required Qualifications: Associates degree (or higher) in Nursing Active RN License in the state of Wisconsin or Compact State License (NLC) 3+ years of experience in a clinical, managed healthcare or healthcare setting Ability to work a schedule that is between the hours of 10:30 am to 7:00pm CST (8-hour shifts), with the ability to work a rotation of being on call for one weekend day every 4-6 weeks Access to a designated workspace and access to install secure high-speed Internet via cable / DSL in home Preferred Qualifications: Experience with EMR systems, preferred with Epic Previous experience working in a remote telephonic role supporting various clinical needs Previous experience in clinical triage in either ED, Urgent Care, or ICU setting Telephonic triage experience Intermediate knowledge of Microsoft Applications and computer experience Experience in handling multiple software applications Strong analytical and interpersonal skills and ability to interact with senior level clients and high level of computer literacy Very good knowledge of healthcare, government and insurance industry trends Excellent understanding of health-service related processes relevant to assigned role and responsibilities

Telephonic nurse triage services Provide education to patients, deploying best practices and standard workflow in their daily activities Apply their expertise across the various areas of responsibility, understand how their interactions with patients affect customer satisfaction, and is able to make recommendations to improve processes Apply established protocols, criteria, and contract guidelines Coordination of the team approach to management of patient care Analyze, investigate and resolve individual care quality, coordination of care, service and access issues Contact patients and providers regarding clinical needs for continuity of care

Elevance Health

Disease Management Nurse I - 100% Virtual - Carebridge

Posted on:

September 1, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Colorado

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. Previously known as Anthem, Inc., we have evolved into a company focused on whole health and updated our name to better reflect the direction the company is heading. Improving health means more than just treating what ails us – it means addressing the physical, behavioral and social drivers that impact whole health. Grounded in our mission and fueled by our bold and ambitious purpose to improve the health of humanity, we are committed to making whole health a reality for our consumers, their families, and our communities.

Carebridge Health is a proud member of the Elevance Health family of companies, within our Carelon business. Carebridge Health exists to enable individuals in home and community-based settings to maximize their health, independence, and quality of life through home-care and community based services Title: Disease Management Nurse Location: 700 Broadway Denver, CO 80273 Virtual: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Alternate locations may be considered. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. Shift: Monday-Friday with occasional Saturday coverage 1/Mth 8AM-5PM MST/9AM – 6PM CST/10AM -7PM EST The Disease Management Nurse is responsible for participating in delivery of patient education and disease management interventions and for performing health coaching for members, across multiple lines, for health improvement/management programs for chronic diseases.

Minimum Requirements: Requires AS in nursing and minimum of 2 years of condition specific clinical or home health/discharge planning experience; or any combination of education and experience, which would provide an equivalent background. Current unrestricted RN license in applicable state(s) required. Preferred Skills, Capabilities and Experiences: BS in nursing preferred. Prior case management experience preferred.

Conducts behavioral or clinical assessments to identify individual member knowledge, skills and behavioral needs. Identifies and/or coordinates specific health coaching plan needs to address objectives and goals identified during assessments. Interfaces with provider and other health professionals to coordinate health coaching plan for the member. Implements and/or coordinates coaching and/or care plans by educating members regarding clinical needs and facilitating referrals to health professionals for behavioral health needs. Uses motivational interviewing to facilitate health behavior change. Monitors and evaluates effectiveness of interventions and/or health coaching plans and modifies as needed. Directs members to facilities, community agencies and appropriate provider/network. Refers member to catastrophic case management.

Elevance Health

Virtual Triage Nurse I - CareBridge - Bilingual Spanish

Posted on:

September 1, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. Previously known as Anthem, Inc., we have evolved into a company focused on whole health and updated our name to better reflect the direction the company is heading. Improving health means more than just treating what ails us – it means addressing the physical, behavioral and social drivers that impact whole health. Grounded in our mission and fueled by our bold and ambitious purpose to improve the health of humanity, we are committed to making whole health a reality for our consumers, their families, and our communities.

Seeking bilingual Spanish-speaking candidates who are licensed in one of following states: AZ, FL, IA, IN, KS, MA, NM, OH, TN, TX or VA. Work location - Virtual: This role enables associates to work virtually full-time, with the exception of required in-person training sessions (when indicated), providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. Work Shift: 9am - 7pm, 11am - 9pm or 1pm - 11pm (Central Standard Time) The RN will work eight (8)10-hour work shifts, in a two-week period which will include Saturday and Sunday every other weekend. CareBridge Health is a proud member of the Elevance Health family of companies, within our Carelon business. CareBridge Health exists to enable individuals in home and community-based settings to maximize their health, independence, and quality of life through home-care and community based services The Virtual Triage Nurse I - CareBridge - Bilingual Spanish is responsible for determining the appropriate Care Management program for members referred through internal and external sources and various data sources and reports. Utilizing department guidelines, completes triage process and applies established criteria to assign members to appropriate care management component. Deals with least complex cases having limited or no previous Triage care experience.

Position requirements: Requires AS in nursing and minimum of 2 years of acute care clinical experience; or any combination of education and experience, which would provide an equivalent background. Current unrestricted RN license in the applicable state(s) required. For Carelon - CareBridge business unit, bilingual or multi-language skills may be required. Bilingual Spanish is required Preferred qualifications, skills, and experiences: Current, active, RN Compact license highly preferred. Emergency Room and/or Urgent Care experience highly preferred. Telehealth experience. Experience with EMR systems. BS in nursing preferred. Participation and/or certification in a managed care or utilization management organization preferred. Ability to understand clinical information and prepare a concise summary following department standards strongly preferred. Basic knowledge of the medical management and care management process and role preferred.

Utilizes the nursing process to meet an individual’s health needs, utilizing plan benefits and community resources. Educates members about contracted physicians, facilities and healthcare providers. Learn to develop favorable working partnerships and collaborative relationships with members, physicians, healthcare service providers, and internal and external customers to help improve health outcomes for members. Works in collaboration with medical management and care management associates to identify issues, problems, and resource needs and assign to appropriate care management program. Facilitates selecting appropriate candidates for referral to CM and/or DM. Partners with social work as appropriate. Identifies and refers cases or issues to QI, SIU, Subrogation, Underwriting, or other departments as appropriate. Documents appropriate clinical information, decisions, and determinations in a timely, accurate, and concise manner. Develops a working knowledge of member benefits, contracts, medical policy, professional standards of practice, and current health care practices.

Atrium Health

Telephone Nurse Triage, Endocrinology

Posted on:

September 1, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

North Carolina

Atrium Health is a nationally recognized leader in shaping health outcomes through innovative research, education and compassionate patient care. Atrium Health is an integrated, nonprofit health system with nearly 70,000 teammates serving patients at 37 hospitals and more than 1,350 care locations. It provides care under the Wake Forest Baptist Health name in the Winston-Salem, North Carolina, region and Atrium Health Navicent in Georgia. Atrium Health is renowned for its top-ranked pediatric, cancer and heart care, as well as organ transplants, burn treatments and specialized musculoskeletal programs. A recognized leader in experiential medical education and groundbreaking research, Wake Forest School of Medicine is the academic core of the enterprise, including Wake Forest Innovations, which is advancing new medical technologies and biomedical discoveries. Atrium Health is also a leading-edge innovator in virtual care and mobile medicine, providing care close to home and in the home. Ranked among U.S. News & World Report’s Best Hospitals for cancer treatment and in eight pediatric specialties, Atrium Health has also received the American Hospital Association’s Quest for Quality Prize and was the recipient of the 2020 Centers for Medicare & Medicaid Services Health Equity Award for its efforts to reduce racial and ethnic disparities in care. With a commitment to every community it serves, Atrium Health seeks to improve health, elevate hope and advance healing – for all, providing more than $2 billion per year in free and uncompensated care and other community benefits.

Independently plans and provides professional nursing care for patients within a specific population and in accordance with the medical and nursing plans of care and established policies and procedures. Delivers, manages, and coordinates care and services via telecommunications technology within the domain of Ambulatory Care Nursing. Provides nursing services to patients and families in accordance with the scope of the RN as defined by the North Carolina Board of Nursing. Directs and leads other assigned team members and collaborates with multidisciplinary team members to provide age/developmentally appropriate care in accordance with nursing standards of care and practice. What We Offer: Day 1 Health Coverage:Choose from either copay or HSA-eligible health insurance options with coverage starting on your first day of work. Parental Benefits:Six weeks paid birthing-mother maternity leave & four weeks paid parental leave for non-birthing parents. Retirement:Up to 7% employer-paid retirement contributions Education Reimbursement:We invest in your professional growth, offering up to $2,500 per year towards a bachelor's degree and up to $5,000 per year towards a graduate degree.

Education/Experience: Graduation from an accredited School of Nursing with two years of acute care experience required. Prefer acute care experience within the last 10 years. Previous experience in Telephone Triage and with Health Insurance and Managed Care concepts preferred. Licenses/Certifications: Current license as a Registered Nurse (RN) in the State of North Carolina Basic Cardiac Life Support (BCLS) certification required

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

Atrium Health

Telephone Nurse Triage, Oncology Gynecology

Posted on:

September 1, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

North Carolina

Atrium Health is a nationally recognized leader in shaping health outcomes through innovative research, education and compassionate patient care. Atrium Health is an integrated, nonprofit health system with nearly 70,000 teammates serving patients at 37 hospitals and more than 1,350 care locations. It provides care under the Wake Forest Baptist Health name in the Winston-Salem, North Carolina, region and Atrium Health Navicent in Georgia. Atrium Health is renowned for its top-ranked pediatric, cancer and heart care, as well as organ transplants, burn treatments and specialized musculoskeletal programs. A recognized leader in experiential medical education and groundbreaking research, Wake Forest School of Medicine is the academic core of the enterprise, including Wake Forest Innovations, which is advancing new medical technologies and biomedical discoveries. Atrium Health is also a leading-edge innovator in virtual care and mobile medicine, providing care close to home and in the home. Ranked among U.S. News & World Report’s Best Hospitals for cancer treatment and in eight pediatric specialties, Atrium Health has also received the American Hospital Association’s Quest for Quality Prize and was the recipient of the 2020 Centers for Medicare & Medicaid Services Health Equity Award for its efforts to reduce racial and ethnic disparities in care. With a commitment to every community it serves, Atrium Health seeks to improve health, elevate hope and advance healing – for all, providing more than $2 billion per year in free and uncompensated care and other community benefits.

Independently plans and provides professional nursing care for patients within a specific population and in accordance with the medical and nursing plans of care and established policies and procedures. Delivers, manages, and coordinates care and services via telecommunications technology within the domain of Ambulatory Care Nursing. Provides nursing services to patients and families in accordance with the scope of the RN as defined by the North Carolina Board of Nursing. Directs and leads other assigned team members and collaborates with multidisciplinary team members to provide age/developmentally appropriate care in accordance with nursing standards of care and practice. What We Offer: Day 1 Health Coverage: Choose from either copay or HSA-eligible health insurance options with coverage starting on your first day of work. Parental Benefits: Six weeks paid birthing-mother maternity leave & four weeks paid parental leave for non-birthing parents. Retirement: Up to 6% employer-paid retirement contributions Education Reimbursement: We invest in your professional growth, offering up to $2,500 per year towards a bachelor’s degree and up to $5,000 per year towards a graduate degree.

Education/Experience: Graduation from an accredited School of Nursing with two years of acute care experience required. Prefer acute care experience within the last 10 years. Previous experience in Telephone Triage and with Health Insurance and Managed Care concepts preferred. Licenses/Certifications: Current license as a Registered Nurse (RN) in the State of North Carolina Basic Cardiac Life Support (BCLS) certification required Skills: Ability to assess nursing needs of acute and chronically ill patients through technology methods Ability to seek out resources independently and work collaboratively Ability to establish and maintain effective working relationships Ability to communicate clearly with patients, families, visitors, healthcare team, physicians, administrators, leadership and others Ability to teach patients and families in accordance with the nursing plan of care Ability to use the computer and learn new software programs Ability to document and communicate pertinent information using computer and/or paper documentation tools

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

Stormont Vail Health

Utilization Review Manager - Clinical Performance - FT - Days

Posted on:

September 1, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Kansas

Stormont-Vail Health helps to take care of the health of residents in northeastern Kansas. Its facilities include the 590-bed hospital, an emergency and trauma center, an outpatient surgery center, and a network of community clinics located throughout the 12-county region. Its Cotton-O'Neil centers treat heart disease, cancer, skin problems, and digestive system ailments, as well as various clinics and ExpressCare locations. Specialized services include behavioral health, obstetrics, orthopedics, and physical and occupational rehabilitation. Geographic Reach: Stormont-Vail Health serves a 12-county area in northeast Kansas. Strategy: The health system pursues strategic partnerships and organic growth to keep up with demand. The system has partnerships with the Baker School of Nursing, Kansas Rehabilitation Hospital, and Mayo Clinic. In 2011, Stormont-Vail Health added pediatric critical care services to provide care to infants in the neonatal intensive care unit.

The Manager of Utilization Review works closely with the Director of Clinical Performance and the internal Physician Advisor to ensure compliance with regulatory requirements and in accordance with the hospitals objectives for assuring quality patient care and effective, efficient utilization of health care services. This role maintains up-to-date knowledge of the regulatory landscape, including CMS Conditions of Participation (CoPs), Medicare billing regulations, and The Joint Commission (TJC) standards. The Manager collaborates with Patient Financial Services, external Physician Advisor groups and the denial management team to ensure that utilization review processes support compliant denial prevention and accurate billing and reimbursement practices. They are responsible for organizing and overseeing the systems and services necessary for effective utilization review and case management operations. In addition, the Manager assumes day-to-day responsibility for process and performance improvement initiatives related to RN Case Managers involved in utilization management. This includes monitoring key performance indicators, identifying workflow inefficiencies, and implementing evidence-based strategies to enhance operational effectiveness. The Manager understands the compliance and financial implications of utilization review activities and demonstrates a strong commitment to continuous improvement. They proactively optimize workflows, support staff education, and ensure that documentation and review practices meet both clinical and regulatory standards while facilitating efficient care delivery and reimbursement.

Education Qualifications: Bachelor's Degree Bachelor's of Science in Nursing (BSN). Required Master's Degree Related health field. Preferred Experience Qualifications: 5 years Acute Care Experience Required 2 years Utilization Management/Case Management experience Preferred Skills and Abilities: Must have excellent interpersonal and communication skills. Ability to read, analyze and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public. (Required proficiency) Must demonstrate the ability to work independently and to complete work in a timely manner. (Required proficiency) Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables. (Required proficiency) Word processing, Spreadsheets, Healthcare software, Payroll, Internet software, E-mail, Inventory, Database software, Contact Management (Required proficiency) Licenses and Certifications: Registered Nurse - KSBN Required Certified Professional Utilization Review (CPUR) Preferred MCG Care Guidelines Specialist Certification Preferred Travel Requirements: 10% Travel within facilities 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.

Oversee Utilization Review Operations: 1. Manage daily operations of the utilization review team to ensure timely and accurate reviews, status determinations, clinical submissions and authorizations. 2. Supervise and mentor UR nurses and specialists, providing training and performance evaluations. 3. Facilitate the standardization of processes among all staff. 4. Ensures timely and accurate submissions by the UM staff to support authorization for services, in compliance with regulatory and payer requirements. 5. Collaborates closely with clinical teams, case managers, and payers to facilitate efficient care delivery and reimbursement. 6. Conducts internal audits of utilization review activities to ensure adherence to federal and state regulations and prepares for external audits or surveys. Applies organization-approved care guidelines (e.g., MCG) and other evidence-based utilization review criteria to guide decision-making and provide ongoing education to UM, Case Management staff, and other departments. Act as a liaison between clinical departments, finance, and administration to align utilization goals. Stay current with changes in healthcare laws, payer requirements, and clinical guidelines. Ensure compliance with CMS, Joint Commission, NCQA, and other regulatory bodies. Responsible and accountable for providing quality monitoring of the organization’s UM scorecard in collaboration with the Clinical Analytics team. Works closely with Clinical Performance Director and the Clinical Documentation and Health Information Management teams to support appropriate documentation to aid in medical necessity denial prevention. Works closely with the physician advisor to: 1. Assist with level of care and length of stay management. 2. Assist with the denial management process. 3. Review and make suggestions related to resource and service management. 4. Provide feedback to staff regarding level of care length of stay, and quality issues. 5. Review cases that indicate a need for issuance of a hospital notice of non-coverage/Important Message from Medicare. 6. Provide ongoing education related to necessary documentation to support acute care services. Technology and System Optimization: 1. Evaluate and implement software tools to streamline utilization review workflows. 2. Monitor system performance and recommend enhancements. Identifies quality, safety, patient satisfaction and efficiency issues leading to suboptimal care. Responds to and recognizes the need to engage leadership for complex case reviews and or system needs to support appropriate management of resources. Represents the UM/case management department on various hospital committees to enhance and foster optimal UM/case management outcomes. Creates an environment in which staff contributes to decision making.

Stormont Vail Health

Ambulatory RN (Remote - Phone Triage Float) - North Clinic - FT - Day

Posted on:

September 1, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Kansas

Stormont-Vail Health helps to take care of the health of residents in northeastern Kansas. Its facilities include the 590-bed hospital, an emergency and trauma center, an outpatient surgery center, and a network of community clinics located throughout the 12-county region. Its Cotton-O'Neil centers treat heart disease, cancer, skin problems, and digestive system ailments, as well as various clinics and ExpressCare locations. Specialized services include behavioral health, obstetrics, orthopedics, and physical and occupational rehabilitation. Geographic Reach: Stormont-Vail Health serves a 12-county area in northeast Kansas. Strategy: The health system pursues strategic partnerships and organic growth to keep up with demand. The system has partnerships with the Baker School of Nursing, Kansas Rehabilitation Hospital, and Mayo Clinic. In 2011, Stormont-Vail Health added pediatric critical care services to provide care to infants in the neonatal intensive care unit.

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

Education Qualifications: Bachelor's of Science in Nursing (BSN) Preferred Experience Qualifications: 1 year Nursing experience. Preferred Skills and Abilities: Skill in applying and modifying the principles, methods and techniques of professional nursing to provide on-going patient care. (Required proficiency) Skill in establishing and maintaining effective working relationships with patients, medical staff and the public. (Required proficiency) Ability to maintain quality control standards. (Required proficiency) Ability to react calmly and effectively in emergency situations. (Required proficiency) Licenses and Certifications: Registered Nurse - KSBN Required Required for All Jobs: Complies with all policies, standards, mandatory training and requirements of Stormont Vail Health Performs other duties as assigned Patient Facing 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.

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

IntellaTriage

Remote Hospice Triage RN - PT Baylor- Weekend Only (Sat & Sun)

Posted on:

August 31, 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.

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 7:30AM – 4PM

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

Hospice Telephone Triage RN- PT 1:30p-7p Mon-Fri/no wknds (REMOTE)

Posted on:

August 31, 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 schedule: Work Monday-Friday 1:30p-7p CST/ no wknds

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

Brockton Visiting Nurse Association

Weekend Triage Nurse Supervisor (RN) - Remote

Posted on:

August 31, 2025

Job Type:

Role Type:

Triage

License:

RN

State License:

Massachusetts

Are you looking for a wonderful clinical remote opportunity that working for a tremendous community based Agency that has been around for 120 years and is 4.5 CMS quality star rating? We are currently searching for a dynamic Weekend Triage Nurse Supervisor (RN) - Remote who is flexible to work either every weekend or every other weekend or a combination of weekend and week days. Give us call at 508-894-5381 or via email at careers@brocktonvna.org to learn more about this wonderful opportunity.

TITLE: WEEKEND TRIAGE NURSE SUPERVISOR (RN) - REMOTE REPORTS TO: CLINICAL DIRECTOR POSITION SUMMARY: To support the direct care clinician and managers, by assisting with phone triage and MD orders.

Registered Nurse in Massachusetts BSN preferred 2 years of Home Care experience 1 year minimum of case management Able to work independently

Assists clinicians with medication reconciliation as needed Triages, reviews and enters new phone or fax orders into the EMR; orders supplies as updates schedules as needed Assists with patient related issues, making calls to MD’s referral sources, families and other community agencies Triages, reviews and enters new labs orders, generates interim orders and updates schedules as needed Task for internal referrals based on orders received Triage calls, provides telephone interventions and documents nursing interventions in the clinical record Communicates findings, issues, problems regarding compliance and documentation to Clinical Manager. Responsible for triaging uncovered visits Follows up with client concerns Works with the primary nurse to expedite a clinical plan of care reflective of assessment data, skilled nursing needs, patient/ family self- management goals and measurable outcome Supports clinical field staff with emergent issues and/or questions

Optum

RN Telehealth After Hours Triage - Part-time/Weekend - Kelsey Seybold Clinic - Pearland, TX - Remote

Posted on:

August 31, 2025

Job Type:

Part-Time

Role Type:

Telehealth

License:

RN

State License:

Texas

Explore opportunities with Kelsey-Seybold Clinic, part of the Optum family of businesses. Work with one of the nation’s leading health care organizations and build your career at one of our 40+ locations throughout Houston. Be part of a team that is nationally recognized for delivering coordinated and accountable care. As a multi-specialty clinic, we offer care from more than 900 medical providers in 65 medical specialties. Take on a rewarding opportunity to help drive higher quality, higher patient satisfaction and lower total costs. Join us and discover the meaning behind Caring. Connecting. Growing together.

A registered nurse who is responsible for incoming calls from patients, physicians and healthcare organizations. Using the nursing process and software protocols, the nurse will assess the patient and based upon Triage guidelines, will offer appropriate options for care. The nurse will facilitate referrals to primary care providers, specialists, healthcare facilities, and community resources. The nurse will facilitate communication with providers and healthcare organizations as appropriate. This position is part-time and must have the ability to work Saturday and Sunday 10 hour shifts. If you live in Greater Houston Area, you will have the flexibility to work remotely* as you take on some tough challenges.

Required Qualifications: Associates of Applied Science in Nursing or higher RN from an approved school of nursing with current TX license 5+ years progressive clinical RN experience in acute care setting for adult and/or pediatric patients Preferred Qualifications: 3+ years RN experience in an Emergency Department 1+ years of Triage nurse experience

10% Provide accurate and complete information about available resources Records significant health history for caller Assign relevant health risk tag(s) to caller Demonstrates excellent communication skills Maintains a customer-driven professional attitude Close call by thanking caller and offer service for future inquiries for 90 percent of inbound calls Functions as an interdependent and supportive team member, as well as a team leader, providing direction and established resources Facilitated productivity, team building and high team moral in the clinic 10% Maintains a sense of pride and “ownership” for the program Demonstrates knowledge and expertise in triaging callers properly such that all callers receive a timely and appropriate response Introduces self and service with each inbound call Consistently communicates in a professional and courteous manner while maintaining a calm and purposeful demeanor 10% Accepts incoming calls from patients who request assistance with acute or chronic medical issues. Establishes and maintains a positive rapport with callers and/or family members as an advocate to assist them though the healthcare system Complete registration information and/or confirm current patient data for all inbound calls 10% Consistently and accurately records patient complaints, symptoms and problems as well as nursing assessment following departmental documentation guide lines Directly addresses and seeks to rectify complaints or concerns from all callers while Documenting and forwarding them to management 10% Duties and responsibilities that are performed in the telephone consultation department require the ability to analyze information of a complex nature; the ability to organize and prioritize multiple conflicting complex tasks; and the ability to solve problems and make decisions quickly The position involves two-way communication with patient’s families, care givers, physicians, and operators-often when all parties are under pressure Specific job requirements or physical location of some positions allocated to this classification may render it security-sensitive, thereby subject to provisions of section 51.215, Texas Education Code Is organized, able to set priorities Remains calm and purposeful, responds competently when giving direction to callers on emergent or chaotic situations Refers inquiries to appropriate source 10% Assumes responsibility for remaining current on job-related knowledge and skills and ongoing education/in-service/credentialing/certification requirements in accordance with policy and procedures To be familiar with all equipment and demonstrate the ability to utilize equipment and resources in a cost-effective and safe manner 10% Utilizes knowledge in referencing the appropriate triage guideline for 100 percent of callers 1. Facilitates appropriate disposition based on assessment information, triage parameters, and clinical judgment 10% Creates progress notes that document the assessment, information provided, and the disposition in the event that a pertinent database resource document does not exist Documents all inquiries for medico legal/statistical purposes 10% Schedules call-back within 24 hours for 10 percent of all emergency referrals to determine compliance with recommendations 10% Performs related duties as required Participates in committees and in meetings for improvements in telephone nursing

Maximus

RN Lead (Remote)

Posted on:

August 31, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

California

Maximus (https://www.maximustribe.com/) is a mission-driven consumer performance medicine telehealth company that provides men and women with content, community, and clinical support to optimize their health, wellness, and hormones. Maximus has achieved profitability, 8-figure ARR, and is doubling year over year - with a strong cash position. We have raised $15M from top Silicon Valley VCs such as Founders Fund and 8VC as well as leading angel investors/operators from companies like Bulletproof, Tinder, Coinbase, Daily Stoic, & Shopify.

As the RN Lead at Maximus Medical Group, you will oversee and help shape the future of nursing operations within our integrated care team. This individual will serve as both a clinical and administrative leader—managing our Care Coordination team while also contributing to the development of nursing workflows and protocols. As the RN Lead, you’ll report directly to the Medical Director and work closely with the Practice Manager. You’ll be instrumental in establishing and refining the scope of practice for RNs at Maximus Medical Group, building efficient workflows, and improving the overall delivery of patient care. You’ll also serve as a frontline clinical resource, providing hands-on support through patient messaging and clinical guidance. This is a critical leadership role for someone passionate about scaling high-quality, patient-centered care in a digital environment.

Current, unrestricted Compact RN license required; CA licensure preferred. Minimum 5 years of nursing experience, with at least 2 years in telehealth or remote care delivery. Prior experience leading or managing teams. Deep understanding of digital health workflows and the role of nursing within integrated care models. Strong communication skills, both written and verbal. Able to work cross-functionally and thrive in a fast-paced, evolving startup environment. Comfortable using EHRs, patient communication platforms, and clinical decision support tools. Preferred Qualifications: Experience launching or scaling care coordination functions in a digital health environment. Exposure to chronic care management, hormone health, or wellness-focused protocols. Background in developing clinical workflows or training materials.

Team Leadership & Oversight Lead and manage the Care Coordination team, providing coaching, feedback, and performance management. Serve as the primary point of contact for day-to-day clinical operations within the Integrated Care team. Partner with the Medical Director and Practice Manager to set team priorities and ensure alignment across departments. Clinical Care & Support Support patient messaging workflows by responding to clinical inquiries and concerns with empathy and professionalism. Assist in triaging patient concerns and coordinating appropriate follow-up care. Act as a clinical escalation point for Care Coordinators and Providers. Workflow & Protocol Development Define and evolve the RN scope of practice in alignment with Maximus’ protocols and regulatory requirements. Develop and optimize workflows for Care Coordination, lab tracking, prescription support, and other clinical operations. Collaborate with Product and Operations teams to improve tools and processes for nursing functions. Cross-functional Collaboration Liaise with Engineering, Product, and Clinical leadership to represent the voice of nursing in platform improvements. Participate in QA reviews and support onboarding/training of new RNs or care team members.

CVS Health

Utilization Management Nurse Consultant - Medical Review (Mon–Fri 8:00am-5:00pm EST) (Remote)

Posted on:

August 31, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Compact / Multi-State

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day. About Us American Health Holding, Inc. (AHH), a division of Aetna/CVS Health, is a URAC-accredited medical management organization founded in 1993. We provide flexible, cost-effective care management solutions that promote high-quality healthcare for members.

Position Information Schedule: Monday–Friday 8:00am-5:00pm EST (Shift times may vary based on business needs) Location: 100% Remote (U.S. only) Join a team that’s making a difference in the lives of patients facing complex medical journeys. As a Utilization Management (UM) Nurse Consultant specializing in Medical Review, you’ll play a vital role in ensuring members receive timely, medically necessary care through thoughtful clinical review and collaboration with providers. This fully remote position offers the opportunity to apply your clinical expertise in a fast-paced, desk-based environment where precision, communication, and compassion intersect.

Remote Work Expectations: This is a 100% remote role; candidates must have a dedicated workspace free of interruptions. Dependents must have separate care arrangements during work hours, as continuous care responsibilities during shift times are not permitted. Required Qualifications: Active, unrestricted RN license in your state of residence with multistate/compact licensure privileges. Ability to obtain licensure in non-compact states as needed. Minimum 3 years of clinical experience. 5 years demonstrated to make thorough independent decisions using clinical judgement. 5 Years proficient use of equipment experience including phone, computer, etc. and clinical documentation systems. 1+ Year of Utilization Review Management and/or Medical Management experience. Commitment to attend a mandatory 3-week training (Monday–Friday, 8:30am–5:00pm EST) with 100% participation. Preferred Qualifications: Experience with interpreting Plan Language, Policies, and Benefits to determine medical necessity. MCG Milliman, InterQual, CPB or other criteria guideline application experience is preferred. Education: Associate's degree in nursing (RN) required, BSN preferred.

Utilizes clinical experience and skills in a collaborative process to implement, coordinate, monitor and evaluate medical review cases. Applies the appropriate clinical criteria/guideline and plan language or policy specifics to render a medical determination to the client. Applies critical thinking, evidenced based clinical criteria and clinical practice guidelines. Med Review nurses use specific criteria to authorize procedures/services or initiate a Medical Director referral as needed. Assists management with training new nurse reviewers/business partners or vendors to include initial and ongoing mentoring and feedback. Actively cross-trains to perform reviews of multiple case types to provide a flexible workforce to meet client needs. Recommends, tests, and implements process improvements, new audit concepts, technology improvements, etc. that enhance production, quality, and client satisfaction. Must be able to work independently without personal distractions to meet quality and metric expectations. Participate in occasional on-call rotations, including some weekends and holidays, per URAC and client requirements.

Included Health

Infertility/Maternity Nurse Care Manager

Posted on:

August 31, 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 seeking a Maternity Nurse Care Manager to join our Care and Case Management team. This role is ideal for a compassionate, patient-centered nurse who is passionate about supporting individuals through the full spectrum of their maternity journey—from preconception to postpartum—with evidence-based, holistic care. As a telephonic Maternity Nurse Care Manager, you will guide members through both routine and high-risk pregnancy experiences, working closely with a multidisciplinary team of providers, care coordinators, and support staff to deliver integrated remote care. You’ll spend your day connecting directly with members, listening to their concerns, answering questions, and serving as a trusted advocate. This role requires strong clinical expertise in maternity care, as well as the ability to develop personalized care plans that support members through fertility planning, prenatal care, delivery preparation, and postpartum recovery. You'll also help members navigate their health benefits and connect them to appropriate resources, with a focus on delivering high-quality, coordinated care that leads to better health outcomes for parents and their growing 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 or eligibility to sit exam within 6 months of hire 5 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 Schedule: M-F 9a-6p PST 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.

CareHarmony

Remote - LPN Intake Coordinator - Michigan & Compact Licensure Required

Posted on:

August 31, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

LPN/LVN

State License:

Compact / Multi-State

At CareHarmony, we are singular in focus—we seek to improve the patient experience and clinical outcomes by providing compassionate, whole-person care coordination services. Our high-tech, high-touch offering includes a turnkey Chronic Care Management solution designed to offer healthcare providers an easy, limited-risk first step into value-based care. CareHarmony serves a variety of organizations across the country, including physician practices, ACO and IPAs.

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

Additional Requirements: Active Michigan and Multistate/Compact License (LPN) Technical aptitude – Microsoft Office Suite Excellent written and verbal communication skills Plusses: Epic Experience Bilingual Additional state licensures (LPN) Remote Requirements: Must have active high-speed Wi-Fi Must have a home office or HIPAA-compliant workspace Physical Requirements: This position is sedentary and will require sitting for long periods of time This position will require the ability to speak clearly and listen attentively, often by telephone, for an extended period of time The position will require the ability to understand, process, and take thorough notes in real-time on telephone conversations

Manage patient census with a resolution-driven approach to close gaps in clinical and non-clinical patient care. Identify and coordinate community resources with patients that would benefit their care. Provide patient education and health literacy on the management of chronic conditions. Perform medication management, including identifying potential medication concerns, reconciliation, adherence, and coordinating refills. Assist in ensuring timely delivery of services to your patients; Home Health, DME, Home Infusion, and other critical needs. Resolve patients' questions and create an open dialogue to understand needs. Assist/Manage referrals and appointment scheduling.

MedStar Health

(RN) Denials/Appeals Management Specialist

Posted on:

August 30, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

MedStar Health is dedicated to providing the highest quality care for people in Maryland and the Washington, D.C. region, while advancing the practice of medicine through education, innovation, and research. Our team of 32,000 includes physicians, nurses, residents, fellows, and many other clinical and non-clinical associates working in a variety of settings across our health system, including 10 hospitals and more than 300 community-based locations, the largest home health provider in the region, and highly respected institutes dedicated to research and innovation. As the medical education and clinical partner of Georgetown University for more than 20 years, MedStar Health is dedicated not only to teaching the next generation of doctors, but also to the continuing education, professional development, and personal fulfillment of our whole team. Together, we use the best of our minds and the best of our hearts to serve our patients, those who care for them, and our communities. It’s how we treat people.

Registered Nurse Admitting Appeals/ Denials (Fully Remote) Do you have the aptitude to work at home in your own environment? Bring your expertise to our talented Utilization Review Team! We are currently seeking a Registered Nurse with 2 to 3 years clinical nursing background, 2 to 3 years UR/ case management, and a minimum of 2 years' experience in hospital audits. The ideal nurse for this role would also be proficient in writing appeals letters, processing appeals, understanding the revenue cycle, reducing financial risk, and working with payers while having regulatory awareness. Although this is a remote position, it is supported by a collaborative team committed to delivering exceptional results. Our choice candidate would also foster a positive work ethic to enhance our team by introducing fresh ideas, helping with change management, and workflow efficiency to take our performance to the next level. The nurse for this role would feel comfortable working autonomously, and taking the initiative, while passionate about innovation, quality improvement and development. Please note, our office typically operates M-F, within the hours of 9 am-5pm with some scheduling flexibility available.

Education: Associate's degree in Nursing required and Bachelor's degree in Nursing preferred Experience: 3-4 years 2 to 3 years clinical experience required and 3-4 years 2 to 3 years UR experience in health care setting preferred and 1-2 years 2 years background/experience in hospital audits preferred Licenses and Certifications: RN - Registered Nurse - State Licensure and/or Compact State Licensure RN license in the District of Columbia or the State of Maryland depending on work location Upon Hire required and Certification in Utilization review, case management and health care quality Upon Hire preferred and If MFM, maternal fetal medicine (MFM) coding and billing yearly seminars Upon Hire preferred Knowledge, Skills, and Abilities: Excellent verbal and written communication skills. Persuasive writing skills required. Working knowledge of Office Suite software applications preferred.

Completes appeal process for denied days for medical necessity that meets Interqual criteria, or appear to be clinically justified. Completes evaluation of all external denials for medical necessity received by the hospital and coordinates decision making regarding the feasibility of initiating an appeal for each external denial for medical necessity. Develops medical summaries of denied cases for review by hospital administration and for possible legal/Maryland Insurance Administrative (MIA) action, where indicated. Identifies and implements strategies to avoid denials and improve efficiency in delivery of care through review and examination of denials. Identifies system delays in service to improve the provision of efficient and timely patient care. Identifies process issues related to the concurrent Case Management system, including appropriate resource utilization and identification of avoidable days. Maintains records of concurrent and retrospective denial activity in conjunction with Case Management support staff. Monitors and tracks denials and appeal results, and coordinates information with Patient Financial Services (PFS). Reports data to the Director and Operations Review Committee. Meets with attending physicians and Physician Advisor, as appropriate, to clarify or collect information in the process of development of appeal letters. Participates in meetings and on committees and represents the department and hospital in community outreach efforts as required. Participates in the educational process for physicians and hospital staff to address issues that impact the number and type of denials. Serves as a resource to all staff in areas of utilization review/management. Utilizes and analyzes current medical/clinical information as well as medical record information to complete appeal letters. May interact with and assist third party payer reviewers to facilitate appropriate care and ensure payment of services. Performs concurrent and retrospective reviews telephonically as required. Completes all forms and documentation necessary to support appropriate utilization of resources. May utilize research methods to collect, tabulate, and analyze data in collaboration with the medical staff, and hospital performance improvement initiates. Implements strategies to correct or modify trends seen through data analysis and outcome monitoring. May serve as a resource to all staff in areas of utilization review/management. Educates members of health care team through in-services, staff meetings, orientation and formal educational offerings. Assists in the orientation of new staff regarding the denials and appeals process. May manage the department in the Managers absence. Keeps Manager informed about issues related to staffing and problem areas. Keeps Manager informed about issues related to quality, risk, patient/family issues and concerns, allocation of resources and vendor/payer issues. Assists the Manager in monitoring performance issues. Contributes to the performance evaluation process by providing feedback to the Manager and assisting the creation of professional development plans for UR Coordinators. Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards and safety standards. Complies with governmental and accreditation regulations.

Pediatric Associates Family of Companies

Care Manager-LPN

Posted on:

August 30, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

LPN/LVN

State License:

Florida

Company Overview: Pediatric Associates has been caring for infants, children and adolescents since 1955. Pediatric Associates opened its first office in Hollywood, FL. Since then, our physicians have cared for four generations of families with our first patients now bringing their children, grandchildren and great-grandchildren to our practice. With Coastal Kids in California, ABCD and MDMG in Texas, Arbor in Arizona, Tri-County in Pennsylvania, Mexico operations, and our operations based in New York and New Jersey, and Florida Pediatric Associates Family of Companies is proud to have expanded as much as we have and hope to grow even more in the future. We invite you to follow our path as we are the largest pediatric organization in the United States. This new growth brings great opportunities for candidates looking to join our fun and dynamic family of over 2,500 employees. Search our jobs today and see why Pediatric Associates is one of the best Pediatric practices in the United States. Job Opportunities: We offer excellent job opportunities for administrative, business and medical professionals. Our jobs include: front office receptionists, clinical staff, lab and x-ray technicians, billing and collections, operations managers, business professionals and healthcare providers. We also have opportunities for LPNs and RNs to provide triage and care via telemedicine.

Remote Opportunity Schedule: Monday - Friday 8am - 5pm EST Spanish Speaking Required PRIMARY FUNCTION The Care Manager, LPN assists in the care coordination for identified medically fragile and complex pediatric patient population. Functions as a liaison between the patient and the care team. Interacts with Primary Care Physician (PCP), front office, outside specialists, health plans, and patients/caregivers. Provides guidance and direction to Chronic Care Coordinators and may provide education to patients.

EDUCATION: Minimum associate degree or two years’ technical schooling in related area required. Combination of education and experience in care management, practice administration and/or managed care will be considered. EXPERIENCE: A minimum of 3 years previous healthcare experience required functioning as an LPN/LVN, A minimum of 5 years preferred. Care management experience in managed care industry, physician group practice or health care required. LICENSURE / CERTIFICATION: Licensure as an LPN/LVN or higher required. KNOWLEDGE, SKILLS, AND ABILITIES: Patient management skills Strong customer service skills including de-escalation expertise. Knowledge of medical billing and health records maintenance. Excellent interpersonal and communication skills. Excellent decision-making and problem-solving skills. Detail oriented and analytical skills. Knowledge of laws governing the protection of patients’ private health information.

Conducts outbound calls to complete assessments of targeted medically complex pediatric patients. Collaborates with family and patient health care team to identify patient needs. Reviews current plans of care and makes recommendations per current state guidelines for medical necessity. Collaborates with the Medical Director to ensure appropriate service delivery including review of findings, criteria not met, determination of appropriate level of care, delay in services, alternative solutions, etc. Communicates treatment changes to the PCP, family, healthcare team, and others involved in patient care. Assists with coordinating and may participate in multidisciplinary rounds, peer to peer reviews, and individual case reviews for established patients. Participates in quality review processes to ensure active reviews are completed. Completes documentation in the care management platform and electronic health record. Responds to incoming and outgoing correspondence and requirements of plans of care and recertification. Reviews incoming referrals, plans of care, and consult notes. May escalate to the medical director for follow up. Functions as a resource on state requirements for home health guidelines. Participates in ongoing development, implementation, and evaluation of program and process effectiveness. Formulates recommendations for process modifications. Identifies opportunities and recommends methods to improve service, processes, and financial performance. Participates in internal initiatives. Participates in gathering information and data for CMS reporting. Functions as expert resource for staff. Provides guidance and direction to Chronic Care Coordinators and may provide education to patients. Provides courteous and prompt service to all internal and external customers.

TriWest Healthcare Alliance

Prescription Monitoring Program Team Lead - RN

Posted on:

August 30, 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. DoD Statement Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position.

We offer remote work opportunities (AK, AR, AZ, 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 Prescription Monitoring Program Team Lead is responsible for managing the assigned team to meet or exceed timeliness and quality standards for all program reporting and tracking. Responsible for training and mentoring of assigned team members as well as providing support to the Medical Director who has oversight for the program. This role performs clinical reviewer duties to include reviewing clinical records for identified TRICARE beneficiaries and providers to assess the need for intervention regarding the use and prescribing of controlled medications. Supports clinical quality efforts toward beneficiary safety and quality clinical practice by network providers and forwards appropriate cases to quality committees. The position influences ongoing assessment, development, and implementation of process improvements and identifies techniques for reporting and measuring outcomes.

Required: Registered Nurse current unrestricted license in appropriate state or territory of the United States 5 years’ experience in any combination of clinical practice, clinical review and intervention, pharmacy compliance management, or managed care U.S. Citizen Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation Hold a current certification from an industry recognized entity in Case Management, Healthcare Compliance, or Healthcare Quality or other appropriate credentials to review standard of care determinations Knowledge of training opportunities to support providers, such as state Prescription Drug Monitoring Programs (PDMP) and Substance Abuse and Mental Health Services Administration (SAMHSA) training Proficiency in Microsoft Office suite of applications and EHR systems to conduct extensive investigations Prior experience in a team lead, mentoring or training role Preferred: Experience in clinical review practices specific to medication management, pharmacy, or healthcare compliance including preparing detailed compliance reports Experience analyzing and evaluating claims data, pharmacy records, and policy guidelines for compliance reviews Experience with TRICARE, VA, or other government benefit programs, particularly with prescription drug monitoring programs (PDMP) or the TRICARE Prescription Monitoring Program (PMP). Formal training in healthcare fraud detection

Provides training, guidance and support to PMP clinical and non-clinical staff. Uses management reports to prioritize and monitor the workload throughout the day and quarter (primary reporting requirements are quarterly, but intervening progress reporting is also required). Makes daily staff assignments and makes adjustments as needed throughout the day to meet contract requirements. Leads and Executes PMP Access and Review: accessing and receiving PMP databases/reports and reviewing patient and provider prescription history to identify patterns or discrepancies. Screens claims for medication line items that show potential over-utilization and medically inappropriate prescribing of controlled substances and reviews to establish the medical necessity for the controlled substances and reviews to establish the medical necessity for the controlled substances. Leads and Supports External Communication and Collaboration: Communicating findings to prescribers (doctors, nurse practitioners, etc.) to inform them of clinical decisions and promote appropriate prescribing practices. Leads Compliance and Advocacy Efforts: Ensuring compliance with Tricare-specific reporting requirements and PMP policies and procedures, advocating patient safety and promoting best practices in controlled substance prescribing. Leads development, refinement, and implementation of high-level compliance protocols, update of desk procedures, clinical guidelines, review processes, and training guides. Works with Medical Directors as needed when interventions are required and/or need to be escalated and serves as Subject Matter Expert for program for clinical and non-clinical staff questions regarding the program. Collaborates with the Defense Health Agency (DHA) and medical claims and pharmacy vendor partners to facilitate the required review of claims and medical records to assess for the need for intervention in circumstances of actual or potential drug abuse situations or medical provider over prescribing patterns. Conducts Data Analysis and Interpretation: Analyzing prescription data for red flags, such as multiple prescriptions, excessive quantities, or unusual prescribing patterns, to assess potential risk. Manages and Executes Reporting and Documentation: Documenting findings and any actions taken based on review, ensuring accurate record-keeping. Conducts and manages program Case Management and Follow-up: Support case management of patients identified as potentially at risk, ensuring appropriate interventions and follow-up. Participate in special projects and cross-functional teams to identify and drive process improvement opportunities and techniques for measuring outcomes. Provides guidance for complex clinical issues and ensures compliance with contractual obligations. Performs audits as assigned and provides results to supervisor. Assists staff with reporting PQIs, critical findings, suspected fraud, HIPAA disclosures. Ensures staff adherence with defined department procedures. Performs other duties as assigned. Regular and reliable attendance is required.

Oscar Health

NP/PA - Virtual Health Assessment (100% Remote)

Posted on:

August 30, 2025

Job Type:

Full-Time

Role Type:

Primary Care

License:

RN

State License:

Compact / Multi-State

Hi, we're Oscar Medical Group. We're hiring a Nurse Practitioner or Physician Assistant to join our Virtual Health Assessment team. At Oscar Medical Group, we are refactoring healthcare. We want to help each of our members achieve their healthcare goals in a personalized way. To help us achieve that goal we are looking for innovative leaders who think big and push boundaries to refactor healthcare and the healthcare delivery system.

Oscar Medical Group runs a Virtual Health Assessment (VHA) program that outreaches and virtually engages Oscar Health Insurance members in an evaluation and management visit. You will also help to support teams across Oscar Medical Group, including Virtual Primary Care and Virtual Urgent Care when needed. Hours 8a-8p EST Monday - Thursday 8a-6p EST Friday & Saturday 8hr or 10hr shifts 1 late day (working shift ending at 8p EST) is required per week 2 Saturday shifts required per quarter You will report into the Lead APP, Virtual Health Assessment. Work Location: Oscar Medical Group is a blended work culture where everyone, regardless of work type or location, feels connected to their teammates, our culture and our mission. This is a remote / work-from-home role. You must reside in one of the following states: Arizona, California, Colorado, Florida, Georgia, Illinois, Massachusetts, Michigan, Nevada, New Jersey, New York, North Carolina, Ohio, Pennsylvania, Texas, or Virginia. Note, this list of states is subject to change. Pay Transparency The base pay for this role is: $104,000 - $136,500 per year. You are also eligible for employee benefits, annual vacation grant of up to 18 days per year, and annual performance bonuses.

Requirements: DNP, FNP, ENP, or PA from accredited program Board Certification (NCCPA or AANP or ANCC) Compact RN license (only applicable to NP) Experience with Clinical Documentation Improvement and/or managing HEDIS quality measures Licensed in TX and at least 1 of these states: OH, NJ Ability to obtain licensure in additional states 3+ years experience in outpatient Family Medicine, Internal Medicine, or Primary Care Bonus Points: Fluent in Spanish 1+ year Telemedicine experience Additionally Licensed in: New York, Oklahoma, Ohio, Connecticut, North Carolina, Iowa,Virginia, New Jersey, Nebraska, Arizona, Illinois, Michigan, Nebraska, and/or California

Perform preventative care screenings, complete medication reconciliation, diagnose medical conditions and provide health coaching, referrals and treatment when clinically appropriate. Outreach members who are more chronically ill based on historical and suspected health information. Engage members who have a lower probability of seeing their PCP. Identify areas in the member's medical journey that can be improved by increasing their access to care with a licensed provider. Cross-train into urgent care and/or virtual primary care service line Interact with members virtually, including virtual assessment, diagnosis and treatment. Compliance with all applicable laws and regulations Other duties as assigned

Vivo Care

Care Navigator- Licensed Nurse - Remote - CST Time Zone - Compact Required, Illinois a Plus

Posted on:

August 30, 2025

Job Type:

Full-Time

Role Type:

Behavioral Health

License:

RN

State License:

Compact / Multi-State

At Vivo Care, we believe the best care doesn’t end at the clinic, it lives in the moments between visits. That’s why we’re building something bigger than software. We’re creating a future where care is continuous, personal, and truly connected. If you’re driven to make a difference, we want you on our team. We’re not here to make care a little better, we’re here to rethink it entirely. From our platform to our partnerships, we challenge the status quo and design for what patients and providers really need. Every team, every role, every idea is part of building something new. While healthcare is complex, we don’t shy away from tough problems. We stay focused, move fast, and push through barriers with creativity, grit, and a commitment to doing what’s right, even when it’s not easy. We care deeply about our work, our mission, and each other. Our team brings heart to everything we do, showing up every day to improve lives, strengthen relationships, and make care feel like care again.

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

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

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

Performant Healthcare, Inc.

Medical Review Nurse II - Readmissions Focus

Posted on:

August 30, 2025

Job Type:

Full-Time

Role Type:

License:

RN

State License:

Florida

At Performant, we’re focused on helping our clients achieve their goals by providing technology-enabled services which identify improper payments and recoup or prevent losses due to errant billing practices. We are the premier independent healthcare payment integrity company in the US and a leader across several markets, including Medicare, Medicaid, and Commercial Healthcare. Through this important work we accomplish our mission: To offer innovative payment accuracy solutions that allow our clients to focus on what matter most – quality of care and healthier lives for all. If you are seeking an employer who values People, Innovation, Integrity, Fun, and fostering an Ownership Culture – then Performant is the place for you!

The Medical Review Nurse II - Readmissions Focus primarily performs medical claims audit reviews. As a MR Nurse, you will join a team of experienced medical auditors and coders performing retrospective and prepayment audits on claims for Government and Commercial Payers. You will work remotely in a fast paced and dynamic environment and be part of a multi-location team.

Knowledge, Skills and Abilities Needed: Experience with utilization management systems or clinical decision-making tools such as Medical Coverage Guidelines (MCG) or InterQual. Experience with and deep knowledge of ICD-9, ICD-10, CPT-4 or HCPCS coding. Knowledge of insurance programs program, particularly the coverage and payment rules. Ability to maintain high quality work while meeting strict deadlines. Excellent written and verbal communication skills. Ability to manage multiple tasks including desk audits and claims review. Must be able to independently use standard office computer technology (e.g. email telephone, copier, etc.) and have experience using a case management system/tools to review and document findings. Must be able to manage multiple assignments effectively, create documentation outlining findings and/or documenting suggestions, organize and prioritize workload Effectively work independently and as a team, in a remote setting. Required and Preferred Qualifications: Active unrestricted RN license in good standing, is required. Must not be currently sanctioned or excluded from the Medicare program by the OIG. Minimum of five (5) years diversified nursing experience providing direct care in an inpatient or outpatient setting. One (1) or more years' experience performing medical records review. One (1) or more years' experience in health care claims that demonstrates expertise in, ICD-9/ICD-10 coding, HCPS/CPT coding, DRG and medical billing experience for an Insurance Company or hospital required. Strong preference for experience performing utilization review for an insurance company, Tricare, MAC, or organizations performing similar functions.

Auditing claims for medically appropriate services provided in both inpatient and outpatient settings while applying appropriate medical review guidelines, policies and rules. Document all findings referencing the appropriate policies and rules. Generate letters articulating audit findings. Supporting your findings during the appeals process if requested. Working collaboratively with the audit team to identify and obtain approval for particular vulnerabilities and/or cases subject to potential abuse. Work in partnership with our clients, CMD colleagues, and other contractors on improving medical policies, provider education, and system edits. Keep abreast of medical practice, changes in technology, and regulatory issues that may affect our clients. Work with the team to minimize the number of appeals; Suggest ideas that may improve audit workflows; Assist with QA functions and training team members. Participate in establishing edit parameters, new issue packets and development of Medical Review Guidelines. Interface with and support the Medical Director and cross train in all clinical departments/areas. Other duties as required to meet business needs.

Analyte Health

Telehealth Nurse Educator

Posted on:

August 30, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

LPN/LVN

State License:

Texas

Analyte Health's mission is to provide easy, accessible and affordable online health care services for everyone. Everything we do focuses on helping our patients become healthier and happier. We have easy-to-use online platforms that provide fast, convenient, private and cost-effective clinical services anytime, anywhere. Our trained health counselors will guide our patients every step of the way while our physicians are ready to deliver treatment. We provide innovative health care services through the elegant mixture of technology, science and patient-centric care that gets our patients back on the path towards wellness.

Seeking Licensed Vocational/Practical Nurse - REMOTE! (In partnership with Wilcrest Medical Group) Analyte Health is currently seeking a licensed LVN/LPN for a 6-month temporary role with the possibility of extension. In this role, you will be responsible for providing telephonic intake services and sexual health counseling under direction of the healthcare provider.

Minimum of 1-2 Years of experience in a clinical or telehealth/telemedicine setting. Demonstrates progressive proficiency with computers/technology (WPM Typing: 60+) Demonstrates exceptional customer service, leadership, communication, interpersonal, and problem-solving skills Ability to maintain a hard wired (Ethernet) internet connection (Must have High-Speed Internet). Experience working with the adult population. Experience working as a telecommuter or in a call center setting. Experience in clinical telephone triage. Experience working with Electronic Health Record (EHR) systems. Education and Certifications: Graduated from an accredited School of Nursing. Current license to practice as an LVN/LPN. Physical Requirements: Ability to sit and work in front of a computer for long periods of time. Ability to speak on the phone for long periods of time. Bilingual in Spanish (Preferred, but not required).

Intake Process/Chart/Document patient consultations in the practice's EMR Perform Sexual Health Counseling (over the phone) Medication and Treatment Plan review Referral coordination LVNs/LPNs are expected to work from home efficiently to meet daily caseload Attend scheduled meetings with staff and leadership.

Pacer Group

Clinical Review Nurse- Prior Authorization

Posted on:

August 30, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Ohio

Founded in 2008, PACER is a Minority Woman-owned Global Staffing firm serving Fortune 500 Clients with customized and scalable workforce solutions. With our Account Management integrated into our service delivery processes, we provide our clients with staffing solutions that are transparent and robust irrespective of the industry they function in.

Title - Clinical Review Nurse- Prior Authorization Duration - 6 months | Possibility to extend Shift - 8 am- 5 pm Location - Remote OH Pay rate: $35.00-42.00/hr

Must Haves: Computer skills, medical knowledge, Care manager or clinical nursing experience Word, Excel, Virtual meeting skills MS outlook and EMR systems Nice To Haves: Works well for this role: Prior Authorization Nurse, Medical Review Nurse, Appeals Nurse, Utilization Management or Quality Assurance Nurse Critical thinking skills good people skills and able to communicate needs Comfortable with provider interaction Disqualifiers: not having the requirements mentioned, remaining disqualifiers TBD during interview Performance indicators: (Meet expectations) Quality documentation, timely processing of up to 18 authorizations per day on average, team player with positive attitude Top 3 RN/LPN licensed professional Comfortable toggling between multiple computer systems Very agile and comfortable in fast paced environment Prior Authorization experience Education: Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience. Licensure: Nursing Licensure

Clinical review and documentation of medical request for prior authorization of medically necessary services, sitting in front of a computer for 8 hours with allowance for breaks and 1 hour lunch, biweekly team huddles (virtual), and attention to emailed team instructions, proficient in toggling between multiple systems BHP Prior Authorization Clinical Review Nurse Biweekly team huddles (virtual), and attention to emailed team instructions, proficient in toggling between multiple systems Review of prior auth requests for Medicaid Line of Business. To assist the PA Team reviewing a backlog of requests from providers

AORN

Informatics Nurse Specialist

Posted on:

August 30, 2025

Job Type:

Full-Time

Role Type:

Informatics

License:

RN

State License:

Colorado

“Mission driven, great benefits and room for growth!” Why consider AORN, Association of periOperative Registered Nurses, as the next place for your career as our Informatics Nurse Specialist? Because we’re innovative and all about quality and collaboration – we’re continually seeking to enhance our offerings to allow us to better tailor to the needs of our nurse members while expanding our market position and growing revenue across our business and sales divisions. Our mission is to define, support, and advocate for patient and staff safety through exemplary practice for each phase of perioperative nursing care using evidence-based guidelines, continuing education, and clinical practice resources. We collaborate with professional and regulatory organizations, industry leaders, and other health care partners who support our mission. Our culture is one of openness, teamwork, risk taking and being at the cutting edge of our field and we only look for employees who hold these same traits. Values mean more to AORN than just bullets on a page. They drive our daily decisions and impact how we work as an organization: Innovation: Taking courageous and bold actions for growth and sustainability. Communication: Exemplifying respect, collaboration, transparency and honesty. Quality: Ensuring accountability and excellence. Diversity, Equity, Inclusiveness: Promoting fairness, valuing differences, considering all perspectives. Achievement: Achieving our mission, realizing the vision.

Our Informatics Nurse Specialist, in collaboration with the Perioperative Informatics Solutions Manager(s), is responsible for providing clinical and informatics expertise to support the development and implementation of the AORN Syntegrity® Solution and to provide recommendations to clients and vendor partners, AORN staff and board members, and standard setting bodies related to perioperative informatics. Responsibilities include: an active involvement in the ongoing development and maintenance of the AORN Syntegrity Solution content, the ongoing development and maintenance of the Perioperative Nursing Data Set (PNDS) language; active involvement in perioperative informatics, assisting vendor partners and clients with the integration of the AORN Syntegrity Solution into perioperative clinical information systems; ensuring alignment with clinical standards, accreditation specifications, and regulatory requirements to promote ongoing compliance and consistent patient care; and the understanding and utilization of standardized terminologies (e.g. CPT4®, LOINC®, SNOMED CT®). This also includes leveraging emerging technologies such as artificial intelligence (AI), natural language processing (NLP), and predictive analytics to enhance AORN Syntegrity offerings and internal workflows. AORN is based in Denver, CO. Our Informatics Nurse Specialist will work remotely. WORKING CONDITIONS: Remote work environment, using a computer, telephone and Microsoft Teams daily. Ability to travel as needed in support of department and Association functions.

MINIMUM QUALIFICATIONS: Master’s in Nursing Informatics or Master’s in Nursing with a certificate in Nursing Informatics. 5+ years of experience in perioperative nursing practice or experience implementing an electronic perioperative health record and associated workflows. Epic Certified or Accredited OpTime Analyst with build experience. Registered Nurse. PREFERRED QUALIFICATIONS: CNOR. Board Certification in Informatics. Intraoperative nursing experience. Experience in and knowledge of perioperative informatics and clinical workflow. Holds a certification or possesses equivalent experience in perioperative EHR development and support, especially in the Epic environment. Management experience in perioperative nursing. Project management experience with an emphasis on workflow improvement. Experience with EMR system configuration and support across multiple platforms (e.g., Epic, Oracle Health, MEDITECH). KNOWLEDGE, SKILLS AND ABILITIES: Understands relational databases and data structure. Knowledge of AORN guidelines and standards of practice. Knowledge of PNDS as it relates to perioperative nursing practice and nursing language standards. Knowledge of healthcare information technology standards and policies (e.g. interoperability, meaningful use). Knowledge of healthcare quality measurement (e.g. eCQM, NQF, AHRQ). Knowledge of standards, accreditation, and regulatory issues related to the perioperative environment in acute care and ASC settings. Knowledge of standardized healthcare terminologies (e.g. LOINC, SNOMED CT, CPT4). Publication, public speaking, and teaching skills. Ability to establish rapport quickly. Excellent written and verbal communication skills. Strong interpersonal skills and the ability to work effectively with clients, vendor partners, headquarters staff and others. Ability to problem-solve, plan collaboratively, and demonstrate professional accountability. Working knowledge of Microsoft Office applications. Familiarity with applying AI/ML in clinical settings, including Natural Language Processing, predictive analytics or workflow automation. Familiarity with data governance, privacy, and security frameworks (e.g. HIPAA, HITRUST). Ability to collaborate across interdisciplinary teams and contribute to shared documentation and planning platforms (e.g., SharePoint, OneNote). Ability to demonstrate and hold others accountable for organizational values of: Innovation, Communication, Quality, Diversity, Equity and inclusion, and Achievement.

Supports the development and refinement of the AORN Syntegrity content including research, creation, revision, and removal of content in the internal tool (e.g. MAKe) and other systems. Provides technical assistance and client support for EHR integrations (e.g., Epic, Oracle Health, MEDITECH), including troubleshooting and enhancement recommendations. Participates in the development, validation, and enhancement of the databases and tools associated to the AORN Syntegrity Solution and PNDS. Provides perioperative clinical and informatics expertise with respect to the PNDS and the AORN Syntegrity Solution; areas of consultation include: PNDS; perioperative nursing management data needs; quality assessment and process improvement measurement criteria; standards, regulatory and accrediting agencies requirements related to the AORN Syntegrity Solution in the electronic health record; liaison for vendors/facilities utilizing the AORN Syntegrity Solution within their electronic perioperative health record; development of data repositories/warehouses and data analytics; and the appropriate utilization of standardized terminologies. Maintains current knowledge base in perioperative nursing practice and health care informatics. Engages in on-going assessment and evaluation of the nursing documentation and informatics needs of perioperative practitioners, leaders and patients. Engages in on-going assessment and evaluation of procedure list and informatics needs of perioperative practitioners, leaders and patients. Engages in on-going environmental assessment for adaptation of regulatory, accreditation, standards- and evidence-based practices and updates the AORN Syntegrity Solution accordingly. Contributes to AORN publications and other products as needed. Represents AORN and AORN Syntegrity at specific organizations and functions, as assigned. Participates as a self-directed team member by initiating and maintaining a consultative/collegial relationship with peers, staff, volunteers and other business entities; participating in orientation of new staff members; serving as a mentor to peers, informatics students and other Association staff. Sets priorities and achievable goals; self-evaluates progress toward pre-established goals. Collaborates with other departmental teams on projects. Collaborates on the design and implementation of AI-driven tools to support workflow optimization and AORN Syntegrity offerings. Contributes to internal strategic planning to align team capabilities with evolving organizational needs. Assists in the onboarding and mentoring of new team members, including defining role expectations and evaluating competencies across education levels. Maintains confidentiality of sensitive information. Other duties as assigned.

Avel eCare

RN Behavioral Health PRN: Remote

Posted on:

August 30, 2025

Job Type:

Part-Time

Role Type:

Behavioral Health

License:

RN

State License:

California

Avel eCare is a nationally recognized leader in telemedicine, operating one of the most extensive virtual healthcare networks in the world. Based in Sioux Falls, South Dakota, Avel partners with over 650 healthcare systems, rural hospitals, clinics, and facilities to deliver innovative telehealth solutions. Our services span Behavioral Health, Critical Care, Emergency, Hospitalist, Pharmacy, Specialty Care, Senior Care, and School Health, impacting nearly two million patients annually. For three decades, Avel has been at the forefront of healthcare innovation, developing telehealth solutions that reduce costs, save time, and remove barriers to quality care. Join our mission-driven team and help reshape the future of healthcare.

Avel eCare is seeking a dedicated Registered Nurse (RN) for our Behavioral Health team. This role is designed for individuals who can provide acute mental health crisis evaluation for patients of all ages and ethnic groups. As a key member of the team, the RN-C will apply specialized clinical knowledge and advanced skills in assessment and crisis intervention for individuals facing mental, emotional, and behavioral challenges. The role requires the ability to work in a fast-paced, stressful environment, performing rapid assessments while multitasking effectively.

EDUCATION And/or EXPERIENCE: Graduate from a CCNE or NLN accredited nursing program is strongly preferred; graduation from an approved nursing program is acceptable. At least two years of Behavioral Health nursing experience preferred. Bachelor’s degree preferred. CERTIFICATION, LICENSURE, And/or REGISTRATIONS: Active and unrestricted Registered Nurse license required. Active Registered Nurse California license preferred. RN licensure required within the states that eCare Behavioral Health operates within 120 days of hire. Certification in Psychiatric Mental Health Nursing (PMHN) by the American Nurses Credentialing Center (ANCC) preferred. Completion of state-specific certification/education within required time periods.

Inquiry and Assessment: Answer all inquiry calls promptly, provide on-demand assessments, and maintain an updated database with accurate patient information. Ensure excellent customer service as the point of contact for all eCare Behavioral Health services. Psychosocial Assessment: Conduct psychosocial assessments, including suicide/homicide risk evaluations, determine appropriate care levels, and collaborate with providers at the site of care. Patient Placement Support: Assist telemedicine sites with patient placement for psychiatric inpatient beds. Mental Health Support: Provide de-escalation strategies, counseling, and disposition recommendations to individuals in Behavioral Health programs. Develop safety plans to help individuals stay safe in their communities. Community Support: Encourage outpatient care and promote mental health services to keep patients in their communities. Project Support: Participate in additional responsibilities for eCare Behavioral Health projects and community activities as assigned by the Director. Demonstrate proficiency in computer skills – Windows, Instant Messaging, Microsoft (Word/ Teams/ Outlook). Proven exemplary clinical documentation skills.

FitCam Health

Bilingual RN (Arabic – Iraqi/Syrian) for Remote Patient Monitoring

Posted on:

August 30, 2025

Job Type:

Contract

Role Type:

Behavioral Health

License:

RN

State License:

Compact / Multi-State

FitCam Health is a leading digital health platform specializing in pain management. We work with pain clinics to offer comprehensive Remote Therapeutic Monitoring (RTM) programs, helping patients manage their pain through personalized home exercise programs and cognitive behavioral therapy (CBT) techniques.

We are currently seeking licensed Bilingual Registered Nurses (Arabic – Iraqi/Syrian) to join our remote team and provide monitoring services for our RTM programs. This is an excellent opportunity to be part of a cutting-edge digital healthcare service that enhances patient care while providing a flexible work schedule.

Prior experience in telehealth, pain management, or monitoring patients remotely is preferred. Tech-Savvy: Comfortable using digital health tools, apps, and telehealth platforms for patient monitoring and engagement. Strong Communication Skills: Ability to effectively communicate and engage with patients and care teams through various channels. Nice to Have: Experience as a Psychiatric Nurse, understanding the psychological aspects of chronic pain management, and mental health care. Benefits: Flexible Work: Choose part-time or full-time hours to suit your schedule. Competitive Pay: Hourly rates with the potential for performance-based bonuses. Remote Opportunity: Work from the comfort of your home, while still making a direct impact on patient care. Ongoing Training: Access to continuous professional development through FitCam Health's training programs. Apply Now

Monitor Patient Data: Track patients’ progress, including therapy adherence, pain levels, and overall health data reported through the FitCam Health Console. Patient Communication: Engage with patients via in-app messaging, phone, and video calls to answer questions, offer guidance, and ensure they are following prescribed treatment plans. Program Customization: Work closely with physicians and other healthcare providers to tailor patient programs based on real-time data, adjusting treatments to optimize outcomes. Patient Education: Provide information on managing pain through the FitCam platform, guiding patients on self-care techniques and therapy adherence. Documentation and Reporting: Maintain thorough patient records and ensure all RTM interactions meet regulatory requirements. Compliance: Ensure adherence to HIPAA regulations and clinic protocols during patient interactions. Qualifications: Licensure: Active Registered Nurse (RN) license in one or more of the following states: Compact License, Alaska, New Jersey, New York, Ohio, South Carolina, California.

Maximus

Health Coordinator

Posted on:

August 30, 2025

Job Type:

Part-Time

Role Type:

License:

None Required

State License:

Virginia

Maximus is a global organisation that specialises in providing health and employment services to millions of people every year. Here in the UK we employ around 5,000 people across the country to deliver services that have a profound impact on people’s lives. From assessments and health services to employability programmes and specialist support, we do work that matters with people who care.

We are looking for passionate and empathetic person to support the National Child Measurement Programme (NCMP). This role will include calling families that have taken part in the NCMP and encourage them to access our free healthy lifestyle programmes. You will be a connector within the delivery team, to link families who are looking for support within the programmes we are running across local community services and professionals.

Qualifications and Experience: Level 4 in office admin, diploma in office admin or equivalent Experience of working in a public health environment Experience of working in a customer facing role Experience and competence in using a data management system Experience of using IT systems Experience of inputting and processing data Experience of managing customer concerns or issues Experience of working remotely Experience in communicating information with other teams An understanding of the stages of behaviour change Individual competencies A personable, non-judgmental and sensitive approach to communicating with the public IT literate especially excellent working knowledge of Microsoft Office Excellent organisational skills to manage and prioritise workload, anticipate needs and work on own initiative and as part of a high functioning team Fluent and clear in English speaking Active listening skills Excellent data processing and data management system skills Confident, self motivated, passionate, flexible and adaptable Good attention to detail Able to respond positively to new situations Methodical with the ability to understand and meet targets and deadlines, able to learn and assimilate new information. Ability to reflect and appraise own performance and that of others

You will be responsible for calling families who receive the National Child Measurement Programme to chat about the impact of the results, discuss what is happening for them as a family, and encourage them to take up any of our free services. Whilst calling families, you'll need to be flexible and adopt multiple approaches and techniques to encourage parents to make use of free services that will ultimately improve the health and wellbeing of their family. You'll thrive in this role if you enjoy having meaningful conversations, have skills around motivational interviewing, empathetic listening and have the courage to approach parents/carers with tenacity and challenge decisions with curiosity. In this role, you'll be able to engage in meaningful work that truly impacts childhood obesity, enhancing lives by improving quality and longevity. Call families who receive an above healthy weight NCMP letter Discuss how they feel about receiving the letter Have sensitive and perhaps tough conversations with parents regarding their child’s weight Discuss the support available in the local community and talk through the services we provide If families would like support book them into the system and send confirmation/welcome packs, as well as share any relevant resources with families Update system with communications with families Manage family profiles on the CRM Manage the NCMP data Understand the community support available for families Support the delivery team on asset mapping of local services Meet with local partners and stakeholders to update on our services Any other requirements for the business

Maximus

Case Recovery RN (Part-Time, Remote in Montana)

Posted on:

August 30, 2025

Job Type:

Part-Time

Role Type:

Behavioral Health

License:

RN

State License:

Compact / Multi-State

Maximus is seeking a part-time Case Recovery - (RN) to support our Montana Recovery Program (MTRP). In this role, you will be a key member of the clinical team, responsible for conducting check-in calls with participants, reviewing lab results and medications, and assisting participants in finding treatment options in Montana. You will also connect participants with resources and support groups. You will serve as the point of contact for the board, providing status updates on participants when requested, and offering crisis management support when necessary. Strong knowledge of mental health, behavioral health, and substance use disorders is essential for success in this role. If you have this expertise, we encourage you to apply! This is a part-time remote position, requiring 24 hours per week, scheduled on Tuesday, Wednesday, Thursday, and Friday. About the Program: The Montana Recovery Program (MTRP) is a monitoring program contracted with the Montana Department of Labor and Industry. We support the healthcare professionals afflicted with substance use disorder, mental health, and/or chronic physical illness to return to safe professional practice. We work with the State Boards of Medical Examiners, Pharmacy, Dentistry and Nursing.

Minimum Requirements: Bachelor's degree from an accredited college or university in Business, Behavioral Science, or related field strongly preferred. Clinical licensure requirements are based on program contract requirements and are outlined in job posting Associate's degree Current RN licensure in the state of Montana or a multistate compact RN license. Minimum of 1 to 3 years of experience in a behavioral health care setting focused on chemical dependency, recovery, and/or mental health. Minimum 3 years of experience and a strong level of comfort working in substance abuse and/or mental health treatment settings. Must have computer literacy, including a strong working knowledge of Word and Excel. Excellent organizational, interpersonal, written, and verbal communication skills. Ability to perform comfortably in a fast-paced, deadline-oriented work environment. Ability to successfully execute many complex tasks simultaneously. Ability to work as a team member, as well as independently. Strong knowledge of care coordination, and an understanding of American Society of Addiction Medicine. Preferred Requirements: Montana Resident Prior case management Prior experience with conducting telephonic intakes Home Office Requirements: Maximus provides company-issued computer equipment Reliable high-speed internet service Minimum 20 Mpbs download speeds/50 Mpbs for shared internet connectivity Minimum 5 Mpbs upload speed s Private and secure workspace

Manages participants through their period of participation in the Program by monitoring overall program compliance, oversight of recovery activities, recommendations for treatment, and liaison with the Board. Conducts remote, telephonic assessment and reassessments of healthcare professional licensees to evaluate their status, overall compliance with program requirements, and progress in recovery. Contacts the participant, the appropriate Board/Committee (or their designee) or treatment providers, facilities and labs in response to participant non-compliance with the Program Agreement. Meets with applicant/participant telephonically weekly until seen by Review Committee, and monthly thereafter, to review compliance and progress in recovery. Responds to incoming calls on the toll-free line, as needed, and after-hour, weekend, and holiday calls on a rotating basis with other Program staff. Evaluates incoming information submitted by treatment providers, facilities, participants, and labs to monitor participant's progress and compliance with the Program Agreement. Reviews data in the History and Profile (H&P) reports to ensure accuracy prior to submission to Program Managers (PMs). Works on issues where analysis of situation and of data requires review of relevant factors: Exercises judgment within defined procedures and policies to determine appropriate action. Engages in quality assurance monitoring and evaluation for the Program, as necessary. Conduct comprehensive assessments to determine patient needs and appropriate care plans. Coordinate services and resources to support patient care, including referrals, follow-ups, and transitions of care. Monitor patient progress and adjust care plans as needed to achieve optimal outcomes. Collaborate with physicians, nurses, social workers, and other healthcare professionals to ensure continuity of care. Maintain accurate and timely documentation in compliance with regulatory and organizational standards. Participate in quality improvement initiatives and contribute to program development.

Guardian Life

RN Clinical Consultant, LTD and STD Claims

Posted on:

August 29, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Pennsylvania

At Guardian, you’ll have the support and flexibility to achieve your professional and personal goals. Through skill-building, leadership development and philanthropic opportunities, we provide opportunities to build communities and grow your career, surrounded by diverse colleagues with high ethical standards. Inspire Well-Being: As part of Guardian’s Purpose – to inspire well-being – we are committed to offering contemporary, supportive, flexible, and inclusive benefits and resources to our colleagues. Explore our company benefits at www.guardianlife.com/careers/corporate/benefits. Benefits apply to full-time eligible employees. Interns are not eligible for most Company benefits.

The RN Clinical Consultant, LTD and STD Claims serves as a clinical resource for the investigation and assessment of medical information regarding disability by providing comprehensive medical reviews and analysis of long-term disability claims. You will be responsible for restrictions, limitations and duration impacting functional capacity based on medical data, to assist the Claim Managers in determining claim liability. In addition, you will collaborate with treating providers to assist individuals to obtain appropriate care and ensure optimal treatment outcomes and acts with urgency and ownership to resolve customer issues and prioritize the customer experience. You will also review long and short-term disability claims to determine the impact of claimants’ medical condition on their function as well as the impact of their medical treatment in achieving improved functional outcomes.

You are: Well versed with a strong clinical background in understanding and applying rationale of how injury or illness may impact the claimant’s function. Excellent with verbal and written communications and able to gather and report information accurately, ask appropriate questions to facilitate partnership with treating providers, claimants, and internal partners to encourage participation of claimant in appropriate treatment goals. Able to work collaboratively with internal vocational rehab specialists in identifying opportunities for return to work. Experienced in identifying and resolving customer issues, when possible, to enhance the customer experience. You have: Must have at least 5 years in a clinical care setting and at least 2 in an acute care role. Must have experience handling LTD and STD disability claims. A valid RN license from an accredited school of nursing. Proficiency in multiple computer systems required. CCM preferred. Location/Travel: This role is remote with occasional in office meetings as required by the people leaders. No travel required. Disability experience strongly preferred. Location/Travel: This role is remote with occasional in office meetings as required by the people leaders. No travel required.

Review and assess claimant subjective reports and objective medical evidence to determine the impact of medical conditions on function. Clarify medical information, interpret medical reports, and evaluate restrictions and limitations to assess current and ongoing level of impairment. Apply current medical knowledge regarding diagnosis, treatment, prognosis, and impairment. Participate proactively through early assessment of medical issues, work capacity and RTW opportunities. Conduct analysis of claimant’s current treatment plan and collaborate with health care providers and claimants to promote accountability for the appropriateness and status of treatment plan and length of disability. Plan for ongoing case management through proactive partnering with treating providers to move claimants toward appropriate care. Serve as a technical resource on the medical aspect of the claim. Identify opportunities to educate claim staff and peers on medical aspect of disability. Provide ongoing training and mentoring to claims staff and peers regarding issues impacted by the nature of injury or illness and its impact on function in work or daily activities.

CorroHealth

Trainer, Clinical Solutions (Remote/Full-Time) (Active RN Licence Required)

Posted on:

August 29, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Texas

Our purpose is to help clients exceed their financial health goals. Across the reimbursement cycle, our scalable solutions and clinical expertise help solve programmatic needs. Enabling our teams with leading technology allows analytics to guide our solutions and keeps us accountable achieving goals. We build long-term careers by investing in YOU. We seek to create an environment that cultivates your professional development and personal growth, as we believe your success is our success.

As a Remote Clinical Trainer with CorroClinical, you play a crucial role in supporting the education of newly hired physicians and team members. You will provide essential training and guidance to help them excel in their roles. This position offers a unique opportunity to be the first steppingstone in their career journey, overseeing their onboarding, training curriculum, and professional development as they progress over time. Working at CorroHealth: All necessary hardware and software is provisioned to each of our employees You have the ability to work remotely in a comfortable environment

RN degree with strong clinical knowledge. Active unrestricted nursing license in at least one state within the United States. Recent experience in Acute Care, ICU, ED, or Teaching Hospitals a must. Previous experience in clinical training or education preferred. Utilization Management experience preferred. Strong communication and presentation skills. Excellent computer proficiency. Ability to work independently, undistracted, and collaboratively in a remote setting. Knowledge of MS Teams, PowerPoint, Excel, and Word applications.

ESSENTIAL DUTIES AND RESPONSIBILITIES: Note: The essential duties and responsibilities below are intended to describe the general duties and responsibilities of this position and are not intended to be an exhaustive statement of duties. This position may perform all or most of the primary duties listed below. Specific tasks, responsibilities or competencies may be documented in the Team Member’s performance objectives as outlined by the Team Member’s immediate Leadership Team Member. The Impact You Will Have: CorroHealth is a trusted third-party vendor partnering with hospitals to improve compliance and ensure appropriate payment for care delivered. Our team of clinicians plays a pivotal role in guiding hospital clients, ensuring quality care and financial sustainability. We are dedicated to making a positive impact not only on the hospitals we serve but also on the communities relying on their services. In This Role You Will: Support newly hired physicians and team members through the onboarding phase, guiding operational processes and workflows. Develop and deliver weekly training curriculums. Teach, follow, and review practice cases to ensure proficiency and understanding (via MS Teams chats and meetings). Provide constructive feedback via review calls, individual case notes, and internal team tracking reports. Teach how to remotely access CorroHealth client electronic medical records (EMR) and identify pertinent medical information, then document and record findings in the CorroHealth Information system (Salesforce Platform). Collaborate with physicians and team leads on training processes, documentation, and procedures. Assist in updating and creating training materials, such as presentations, manuals, and online modules, to effectively communicate medical concepts and best practices. Evaluate training effectiveness through assessments, surveys, and feedback mechanisms, making recommendations for continuous improvement.

Insight Global

Nurse Aid Evaluator

Posted on:

August 29, 2025

Job Type:

Full-Time

Role Type:

License:

RN

State License:

New York

Location: Remote, but must be flexible to cover testing in territory when needed (Bronx and Brooklyn, NY) Must own a laptop and cellphone Mileage can be expensed at 70 cents per mile beyond 30 miles, and any driving time exceeding 60 minutes can be compensated at half your hourly pay Summary: An employer is looking for Senior Nurse Aide Evaluators. The Senior Nurse Supervisor leads a team of 6–15 Nurse Aide Evaluators and Proctors, providing operational support, ensuring compliance with Prometric standards, and fostering a culture of continuous improvement. This role requires strong leadership, effective communication, and collaboration with cross-functional teams to deliver world-class service. The ideal candidate is detail-oriented, self-motivated, and adaptable, with a focus on maintaining high standards in a dynamic environment.

RN License 2 or more years overall in a healthcare leadership position Must have experience being responsible for direct reports, conducting reviews, taking disciplinary/corrective action, interviewing, managing scheduling for direct reports Excellent computer skills with ability to use teams/Webex, manage scheduling system online, when testing sign into database and access weblinks to log information, with instruction can upload candidates test results accurately Ability to step in to test in person when needed

Lead and develop a team of 6–15 Nurse Aide Evaluators and Proctors, fostering engagement and empowerment with a fair and independent leadership approach. Manage staffing, scheduling, and operational support to ensure testing availability in Prometric systems while minimizing overtime. Communicate effectively, providing feedback and resolving conflicts with professionalism, emotional intelligence, and a strong, principled stance. Oversee recruitment, training (including receiving the same training as Nurse Aide Evaluators), and compliance of NAEs and Proctors, securing approvals for hiring. Approve new test locations and ensure existing ones meet Prometric standards. Conduct annual performance evaluations for NAEs and Proctors, or as requested. Collaborate with Operations, HR, and Test Hours Management to share best practices and ensure event coverage. Work with HR to implement corrective action policies when needed. Maintain flexible work hours and be willing to provide coverage in a pinch if needed.

Allan Koba Compliance Solutions

Nurse Allocator-Compliance Specialist REMOTE

Posted on:

August 29, 2025

Job Type:

Full-Time

Role Type:

License:

RN

State License:

Conneticut

Allan Koba Compliance Solutions is a growing Medicare Secondary Payer service provider with a national client base comprised of high-profile and globally recognized businesses. We focus on balancing our clients’ needs with Medicare Secondary Payer demands in a manner that saves time and money. Our promise is to deliver effective solutions in a prompt, clear and efficient manner. We are experiencing tremendous expansion and currently seeking a Nurse Allocator-Compliance Specialist to join our team.

The ideal candidate would have 1-3 years of experience working in a professional environment. Candidates with experience in writing Medicare Set-Aside allocations and familiarity with Medicare Secondary Payer matters, workers’ compensation and/or liability insurance preferred.

Mastery of the Workers’ Compensation Medicare Set-Aside Reference Guide Current understanding of trending with the Workers’ Compensation Review Contractor Competence in writing Medicare Set-Asides for the purpose of CMS submission Experience in writing Evidence Based Medicare MSAs for non-submission Excellent writing, organizational and communication skills Knowledge of state fee schedule pricing methodology Familiarity with usual and customary pricing methodology Knowledge of Redbook and alternative pharmacy pricing methodology Ability to independently handle multiple priorities and deadlines with minimal supervision while simultaneously functioning smoothly in a fast-paced, close-knit environment Ability to manage multiple tasks Proficient in Microsoft Office Suite, Word and Excel. Ability to allocate pursuant to client-specific protocols and methodologies Responsible for successful file management, problem solving and client satisfaction Resolve and troubleshoot issues, requiring subject matter knowledge and understanding of company policies and procedures Bachelor’s degree Active nursing license

Curana Health

Utilization Management Nurse

Posted on:

August 29, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Texas

At Curana Health, we’re on a mission to radically improve the health, happiness, and dignity of older adults—and we’re looking for passionate people to help us do it. As a national leader in value-based care, we offer senior living communities and skilled nursing facilities a wide range of solutions (including on-site primary care services, Accountable Care Organizations, and Medicare Advantage Special Needs Plans) proven to enhance health outcomes, streamline operations, and create new financial opportunities. Founded in 2021, we’ve grown quickly—now serving 200,000+ seniors in 1,500+ communities across 32 states. Our team includes more than 1,000 clinicians alongside care coordinators, analysts, operators, and professionals from all backgrounds, all working together to deliver high-quality, proactive solutions for senior living operators and those they care for. If you’re looking to make a meaningful impact on the senior healthcare landscape, you’re in the right place—and we look forward to working with you. For more information about our company, visit CuranaHealth.com.

The primary role of the Utilization Management Nurse is to review and monitor members' utilization of health care services with the goal of maintaining high quality cost-effective care. The role includes providing the medical and utilization expertise necessary to evaluate the appropriateness and efficiency of medical services and procedures. This includes providing prior authorizations, concurrent review, proactive discharge/transition planning, and high dollar claims review. There is a heavy emphasis on concurrent review and proactive transition planning, and high dollar claims review. There is a heavy emphasis on concurrent review and proactive transition planning for members in the hospital and skilled nursing facility. This is primarily a remote telephonic position with normal business day hours, with one weekend day per month coverage. This position serves as a liaison to the Plan Medical Director working closely with appeals and medical decisions.

Education and Experience: Minimum 2 years clinical experience as RN, LPN/LVN required. Minimum 1-year managed care or equivalent health plan experience preferred. Demonstrated experience in health plan utilization management, facility concurrent review discharge planning, and transfer coordination required. Medicare Advantage experience preferred. Experience with InterQual or MCG authorization criteria preferred. Excellent computer skills and ability to learn new systems required. Strong attention to detail, organizational skills and interpersonal skills required. Demonstrated ability to problem solve and manage professional relationships. Certificates, Licenses and Registrations: Active unrestricted Nursing license required.

Performs concurrent and retrospective reviews on all facility and appropriate home health services. Monitors level and quality of care. Responsible for the proactive management of acutely and chronically ill patients with the objective of improving quality outcomes and decreasing costs. Evaluates and provides feedback to member’s providers regarding a member’s discharge plans and available covered services, including identifying alternative levels of care that may be more appropriate. As part of the hospital prior authorization process, responsible for determining “observational” vs “acute inpatient” status. Integral to the concurrent review process, actively and proactively engages with member’s providers in proactive discharge/transition planning. Actively participates in the notification processes that result from the clinical utilization reviews with the facilities. Prepares CMS-compliant notification letters of NON-certified and negotiated days within the established time frames. Reviews all NON-certification files for correct documentation. Maintains accurate records of all communications. Monitors utilization reports to assure compliance with reporting and turnaround times. Addresses care issues with Director of Quality and Care Management and Chief Medical Officer/Medical Director as appropriate. Coordinates an interdisciplinary approach to support continuity of care. Provides utilization management, transition coordination, discharge planning and issuance of all appropriate authorizations for covered services as needed for providers and members. Coordinates identification and reporting of potential high dollar/utilization cases for appropriate reserve allocation. Identifies and recommends opportunities for cost savings and improving the quality of care across the continuum. Clarifies health plan medical benefits, policies and procedures for members, physicians, medical office staff, contract providers, and outside agencies. Responsible for the early identification of members for potential inclusion in a Chronic Care Improvement Program. Assists in the identification and reporting of Potential Quality of Care concerns. Responsible for assuring these issues are reported to the Quality Improvement Department. Work as interdisciplinary team member within Medical Management and across all departments. Other duties as assigned.

Brighton Health Plan Solutions

Nurse Case Manager - Behavioral Health

Posted on:

August 29, 2025

Job Type:

Full-Time

Role Type:

Behavioral Health

License:

RN

State License:

New York

At Brighton Health Plan Solutions, LLC, our people are committed to the improvement of how healthcare is accessed and delivered. When you join our team, you’ll become part of a diverse and welcoming culture focused on encouragement, respect and increasing diversity, inclusion, and a sense of belonging at every level. Here, you’ll be encouraged to bring your authentic self to work with all your unique abilities. Brighton Health Plan Solutions partners with self-insured employers, Taft-Hartley Trusts, health systems, providers as well as other TPAs, and enables them to solve the problems facing today’s healthcare with our flexible and cutting-edge third-party administration services. Our unique perspective stems from decades of health plan management expertise, our proprietary provider networks, and innovative technology platform. As a healthcare enablement company, we unlock opportunities that provide clients with the customizable tools they need to enhance the member experience, improve health outcomes, and achieve their healthcare goals and objectives. Together with our trusted partners, we are transforming the health plan experience with the promise of turning today’s challenges into tomorrow’s solutions. Come be a part of the Brightest Ideas in Healthcare™.

Nurse Case Manager - Behavioral Health Brighton Health Plan Solutions Full Time Remote – 100% About The Role Brighton Health Plan Solutions (BHPS) provides Case Management/Utilization Review services to its clients. Cases are maintained by the Nurse Case manager. The Nurse Case Manager reports to the Manager of Case Management for clinical activities.

Current licensed Registered Nurse (RN) with licensure in their state of employment, bachelor’s degree preferred. Case Management Certification, a plus. Additional certifications such as Diabetes educator, Pediatric Nursing, Gerontological Nursing a bonus. Must maintain current licensure(s) and specialty certifications that are relevant to this position. Bachelor’s degree preferred. Minimum of 4 years’ experience in a clinical environment preferred. 2 years’ experience in Case Management necessary. Strong skills in medical assessment/medical record review. Independent problem identification/resolution and critical decision-making skills. Must be able to prioritize plan and handle multiple tasks/demands simultaneously. Strong organizational and task prioritization skills. Excellent customer service skills, including written and oral communication skills. Ability to define and solve problems, collect data, establish facts and make effective decisions a must. Ability to work proficiently on a computer (PC) with working knowledge of Microsoft Word, Office and Excel. Ability to work in a database environment. Experience with Milliman Care Guidelines (MCG) preferred. Experience with URAC/NCQA standards.

Is knowledgeable and compliant with all regulatory and statutory regulations that pertain to Case management and self-insured clients, especially ERISA and HIPAA confidentiality requirements. Assessment of patient needs are accomplished using clinical tools and other data sources. Individualized care plans are created to encompass all patient needs. Communicates directly with patients, physicians, DME providers, etc, to secure positive outcomes for patients. Educate patients and their family members of treatments plans, medications, and goals for successful outcomes. Establish insurance eligibility coverage for various treatment plans, medications, DME products and other medical costs the patient may incur. Utilizes internal and external resource and systems to effectively identify and meet member and family needs in response to Case Management requirements. Determines the appropriate level of care, utilization of resources, and continued needs of patients with complex medical needs, across the continuum of care through application of criteria. Facilitates and expedites discharge planning. Maintains accurate records of individual cases. Evaluates needs for alternative treatment as required. Ensures each case provides optimal medical care that is cost effective. Is kind, caring, sympathetic and positive with all customers and fellow employees. Adheres to established quality assurance standards and all BHPS policies and procedures. Participates in QA activities.

UnitedHealthcare

Clinical Appeals RN - Remote - 5 day work week - Weekends required

Posted on:

August 29, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

California

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

The Clinical Appeals RN is responsible for providing expertise in clinical appeals and grievances (analyzing, reviewing, and evaluating appeals and grievances), and acting as a Clinical Interface Liaison (clinical problem solver with facilities, providers, carriers, resolution of issues concerning members, benefits, program definition and clarification). You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.

Required Qualifications: Active, unrestricted RN license in state of residence 2+ years of clinical experience as an RN, including in an acute, inpatient hospital setting Proficiency in Microsoft Office, Word, Outlook, and Internet applications Available for 5 day work weeks including weekdays and weekends, 8:00- 4:30 in their time zone and some weekend work will be needed Preferred Qualifications: Bachelor of Science in Nursing 1+ years of experience using MCG and/or Medicare criteria 1+ years of Utilization Management, pre-authorization, concurrent review or appeals experience Appeals experience Proven excellent communication, interpersonal, problem-solving, and analytical skills

Review medical records and verify if the requested service meets criteria Review pre-service appeals for clinical eligibility for coverage as prescribed by the Plan benefits Review and interpret Plan language Coordinate reviews with the Medical Director Utilize clinical guidelines and criteria Accurately documenting determinations Adherence to all confidentiality regulations and agreements Hours M-F 8a-5p with alternating Saturdays Comfortable working mandatory overtime

TRC Talent Solutions

Remote Clinical Appeals Nurse PRN

Posted on:

August 29, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Georgia

TRC Talent Solutions is a full-service talent solutions provider with over 40 years of industry experience. Established in 1980, TRC is one of the largest privately held staffing firms in the country. Like his father, President and CEO Brian Robinson, remains focused on the idea that the marketplace continues to need a staffing agency built on principles and values, and is committed to providing the highest level of service in the industry.

100% Remote! This is an hourly PRN (as needed) position, and the hours will vary based on the needs of the department. Bachelor's degree in Nursing, Health Administration, or related field is required. Our team assists healthcare providers with the remediation of 3rd party accounts receivable, call center support and a variety of revenue cycle outsource capabilities. In this role, you will play a vital role in ensuring the accurate and timely review of insurance denials and appeals, advocating for our patients and healthcare providers. You will collaborate with healthcare providers and insurance companies to facilitate the clinical appeal process, utilizing your clinical expertise to support the necessity of medical services.

Experience & Education: Bachelor’s degree in Nursing, Health Administration, or a related field. Advanced clinical degrees preferred (e.g., RN, NP, PA) Minimum of 2 years of clinical experience in a healthcare setting Experience in clinical appeals, pre-authorizations, utilization review, or case management is highly desirable Skills: Strong clinical knowledge and the ability to interpret medical records and documentation Excellent communication and interpersonal skills Detail-oriented with strong organizational and time-management abilities Proficiency in using electronic health records (EHR) and other healthcare-related software

Conduct thorough and accurate reviews of insurance denials and appeals Advocate for patients and healthcare providers by communicating and negotiating with insurance companies Utilize clinical knowledge and expertise to identify and resolve issues with clinical denials and appeals Collaborate with other members of your team to gather necessary information and documentation for appeal Ensure timely and accurate submission of clinical appeals Maintain detailed and organized documentation of denials and appeals processes Stay up-to-date on insurance policies and regulations to ensure compliance in appeals Communicate effectively with patients, healthcare providers, and insurance companies regarding denials and appeals Monitor and track the success rate of appeals and identify areas for improvement Adhere to ethical and legal standards in all aspects of the job Maintain confidentiality of patient information and adhere to HIPAA regulations Participate in meetings and committees related to denials and appeals Continuously seek opportunities to improve processes and efficiency Ensure timely and accurate reporting of denials and appeals to management

Scene Health

Health Coach, Enrollment

Posted on:

August 29, 2025

Job Type:

Full-Time

Role Type:

Coaching

License:

None Required

State License:

Maryland

Scene’s 360° model of care enhances the gold standard of medication adherence, Directly Observed Therapy. Combining personalized video coaching, education, and motivational content, we bring healthcare professionals, patients, and their families together to solve the $500B medication nonadherence problem. Our mobile app allows patients to connect with a care team of pharmacists, nurses, and health coaches through daily video check-ins, anytime and anywhere. We make it fun for patients to stay on top of their medications, help them address medication challenges, and empower them to improve their health by addressing barriers to adherence related to social determinants of health.

As a Health Coach, Enrollment, you will be responsible for high-volume outbound outreach to eligible program participants and enrolling patients into a high-touch health program supporting their medication adherence and lifestyle changes. This role is key to introducing Scene services to potential patient members for enrollment. The health coach must excel at connecting with the patient via phone and discovering what patients need through outbound communication. Once patient needs are identified, we rely on the Health Coach, Enrollment to guide and direct patients into our services ecosystem. Your role is crucial in establishing trust, motivating patients to commit to their health goals, and ensuring they feel supported every step of the way. You will communicate with patients via phone calls, SMS, and video check-ins to help them overcome barriers and stay engaged in their care. Why Join Us? Work remotely with flexible hours Be part of a mission-driven team dedicated to improving patient health Competitive salary and benefits package Opportunities for professional growth and development A supportive and collaborative work environment

Required Qualifications: 3+ years of experience in health education, patient engagement, or a related healthcare role. Background in health coaching, public health, or community health work. Strong interpersonal skills with the ability to engage in warm, empathetic conversations. Excellent verbal and written communication skills. Experience conducting outreach via phone, SMS, and video communication. Ability to explain complex health concepts in a simple, motivating way. Proficiency with database systems and mobile applications. Preferred Qualifications: Certification as a health coach, medical assistant, community health worker, pharmacy technician, or similar role Sales experience Experience working directly with individuals who are ensured by Medicaid Experience in a sales, patient conversion, or call center environment Familiarity with CRM software (e.g., Salesforce) Bilingual (Spanish or other languages preferred)

Communicate with patient prospects via phone call, text, and e-mail to introduce them to Scene services for easy enrollment. This role supports both inbound and outbound support but primarily focuses on outbound calling and texting. Leverage best-practice listening skills to hear what the patient is saying, both spoken and unspoken, to identify which programs and existing services match their insurance benefits and health needs. Candidates must have a mastery of hearing and offering empathy as to offer a supportive and comforting engagement with Scene, handling frustrations and escalated patient calls effectively when necessary. Guide patients through the enrollment process using a balance of motivational support and technical acumen, framing the experience as positive and easy to understand. Accurately manage information while maintaining patient demographics within the Salesforce system. Effectively overcome patient objections, questions, and/or technical barriers to ensure a seamless onboarding process, pivoting the conversation as needed Assist patients with technical setup, including app downloads and troubleshooting, to ensure seamless program participation. Connect patients to the health system and existing health resources via multiple modalities, including their primary care providers, lab services, pharmacies, and health plan benefits Maintain accurate and detailed records of patient interactions, enrollment status, and follow-ups. Assist patients with Scene’s Spotlight app usage, including download and set-up, and guidance on using the app for Health Coach support from our Patient Solutions team (for example: profile creation and video testing). Build performance goals with Scene management and leverage time management and critical thinking skills to achieve and surpass them whenever possible. Embrace change as our services and processes evolve to efficiently meet patients' needs. Provide feedback on patient challenges and recommend process improvements to enhance program effectiveness. Establish strong relationships with patients and the Care Team, which includes nurses, pharmacists, and managers. All other duties as assigned.

Scene Health

Clinical Adherence Coach - Per Diem

Posted on:

August 29, 2025

Job Type:

Role Type:

Telehealth

License:

RN

State License:

Maryland

Scene’s 360° model of care enhances the gold standard of medication adherence, Directly Observed Therapy. Combining personalized video coaching, education, and motivational content, we bring healthcare professionals, patients, and their families together to solve the $500B medication nonadherence problem. Our mobile app allows patients to connect with a care team of pharmacists, nurses, and health coaches through daily video check-ins, anytime and anywhere. We make it fun for patients to stay on top of their medications, help them address medication challenges, and empower them to improve their health by addressing barriers to adherence related to social determinants of health.

Job Title: Clinical Adherence Coach - Registered Nurse (Per Diem) Location: Remote (U.S.) As a Clinical Adherence Coach (Registered Nurse), you will play a vital role in enrolling and engaging with patients in a high-impact medication adherence program designed to improve their health outcomes. You will connect with patients daily through warm, motivational conversations, guiding them in medication adherence, addressing barriers related to social determinants of health, and offering personalized education and support. Your goal is to build trust, encourage program participation, and empower patients to take control of their health.

Required Qualifications: Registered Nurse (RN) license in good standing. 3-5 years of related experience in patient engagement, health education, or care coordination. Strong background in chronic disease management, medication adherence, and patient coaching. Excellent oral and written communication skills with a warm, empathetic approach. Ability to work in a fast-paced, patient-focused environment. Proficiency in electronic health records (EHR), mobile applications, and digital health platforms. Comfortable engaging patients via phone, video, and chat throughout the workday. Experience assessing social determinants of health and connecting patients with resources. Preferred Qualifications: Experience in telehealth, community health work, or digital health settings. Certification in health coaching (e.g., Certified Health Coach, Integrative Health Coach, etc.) or willingness to obtain certification within a specified timeframe. Knowledge of Directly Observed Therapy (DOT) models. Bilingual in Spanish. Experience working with Medicaid and Dual Eligible (DSNP) populations. Familiarity with Salesforce or other CRM platforms.

Conduct outreach via phone, text, and video to educate and enroll patients into the adherence program. Provide compassionate and motivational coaching, case management, and health education services to encourage medication adherence and lifestyle changes. Assess patient needs, including medical, behavioral, and social challenges, and escalate cases as necessary. Complete nurse medication reconciliation phone consultations and video-based guidance on the correct administration of medications Review asynchronous video submissions of patients taking medication, ensuring proper administration and assessing for side effects or concerns. Record short form educational and motivational videos to send to patients for personalized engagement and population-level health education Act as a clinical escalation point for non-clinical team members to send patient cases that need a higher level of clinical review and intervention Assist patients with technical troubleshooting related to the company’s mobile application and adherence platform. Maintain accurate and detailed documentation of all interactions, ensuring compliance with company and regulatory guidelines. Engage with provider offices, health plan services, and pharmacies on behalf of the patient, as needed, to overcome barriers. Provide referrals to healthcare providers and community resources when needed, including direct outreach to provider offices and/or warm transfers to service providers Utilize motivational interviewing techniques to engage patients in long-term adherence strategies. Offer guidance on inhaler techniques, chronic disease management, and medication safety. Support program improvement initiatives by providing feedback based on patient interactions and clinical observations. Work closely with cross-functional teams to develop and refine patient engagement materials and protocols.

ALIS by Medtelligent

Nurse Onboarding Specialist- Assisted Living

Posted on:

August 29, 2025

Job Type:

Full-Time

Role Type:

License:

None Required

State License:

Illinois

ALIS is the industry leading provider of assisted living specific software. We are a purpose driven healthcare technology company passionate about innovation and using technology to help people by solving real world problems. The ALIS team designs, builds, delivers, and supports our flagship product ALIS (pronounced “Alice” and stands for Assisted Living Integrated Solution).

Minimum Years of Experience Required: 2+ Working Location: For candidates with 2+ years of experience, we offer multiple work arrangements : in-office, hybrid, or remote schedules. Relocation subsidies are available. Ideally, the right candidate for this role would be located in Chicago but this position is open to candidates from all States if they have previous SaaS onboarding experience with a healthcare product specifically. Please note that travel is a key component of this role, requiring at least 3 visits per year to our Chicago headquarters and up to 25% additional client travel. Candidates must be able, willing, and excited to travel.

2+ years of Assisted Living Nursing experience required 2+ years in EHR implementation, clinical SaaS implementation, direct usage of ALIS or a comparable AL EHR Experience with G-Suite, CRM usage, and ticket writing Strong project management skills Strong interest in helping communities and learning about their business as to help consult on process transformation from electronic to paper. Reliable: You show up at work for your team and the clients and look forward to doing it. Relationship oriented: You have a history of building long term healthy relationships with people and clients. Organized: You can prepare and execute on project plans. Calm demeanor: You aren’t pulled into drama or anxiety but can see clearly in order to help others. Good communicator: You are transparent with information. Patient: You do not get frustrated with people that are less knowledgeable or tech savvy than yourself. Good judgment: You can prioritize needs appropriately. High integrity: You tell the truth even when it is hard to do so. You avoid drama and gossip and prefer to bond over growth, positivity, and optimism. Adaptable and flexible: You don’t freak out if plans change or meetings get moved. Solution oriented: You take ownership to actually solve problems instead of just reporting all of the issues. Strives for excellence / finding ways to delight clients: Not just someone looking to cross a task off their list but spending time to over deliver and leave the relationship better than you found it. The company and this team commits itself to high standards for reliability and performance. Technologically savvy: You like to help others troubleshoot technology and hardware issues and you have an interest in new technologies and data.

Overhaul of and consultation on Resident Assessments for configuration in the ALIS Resident Evaluation Tool. Managing and maintaining EMR Building in current evaluations into ALIS Becoming a subject matter expert on how ALIS implements assessment workflows Training for other clinicians on using the ALIS evaluation tool Assist clients with other ALIS related clinical issues and consult on best practices Learn and establish a solid understanding of the ALIS software Consult with clients to transform their paper process to electronic; create and document new processes and train staff both digitally and (when the time is right) in-person. Create customized project plans to help guide both internal and external operations to get ALIS operating smoothly for our clients. Liaise between departments on clients’ needs, onboarding department needs, product feedback, and bugs reporting.

Guidehouse

Utilization Management RN - Remote

Posted on:

August 29, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Virginia

What You Will Need: Associate's degree minimum in nursing from an accredited school of nursing Current Registered Nursing License 4+ years of experience in utilization management Familiarity with MCG and InterQual guidelines Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form What Would Be Nice To Have: Behavioral Health Experience Bachelor's degree in nursing Connecticut RN License highly preferred - or willing to obtain. 3+ years of NICU, Peds experience

Performs chart review of identified patients to identify quality, timeliness and appropriateness of patient care Conducts admission reviews for Medicare, Medicaid beneficiaries, as well as private insurers and self-pay patients, based on appropriate guidelines Uses these criteria guidelines to screen for appropriateness for inpatient level of care or observation services based on physician certification Gathers clinical information to conduct continued stay utilization review activities with payers on a daily basis Performs concurrent and retrospective clinical reviews with various payers, utilizing the appropriate guidelines as demonstrated by compliance with all applicable regulations, policies and timelines Adheres to CMS guidelines for utilization reviews as evidenced by utilization of the relevant guidelines and appropriate referrals to the physician advisor and the UR Committee Identifies, develops and implements strategies to reduce length of stay and resource consumption.

Guidehouse

Registered Nurse - Clinical Denials/Appeals - Remote

Posted on:

August 29, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Virginia

The Remote Clinical Denials RN is responsible for review, analysis and appeal of clinical denials from insurance companies and third-party payers. This role requires a strong clinical background, knowledge of medical necessity criteria, and expertise in appealing denied claims. Essential Job Functions: Medical Necessity Reviews Ensure documentation integrity Construct warranted appeals Coordinate pre-service authorization approvals

What You Will Need: Bachelor’s Degree (Relevant experience may be substituted for formal education or advanced degree) Current Registered Nursing License 4+ years of prior clinical experience 1+ years of experience in post claim clinical appeals What Would Be Nice To Have: Acute care experience Bachelor's in nursing

Conduct comprehensive Denial Root-cause analysis Retrospective Medical Record reviews to assure complete and accurate physician/staff documentation is present to support medical necessity Collaboration with hospital Patient Access and Mid-Revenue Cycle Research and application of regulatory policies to support clinical appeal Telephonic communication with payors, provider, hospital staff and patient/family as necessary to bring the account into resolution. Technical ability to multi-task on various systems, desktop and Microsoft applications while managing inbound calls Working knowledge of basic Coding Guidelines May be required to present oral presentations to client facility or Guidehouse staff and leadership Attention to detail, strong organizational skills and self-motivated. Ability to make decisions and assimilate multiple data sources or issues related to problem solving independently & accurately Ability to work under a timeline/deadline & provide clear & accurate update to project leader of assignment progress, hours worked & expected outcomes daily Familiarity with medical records assembly & clinical terminology, coding terminology additionally beneficial Personal responsibility, respect for self and others, innovation through teamwork, dedication to caring and excellence in customer service

Oklahoma Complete Health

Quality of Care Coordinator

Posted on:

August 29, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Compact / Multi-State

Oklahoma Complete Health works to transform the health of our communities, one person at a time, through SoonerSelect and the SoonerSelect Specialty Children’s Plan. Oklahoma Complete Health exists to improve the health of our members through focused, compassionate and coordinated care delivered locally. Through services such as enhanced vision coverage, programs for pregnant and new moms, rewards for healthy behaviors, and so much more, Oklahoma Complete Health is a new managed Medicaid care plan supporting not only our members’ medical coverage but also their complete health. Our mission is to deliver healthcare solutions to our communities every day. Our employees are driven to make a difference and ready to make an impact.

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. **Applicants for this position have the flexibility to work remotely from their home anywhere in the US. Candidates must possess an Oklahoma RN license or a compact RN license. The work schedule will be Monday - Friday, 8am - 5pm Central.** Position Purpose: Review medical records for potential Quality of Care (QOC) incidents, applying clinical criteria to determine if a lack of care was present. Utilize clinical knowledge to provide summary of findings and severity level to physicians.

Education/Experience: Associate’s degree in Nursing required; Bachelor’s degree in Nursing preferred. 3+ years of experience in nursing or related healthcare experience. License/Certification: RN/LCSW required

Review medical records for quality of care incidents by determining if the specified standards of care were met, and assigning an initial severity level of lack of compliance/care Compile timeline and summary of incident, including the details of the potential QOC for presentation to the medical director for a final review; may also be involved in peer review committee actions or next steps Maintains organizational and program policies and procedures; ensures adherence to prescribed policies and procedures and clinical protocols where appropriate

Locum Tenens USA

Virtual Compact RN–Annual Wellness Visit

Posted on:

August 29, 2025

Job Type:

Full-Time

Role Type:

Primary Care

License:

RN

State License:

Compact / Multi-State

Locum Tenens USA was started more than 10 years ago to provide the highest quality physician recruitment and permanent physician staffing possible for clients across the country. From Anesthesia to Radiology, we specialize in many different fields within the physician staffing industry.

We are seeking a dedicated and detail-oriented Full- Time Registered Nurse (RN) to join our virtual care team. In this role, the RN will be responsible for preparing comprehensive patient charts for Annual Wellness Visits (AWVs), ensuring that providers have all necessary information to deliver high-quality care. The RN will review various data points, including patient histories, screenings, and assessments, and provide concise updates to providers prior to each patient encounter. Compensation: $32.50 per hour, this position does not include Health Benefits 35 hours per week between 8:00am-8:00pm EST; This is a remote position. The RN will work from a home office, requiring reliable internet connectivity and a secure, private workspace.

Qualifications: Licensure: Active Registered Nurse (RN) license with compact licensure. Additional states a plus. Experience: Minimum of 2 years of clinical nursing experience, preferably in primary care. Technical Skills: Proficiency in EHR systems and telehealth platforms. Knowledge: Familiarity with Medicare AWV requirements and preventive care guidelines. Communication: Excellent verbal and written communication skills. Organization: Strong organizational skills with attention to detail. Independence: Ability to work autonomously in a virtual environment. Preferred Qualifications: Certification in gerontological nursing or case management. Experience with virtual care coordination or telehealth services. Knowledge of CMS documentation standards for AWVs. Technical Requirements: Computer: Windows or Apple Computer ONLY Headphones: Wired headphones required for optimal audio quality. Internet Speed: Meet minimum internet speed requirements (50 MBPS download speed and 20 MBPS upload speed), with a wired connection to the router Browser and System: Use Google Chrome with Amazon Workspaces (regardless of computer type). Video Capability: Required for video calls. Recommended Equipment: A second monitor is suggested for laptop users; dual monitors for PC users.

Review and update patient medical records, focusing on data pertinent to AWVs. Compile and summarize health information, including: Medical, surgical, and family histories Medication lists and adherence Preventive screenings and immunizations Cognitive and functional assessments Identify care gaps and overdue preventive services. Communicate patient summaries and pertinent findings to providers before each visit. Coordinate with patients to gather missing information or clarify data as needed. Ensure documentation complies with Medicare and organizational guidelines. Utilize electronic health record (CT 360 / RXNT) systems to document findings and updates.

Privia Health

Telephonic After Hours Nurse Care Manager (WEEKENDS)

Posted on:

August 28, 2025

Job Type:

Part-Time

Role Type:

Telehealth

License:

RN

State License:

Compact / Multi-State

Privia Health™ is a technology-driven, national physician enablement company that collaborates with medical groups, health plans, and health systems to optimize physician practices, improve patient experiences, and reward doctors for delivering high-value care in both in-person and virtual settings. The Privia Platform is led by top industry talent and exceptional physician leadership, and consists of scalable operations and end-to-end, cloud-based technology that reduces unnecessary healthcare costs, achieves better outcomes, and improves the health of patients and the well-being of providers.

Available Hours: Shifts are on the weekend, Fri-Sun. Timeframe - Between 1:00pm-9:00pm EST. Bi-Weekly Minimum of 10 weekend hours. Monthly Required Hours: 20 weekend Hours We are actively recruiting for an After Hours Care Manager to join our rapidly growing Population Health team. The primary role of the Care Manager will be to provide our patients with on-demand telephone-based care management services through a 24/7 Nurse Advice Line (i.e. telephone triage). Care Managers will assess symptoms/concerns of callers to determine the urgency and type of care needed, refer to or schedule appointments with providers as appropriate, and give health information and advice to callers. The goal of the Nurse Advice Line is to reduce unnecessary visits to the clinic and emergency department, provide information for self-care and symptom management, and to coordinate care across the healthcare delivery system. Care Managers operate in a team-based model, acting as an extension of the primary care provider.

This part-time role is primarily available for Weekend Nights and Holidays (1pm-9pm EDT) , with flexible and alternating shifts (2, 4, 8, 6, 10 & 12 hours). Must maintain “on average” at least 10 hours of weekend coverage)/week. Weekend times span from Friday, 9p EDT - Monday, 9a EDT. Flexible time off as needed. Privia will help set up the home office setting with computers, high speed internet access and other equipment needed for the role. Registered Nurse (RN) with current resident compact licensure in assigned state(s). Bachelor’s degree, at minimum Experience in a call center, triage position, consulting environment or like environment. Minimum 3+ years of recent clinical experience, with problem-solving and critical-thinking skills Disease Management, Case Management, Utilization Review or Wellness experience Without question, 'Exceptional Customer Service' Strong computer skills. Internet savvy Clear, confident communication and listening skills Self -motivated and self-disciplined a must Willingness to do what it takes to get the job done and make patients the number one priority Able to thrive in a quiet, secure home office environment Detailed-oriented, organized with the ability to work well in fast-paced work environment Bilingual – Spanish, Korean, Vietnamese, or Farsi preferred

Handles inbound communications from patients who are seeking information about symptoms or care concerns Conduct outbound communications for follow-up and care coordination Consult and coordinate with internal and external team members to assess, plan, implement and evaluate patient care plans, make appropriate referrals, and provide follow-up Assist with finding appropriate providers, community resources, care solutions and coordinate priority appointments Record member data in Privia’s web-based medical record system and associated EMRs, or health portals. Research information online and in Privia’s internal knowledge databases Provide health information, coaching, and critical thinking skills to assist our members with medical and wellness related issues Other care management activities as needed (e.g. close “gaps in care,” complex care plans, etc.) Must comply with HIPAA rules and regulations

The Successful Nurse Coaches Inc.

Nurse with Sales Experience – Enrollment Advisor

Posted on:

August 28, 2025

Job Type:

Contract

Role Type:

Coaching

License:

RN

State License:

Oregon

At The Successful Nurse Coach, and Nurse Life Coach Academy we aren’t just building a business — we’re building a movement. Everything we do is rooted in our core values, and we invite every team member to embody them alongside us.Authenticity Over Everything Your realness is your greatest asset. We lead with truth, not perfection. Our team shows up as humans first — messy, evolving, and honest. We believe transformation only happens when people feel safe to be themselves. That means no scripts, no facades, and no “faking it.” Whether we’re coaching, enrolling, or collaborating, authenticity drives connection — and connection drives impact.Freedom as a Lifestyle We’re here to liberate, not trap. We help nurses create careers with choice, spaciousness, and alignment — and we model that inside our team culture. Freedom means flexibility, trust, and ownership. It’s not about chasing endless hustle; it’s about building something sustainable that serves you as much as it serves others. Time, money, energy, voice, identity — we believe all of it should be yours to shape.The Unapologetic Leader We rise, and we own it. We don’t wait until it’s “perfect” to lead — we show up now. That’s true for our students and for our team. Being unapologetic means speaking truth, trusting your gut, and standing in your values even when it’s uncomfortable. We’re bold, we’re brave, and we’re creating the future of nurse coaching one decision at a time.

Job Description: Nurse Enrollment Advisor (Full-Time, Remote) Position Summary We are seeking a driven and experienced Nurse Enrollment Advisor to join our growing team. This role is ideal for a registered nurse with proven sales or enrollment experience who thrives on building relationships, guiding prospects through decision-making, and helping clients step into transformational programs. As the front line of our enrollment process, you will engage with prospective students, understand their goals, and guide them toward the right solutions — blending your clinical insight with strong consultative sales skills. This is a full-time, remote position with significant room for growth in a rapidly expanding company.

Qualifications: Registered Nurse (RN) or nursing background required. Proven sales or enrollment experience - 3+ years preferred (education, coaching, medical device, or pharmaceutical sales preferred). Strong consultative selling skills with the ability to connect authentically and guide decision-making. Excellent communication and interpersonal skills, with confidence in phone and video-based sales. Familiarity with CRMs (ActiveCampaign preferred) and pipeline management. Highly organized, goal-driven, and self-motivated. Comfortable working in a fast-paced, remote environment. Work Setup & Compensation Location: 100% Remote (U.S. preferred) - 1099 Role Schedule: Full-time, flexible hours with some evening and weekend availability for client calls. Compensation: Competitive salary + performance-based bonuses (OTE six figures possible). Growth: We are a 5-year-old company with a rapidly growing start-up arm. There is significant opportunity to grow with us into senior sales or leadership roles.

Consultative Sales: Conduct enrollment calls with prospective students, build trust, identify needs, and guide them to aligned program options. Relationship Building: Nurture leads through consistent, authentic communication across phone, email, and text. Pipeline Management: Track, manage, and prioritize leads in our CRM (ActiveCampaign) to ensure no opportunities are missed. KPI Ownership: Meet and exceed enrollment targets, while also tracking conversion rates and other key sales metrics. Collaboration: Work closely with the leadership team to refine messaging, improve sales processes, and optimize lead flow.

CareSource

REMOTE - Triage Nurse- Compact State License RN - R9778

Posted on:

August 28, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

The Triage Nurse is responsible for using decision support software to perform telephonic clinical triage and health information service for CareSource managed health plans and external clients.

Education and Experience: RN license required Bachelor’s Degree in Nursing preferred Minimum of three (3) years progressive clinical experience as an RN is required Triage, Emergency Nursing, Critical Care, or acute care experience is preferred; Experience within the past 3 years is strongly preferred Behavioral Health experience is preferred Telephone Triage in a call center setting preferred Competencies, Knowledge and Skills: Strong computer skills Strong clinical assessment skills Strong communication skills Ability to work independently and within a team environment Attention to Detail Critical listening and thinking skills Decision making/problem solving skills Proper phone etiquette Customer service oriented Broad base of clinical knowledge Teaching skills Ability to remain calm under pressure and in member life threatening situations Ability to apply multiple communicative skills while utilizing available tools and resources simultaneously Exemplify CareSource’s Mission in our behavior and member interactions Licensure and Certification: Current, unrestricted RN licensure in state of practice is required; multi-state licensure is preferred Ability to obtain licensure by endorsement in non-compact states when applicable Working Conditions: General office environment; may be required to sit or stand for extended periods of time

Utilize assessment skills and evidence-based triage guidelines for triage of healthy, as well as acutely or chronically ill or injured members, including pediatric, adult, maternity, and geriatric members Utilize provided training, skills and evidence-based triage guidelines to assess and assist members experiencing behavioral health challenges and crises. Function as patient advocate by facilitating accessibility to healthcare and provide linkage to other CareSource departments Educate members to assist them in making informed decisions regarding personal healthcare Assess health status and direct members to the most appropriate level of care Utilize critical reasoning in clinical decision-making Inform callers of preventative healthcare measures due Identify and refer appropriate members for Care Management Provide information about benefits, services and programs that allows members to maximize healthcare resources, as needed Manage telephone interactions with compassion and respect for cultural, educational and psychosocial differences of individuals Utilize multiple computer applications to document all information in an accurate manner Practice in compliance with AAACN, URAC and NCQA standards and regulatory requirements Keep abreast of trends in healthcare delivery and managed care Participate in departmental activities such as quality audits, preceptorship/training as needed Maintains and contributes to a collaborative professional and ethical work environment. Perform any other job duties as requested

Acentra Health

RN Case Management, Supervisor (Remote U.S.)

Posted on:

August 28, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Compact / Multi-State

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

Acentra Health is looking for an RN Case Management, Supervisor (Remote U.S.) to join our growing team. Job Summary: The Case Management, Supervisor will lead the care management team, ensuring they meet quality standards. They will use clinical knowledge and effective communication to achieve optimal client outcomes, fostering collaboration with healthcare team members.

Required Qualifications/Experience: Active, unrestricted RN Compact State License. Minimum of a Bachelor’s degree in Nursing. 2+ years of management or supervisory experience. 3+ years of clinical experience in Medical, Behavioral, acute care and/or home care settings. 3+ years of Case Management experience, or Discharge Planning. Required to pursue ongoing education, certification, and self-development to remain current with case management standards. Required to achieve certification in case management within three (3) years of directly supervising the case management process and staff. Previous workload management experience. Preferred Qualifications/Experience: Excellent verbal and written communication skills. Ability to utilize critical thinking and apply sound clinical judgment and assessment skills for decision-making. Excellent interpersonal communication and negotiation skills. Strong analytical and data management skills. Effective organizational and time management skills and the ability to prioritize multiple tasks. Current working knowledge of case management, and managed care. Demonstrate organization and efficiency in prioritizing and managing assignments with minimal oversight and direction. Expertise in Microsoft Office and other software programs. Capability to enter and retrieve data from relevant computer systems.

Mentor and coach, the care management team in supplying personalized care to clients. Utilize clinical knowledge, communication skills, and ability to solve problems and manage conflicts to manage the care of clients through the health or social care systems, based on their individual needs. Assess, evaluate, and address workload to meet the demands of the department and contract requirements. Collaborate with direct leadership to develop and implement plans to address learning needs. Provide training opportunities for continuing education and development of staff. Provide current resources for case management staff to maintain knowledge, skills, and competencies for their role. Function as a resource for staff during the case management process. Manage and evaluate staff performance. Monitor the quality of work done by team members and identify areas of improvement. Address problems that may hinder the progress of diagnosis or treatment. Identify and resolve any delays or obstacles and seek consultation from physicians and other departments proactively. Communicate updates about organizational process and changes affecting case management staff. Clarify requirements related to patients and coordinate care to promote best practices by communicating with providers. Participate in the development, implementation, and revision of guidelines and clinical review criteria. Utilize clinical ability to achieve inter-rater reliability. Preserve open communication with all proper parties. Uphold strict standards for client confidentiality and client-related information; follow all organizational, state, and federal regulations and policies on confidentiality. Remain current on care management documentation and complete reports promptly. Performs other duties related to care management supervision functions as needed. Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules. ** The standard work schedule is Monday through Friday during daytime hours. **

Acentra Health

Clinical Reviewer - RN (Remote within Alabama)

Posted on:

August 28, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Alabama

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.

Utilizes clinical expertise for the review of medical records against appropriate criteria in conjunction with contract requirements, critical thinking and decision-making skills to determine medical appropriateness, while maintaining production goals and QA standards. Ensures day-to-day processes are conducted in accordance with NCQA, URAC and other regulatory standards.

Required Qualifications/Experience: Active, unrestricted RN license in the state of Alabama. Must reside and work in the state of Alabama and be in good standing with the Alabama Board of Nursing. 2+ years of clinical experience in an acute or med-surgical environment. The selected candidate may not hold a concurrent working relationship with a Medicaid-enrolled provider while working on this contract. Preferred Qualifications/Experience: Prior authorization review experience. Knowledge of InterQual criteria. Knowledge of current National Committee for Quality Assurance (NCQA)/Utilization Review Accreditation Commission (URAC) standards. Medical record abstracting skills. Knowledge of the organization of medical records, medical terminology, and disease processes. Strong clinical assessment and critical thinking skills. Excellent verbal and written communication skills. Ability to work in a team environment. Flexibility and strong organizational skills. Must be proficient in Microsoft Office and internet/web navigation.

Reviews and interprets patient records and compares against criteria to determine medical necessity and appropriateness of care; determines if the medical record documentation supports the need for services. Determines approval or initiates a referral to the physician consultant and processes physician consultant decisions ensuring reason for the denial is described in sufficient detail on correspondence. Abstracts review-related data/information accurately and timely on appropriate review tool by the appropriate means. Accurate and timely submission of all administrative and review-related documents to appropriate parties. Performs ongoing reassessment of review process to offer opportunities for improvement and/or change. Fosters positive and professional relationships and acts as liaison with internal and external customers to ensure effective working relationships and team building to facilitate the review process. Responsible for attending training and scheduled meetings and for maintenance and use of current/updated information for review. Always maintains confidentiality through proper use of computer passwords, maintenance of secured files, and adherence to HIPAA policies. Utilizes proper telephone etiquette and judicious use of other verbal communications, following Acentra Health policies, procedures, guidelines. Actively cross-trains to perform duties of other contracts within the Acentra Health network to provide a flexible workforce and meet client/consumer needs. Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules.

Acentra Health

Clinical Reviewer (RN - Remote - SCA)

Posted on:

August 28, 2025

Job Type:

Full-Time

Role Type:

License:

RN

State License:

Virginia

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.

The Clinical Reviewer utilizes clinical expertise during beneficiary interaction in conjunction with contract requirements, critical thinking and utilize decision-making skills to assist with communicating medical appropriateness, while maintaining production goals and QA standards. Ensures day-to-day processes are conducted in accordance with NCQA and other regulatory standards. Shift hours will be 11:30am to 8:00pm EST.

Required Qualifications/Experience: Active unrestricted LPN, RN, or Social Worker license required. Must be able to work a schedule of 11:30am to 8:00pm EST Knowledge of the organization of medical records, medical terminology, and disease process required Medical record abstracting skills required Preferred Qualifications: Excellent written and verbal communication skills Knowledge of medical records, medical terminology, and disease processes Strong clinical assessment and critical thinking skills

Assures accuracy and timeliness of all applicable review type cases within contract requirements Assesses, evaluates, and addresses daily workload and call queues; adjusts work schedules daily to meet the workload demands of the department In collaboration with Supervisor, responsible for the quality monitoring activities including identifying areas of improvement and plan implementation of improvement areas Maintains current knowledge base related to review processes and clinical practices related to the review processes, functions as the initial resource to nurse reviewers regarding all review process questions and/or concerns Functions as providers’ liaison and contact/resource person for provider customer service issues and problem resolution Performs all applicable review types as workload indicates Fosters positive and professional relationships and act as liaison with internal and external customers to ensure effective working relationships and team building to facilitate the review process Attends training and scheduled meetings and for maintenance and use of current/updated information for review Cross trains and perform duties of other contracts to provide a flexible workforce to meet client/customer needs Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules

CVS Health

Utilization Management Nurse Consultant (Mon-Fri 10:30am-7:00pm or 11:30am-8:00pm EST) (Remote)

Posted on:

August 28, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Georgia

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day. American Health Holding, Inc. (AHH), a division of Aetna/CVS Health, is a URAC-accredited medical management organization founded in 1993. We provide flexible, cost-effective care management solutions that promote high-quality healthcare for members

Position Information Schedule: Monday–Friday (Shift times vary based on business needs; must be open to working any of the following EST shifts: 10:30am-7:00pm, or 11:30am-8:00pm EST Hours) Location: 100% Remote (U.S. only) Join our Utilization Management team as a Nurse Consultant, where you'll apply clinical judgment and evidence-based criteria to review inpatient and outpatient services. You'll collaborate with providers, authorize care, and escalate cases when needed, all while navigating multiple systems and maintaining accurate documentation. This role suits nurses who thrive in fast-paced environments, are highly organized, and comfortable with computer-based work.

Remote Work Expectations: This is a 100% remote role; candidates must have a dedicated workspace free of interruptions. Dependents must have separate care arrangements during work hours, as continuous care responsibilities during shift times are not permitted. Required Qualifications: Active unrestricted state Registered Nurse licensure in state of residence required. Minimum 5 years of relevant experience in Nursing. At least 1 year of Utilization Management experience in concurrent review or prior authorization. Strong decision-making skills and clinical judgment in independent scenarios. Proficient with phone systems, clinical documentation tools, and navigating multiple digital platforms. Commitment to attend a mandatory 3-week training (Monday–Friday, 8:30am–5:00pm EST) with 100% participation. Preferred Qualifications: 1+ year of experience in a managed care organization (MCO). Experience in a high-volume clinical call center or prior remote work environment. Education: Associate's degree in nursing (RN) required, BSN preferred.

Utilize clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render 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. Work in clinical telephone queue for 2 to 4 hours a day working with providers to secure additional information for prior authorization review.

CVS Health

Utilization Management Nurse Consultant (Mon-Fri 11:30am-8:00pm EST) (Remote)

Posted on:

August 28, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Arizona

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day. About Us American Health Holding, Inc. (AHH), a division of Aetna/CVS Health, is a URAC-accredited medical management organization founded in 1993. We provide flexible, cost-effective care management solutions that promote high-quality healthcare for members.

Position Information Schedule: Monday–Friday 11:30am-8:00pm EST Hours (Shift times vary based on business needs) Location: 100% Remote (U.S. only) Join our Utilization Management team as a Nurse Consultant, where you'll apply clinical judgment and evidence-based criteria to review inpatient and outpatient services. You'll collaborate with providers, authorize care, and escalate cases when needed, all while navigating multiple systems and maintaining accurate documentation. This role suits nurses who thrive in fast-paced environments, are highly organized, and comfortable with computer-based work.

Remote Work Expectations: This is a 100% remote role; candidates must have a dedicated workspace free of interruptions. Dependents must have separate care arrangements during work hours, as continuous care responsibilities during shift times are not permitted. Required Qualifications: Active unrestricted state Registered Nurse licensure in state of residence required. Minimum 5 years of relevant experience in Nursing. At least 1 year of Utilization Management experience in concurrent review or prior authorization. Strong decision-making skills and clinical judgment in independent scenarios. Proficient with phone systems, clinical documentation tools, and navigating multiple digital platforms. Commitment to attend a mandatory 3-week training (Monday–Friday, 8:30am–5:00pm EST) with 100% participation. Preferred Qualifications: 1+ year of experience in a managed care organization (MCO). Experience in a high-volume clinical call center or prior remote work environment. Education: Associate's degree in nursing (RN) required, BSN preferred.

Utilize clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render 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. Work in clinical telephone queue for 2 to 4 hours a day working with providers to secure additional information for prior authorization review.

Centene Corporation

Care Manager (RN)

Posted on:

August 28, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Compact / Multi-State

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

Medicare Shared Services Team – 100% Remote Telephonic RN Case Mgt Locations: must reside in the state of Texas for this position Schedule: Monday - Friday: 8:00 am - 5:00 pm (CST) Position Purpose: Develops, assesses, and facilitates complex care management activities for primarily physical needs members to provide high quality, cost-effective healthcare outcomes including personalized care plans and education for members and their families.

Education/Experience: Requires a Degree from an Accredited School of Nursing or a Bachelor's degree in Nursing and 2 – 4 years of related experience. License/Certification: RN - Registered Nurse - State Licensure and/or Compact State Licensure required Preferred Experience: Clinical Registered Nurse with experience in Acute Care settings – Critical Care, ICU, Emergency Room, Military or Veteran Hospitals, Adult Home Health, Cardiac ICU, Internal Medicine, LTC, SNF, Triage Nursing, or Nursing Rehab Direct clinical nursing phone queue environment to assess and manage member needs via telephone queue Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care for complex medical conditions Must be able to navigate between multiple databases, screens, Microsoft Office applications and utilize multiple avenues of communication (e.g. phone queue, MS Teams, email, video conferencing) - 90% of the role responsibilities. Strong clinical assessment and critical thinking skills required to communicate with clinical staff, members, and providers

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

LanceSoft, Inc.

Utilization Review Nurse

Posted on:

August 28, 2025

Job Type:

Contract

Role Type:

Utilization Review

License:

RN

State License:

Michigan

Bachelor’s degree in nursing, allied health, business, or related field preferred. Two to four years of clinical experience which may include post-acute care, home care, acute patient care, discharge planning, case management, and utilization review, and caring for aging population in the home or post-acute care setting, etc. Demonstrated clinical knowledge and experience relative to patient care and health care delivery processes. One year health insurance plan experience or managed care environment preferred. Registered Nurse with current unrestricted Michigan Registered Nurse license required.

Use established medical policy and guidelines to perform prospective, concurrent, and retrospective medical necessity review of post-acute care services to ensure medical necessity for appropriate setting, appropriate length of stay, including appeal requests initiated by providers, facilities and members. Will coordinate care through the health care continuum including member outreach. Provides support and alternative care support for members not appropriate for post-acute care service as well formulate discharge readiness for members transitioning from a post-acute care setting to a lower level of care. Should have experience with InterQual

Pro Care Health Solutions

Home Health Nurse

Posted on:

August 28, 2025

Job Type:

Full-Time

Role Type:

License:

RN

State License:

Michigan

Pro Care is the Medicare Home Care agency seeking qualified nurses to join our team!

This is a full-time remote role for a Home Health Nurse. The Home Health Nurse will provide patient care within their homes, including tasks such as wound care, medication administration, monitoring health status, and developing care plans. Responsibilities also include educating patients and their families on health conditions and self-care techniques, coordinating with physicians and other healthcare professionals, and ensuring compliance with healthcare regulations and standards.

Proficient in Nursing and Medicine Experience with Home Care and Patient Care Skilled in Wound Care Excellent communication and interpersonal skills Ability to work independently and remotely Current and valid Registered Nurse (RN) license CPR and First Aid certification Experience in home health care settings is a plus Bachelor's degree in Nursing or related field

CVS Health

Utilization Management Nurse Consultant

Posted on:

August 28, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Texas

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

Utilization Management is a 24/7 operation and work schedules will include holidays and evening hours

Required Qualifications: 3+ years of experience as a Registered Nurse Must have active current and unrestricted RN licensure in state of residence 1+ years of Med/Surg experience 1+ years of experience with Microsoft Office applications (Outlook, Teams, Excel) Must be willing and able to work Monday through Friday, 11:00AM to 8:30pm EST with occasional holiday rotation. Preferred Qualifications: Prior Authorization or Utilization Management experience Managed care experience Experience using MedCompass Ambulatory surgery 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, 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.

Blue Cross & Blue Shield of Rhode Island

RN Case Manager

Posted on:

August 28, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

At BCBSRI, our greatest resource is our people. We come from varying backgrounds, different cultures, and unique experiences. We are hard-working, caring, and creative individuals who collaborate, support one another, and grow together. Passion, empathy, and understanding are at the forefront of everything we do—not just for our members, but for our employees as well. We recognize that to do your best work, you have to be your best self. It’s why we offer flexible work arrangements that include remote and hybrid opportunities and paid time off. We provide tuition reimbursement and assist with student-loan repayment. We offer health, dental, and vision insurance as well as programs that support your mental health and well-being. We pay competitively, offer bonuses and investment plans, and are committed to growing and developing our employees. Our culture is one of belonging. We strive to be transparent and accountable. We believe in equipping our associates with the knowledge and resources they need to be successful. No matter where you’re at in the organization, you’re an integral part of our team and your input, thoughts, and ideas are valued. Join others who value a workplace for all. We appreciate and celebrate everything that makes us unique, from personal characteristics to past experiences. Our different perspectives strengthen us as an organization and help us better serve all Rhode Islanders. We’re dedicated to serving Rhode Islanders. Our focus extends beyond providing access to high-quality, affordable, and equitable care. To further improve the health and well-being of our fellow Rhode Islanders, we regularly roll up our sleeves and get to work (literally) in communities all across the state—building homes, working in food pantries, revitalizing community centers, and transforming outdoor spaces for children and adults. Because we believe it is our collective responsibility to uplift our fellow Rhode Islanders when and where we can, our associates receive additional paid time to volunteer.

Deploy corporate strategy for supporting members in obtaining best-fit care within immediate health care system and other supporting services while promoting access to evidenced based care. Educate, empower, and coordinate services for members to improve members’ well-being and moderate claims trends. Facilitate communication between identified care team members including but not limited to members and or their appointed representatives, providers, community-based organizations, and the health plan to ensure members receive the full benefit of integrated care.

Unrestricted Rhode Island Nursing License or multi state compact license Three years’ experience in a medical/clinical environment or managed health plan Must obtain Certified Case Manager (CCM) certification within three years of employment Knowledge of utilization management and/or coordination of care Knowledge of population health and chronic condition management principles, aligning with corporate initiatives such as specialty within high-risk maternity and rising risk conditions such as diabetes, hypertension, COPD, etc. Understanding of health care delivery system access points and services Demonstration of successful (member) engagement via application of Motivational Interviewing techniques and health coaching Ability to navigate the healthcare delivery system Understanding of evidence-based care programs and approaches Strategic and critical thinking skills Strong analytical skills Strong business acumen Strong presentation negotiation, problem-solving, and decision-making skills Strong written and verbal communication skills Experience in health coaching and motivational interview techniques Ability to work effectively with a wide variety of people in individual and group settings Strong organizing skills, with the ability to prioritize and respond to shifting deadlines Strong time management skills The Extras: Bachelor’s degree in nursing Certified Case Manager (CCM) Reside in Rhode Island or other Nurse Licensure Compact state (NLC) Bilingual Spanish, Portuguese Experience working in a managed care/health maintenance organization Experience implementing and upholding Quality, CMS, NCQA requirements

Manage members through evidence-based care, promote access to healthcare system, and assess needs to identify appropriate interventions. Member management includes, but is not limited to, the conduction of health assessments (telephonic and face-to-face) to identify high-risk or emerging risk members for education and intervention and the evaluation and modification of action plans by working with members and collaborating with providers. Evaluate member services to ensure appropriate levels and coordination of care, including pre-authorization, concurrent review, quality-of-care screening, and discharge planning. Ensure member and provider satisfaction by demonstrating knowledge of member plan benefits and community resources. Identify opportunities to moderate claims costs for the employer group and individual members. Promote and monitor the use of wraparound service programs for optimal member experience while managing chronic and acute care needs. Facilitate communication between members, providers, and stakeholders to coordinate and implement action plans for improving members’ total health. Provide continuity and consistency of care by building positive relationships between members, families, providers, care coordinators, and the health plan. Engage in team operations including supervision, team huddles, staff meetings, case rounds, metric management, training opportunities, department initiatives, and projects. Work collaboratively to develop and implement solutions, identify barriers, and exemplify corporate values through accountability, collaboration, integrity, and respect.

Blue Cross & Blue Shield of Rhode Island

Temporary GAU RN

Posted on:

August 28, 2025

Job Type:

Full-Time

Role Type:

License:

RN

State License:

Compact / Multi-State

At BCBSRI, our greatest resource is our people. We come from varying backgrounds, different cultures, and unique experiences. We are hard-working, caring, and creative individuals who collaborate, support one another, and grow together. Passion, empathy, and understanding are at the forefront of everything we do—not just for our members, but for our employees as well. We recognize that to do your best work, you have to be your best self. It’s why we offer flexible work arrangements that include remote and hybrid opportunities and paid time off. We provide tuition reimbursement and assist with student-loan repayment. We offer health, dental, and vision insurance as well as programs that support your mental health and well-being. We pay competitively, offer bonuses and investment plans, and are committed to growing and developing our employees. Our culture is one of belonging. We strive to be transparent and accountable. We believe in equipping our associates with the knowledge and resources they need to be successful. No matter where you’re at in the organization, you’re an integral part of our team and your input, thoughts, and ideas are valued. Join others who value a workplace for all. We appreciate and celebrate everything that makes us unique, from personal characteristics to past experiences. Our different perspectives strengthen us as an organization and help us better serve all Rhode Islanders. We’re dedicated to serving Rhode Islanders. Our focus extends beyond providing access to high-quality, affordable, and equitable care. To further improve the health and well-being of our fellow Rhode Islanders, we regularly roll up our sleeves and get to work (literally) in communities all across the state—building homes, working in food pantries, revitalizing community centers, and transforming outdoor spaces for children and adults. Because we believe it is our collective responsibility to uplift our fellow Rhode Islanders when and where we can, our associates receive additional paid time to volunteer.

Collaborate with management to assist with the oversight and coordination of the research, negotiation, and resolution of member and provider complaints, grievances and appeals for all products. Investigate and resolve medical necessity appeals on all company products. Ensure compliance with state and federal guidelines, including Centers for Medicare and Medicaid Services requirements. Maintain all appeals documentation according to external agency requirements. Act as a resource on the development, implementation, and maintenance of departmental policies, procedures and programs. Assist in identifying, prioritizing, and implementing health plan opportunities for improvement in the areas of efficiency and effectiveness.

Bachelor’s degree in Nursing, Business Management, or related field, or an equivalent combination of education and experience Active and unrestricted RN license issued by a state participating in the Nurse Licensure Compact (NLC) Three to five years acute care clinical experience Knowledge of health insurance laws and regulations Knowledge of utilization management appeals processes Advanced analytical skills, with the ability to interpret and synthesize complex data sets Good business acumen and political savvy Knowledge of business process improvement techniques and strategies Excellent verbal and written communications skills Negotiation skills Presentation skills Decision-making skills Good problem solving skills Ability to interface with employees at all levels Ability to effectively navigate ambiguous situations with limited direction Excellent organizational skills and ability to successfully prioritize multiple tasks Ability to handle multiple priorities/projects The Extras: Experience in a managed care environment

Investigate and resolve medical necessity appeals for all company products. Maintain documentation of cases. Collaborate clinical lead to assist with the oversight and coordination of the research, negotiation, and resolution of escalated member and provider complaints, grievances and appeals for all products. Respond to internal and external inquiries, assist with special member cases, and suggest resolutions via telephone or written communication. Identify potential quality of care issues within medical appeals; escalate as appropriate. Collaborate with internal areas to perform trend analysis; identify reasons for appeals and determine if a review of corporate policies, procedures, or product design is necessary. Represent the department at clinical workgroup meetings. Participate in departmental audits in preparation of regulatory site visits. Participate in department initiatives and projects. Perform other duties as assigned.

Ascension

RN Utilization Case Management Manager

Posted on:

August 28, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Texas

Ascension associates are key to our commitment of transforming healthcare and providing care to all, especially those most in need. Join us and help us drive impact through reimagining how we can deliver a people-centered healthcare experience and creating the solutions to do it. Explore career opportunities across our ministry locations and within our corporate headquarters. Ascension is a leading non-profit, faith-based national health system made up of over 134,000 associates and 2,600 sites of care, including more than 140 hospitals and 40 senior living communities in 19 states. Our Mission, Vision and Values encompass everything we do at Ascension. Every associate is empowered to give back, volunteer and make a positive impact in their community. Ascension careers are more than jobs; they are opportunities to enhance your life and the lives of the people around you.

Licensure / Certification / Registration: Registered Nurse obtained prior to hire date or job transfer date required. Licensure required relevant to state in which work is performed. BLS Provider preferred. American Heart Association or American Red Cross accepted. Case Manager credentialed from the Commission for Case Manager Certification (CCMC) preferred. Licensure required relevant to state in which work is performed. Education: Required professional licensure/certification AND 3 years of experience and 1 year of cumulative leadership experience required. Additional preferences: Active, unrestricted RN License in state of Texas (required) Health plan/health-care management/leadership experience in related field (required) Excellent oral and written communication and interpersonal skills (preferred) Must work independently and as well as collaboratively within a team (preferred) Must demonstrate strong organizational skills; attentiveness to details (preferred) Ability to communicate, facilitate and problem- solve with people of all levels of the organization, as provider engagement and member outreach (preferred) Ability to solve practical problems and deal with a variety of concrete variables; ability to collect and analyze data, draw valid conclusions and actively contribute to the strategic interventions that support the departmental goals (preferred) #LI-Remote

Responsible for day to day operations of the Utilization Management functions including prior authorization, concurrent review and retroactive reviews. Ensure the department meets the turnaround times and all other quality measures Set team goals and fulfill the goals each year Assisting in the development and maintenance of review criteria Assist with HHSC, URAC and TDI audits Hire and train UM staff Act as back up to prior authorization/concurrent review staff as needed.

Medix™

Remote LPN Care Manager

Posted on:

August 27, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

LPN/LVN

State License:

Compact / Multi-State

Remote Licensed Practical Nurse (LPN/LVN – Compact License & CA License Required) About the Role: We are seeking a dedicated Licensed Practical Nurse (LPN/LVN) with an active multi-state compact license and California LPN/LVN license to join our remote care management team. The ideal candidate will have strong experience in chronic care management and a passion for coaching patients toward healthier lifestyles. Working alongside Registered Nurses and Nurse Practitioners, you will provide proactive, patient-centered support to help individuals manage conditions such as diabetes, hypertension, and cardiovascular disease. Schedule: Monday – Friday, 8:00 AM – 5:00 PM PST Location: Fully remote — must hold a Compact LPN license OR an active California LPN/LVN license.

Active multi-state compact Practical Nurse license OR California LPN/LVN license (required). 5+ years of clinical experience as an LPN/LVN, with a strong background in chronic care management. Strong patient assessment and coaching skills. Excellent written, verbal, and interpersonal communication abilities. Reliable home internet connection (wifi speed test required before hire). Ability to work effectively with minimal supervision while delivering high-quality care. Experience with patient education and remote support strongly preferred.

Deliver patient care under the direction of Nurse Practitioners and clinical protocols. Provide one-on-one coaching and education to patients managing chronic conditions. Conduct comprehensive assessments of patient health, lifestyle, and readiness for change. Support patients in executing care plans with a focus on behavior modification, nutrition, and self-management. Monitor adherence to treatment plans and track health outcomes through remote tools. Educate patients on medication adherence, symptom recognition, and prevention strategies. Ensure compassionate, consistent, and proactive patient support in every interaction.

Point C

Care Management Nurse

Posted on:

August 27, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

LPN/LVN

State License:

Illinois

Point C is a National third-party administrator (TPA) with local market presence that delivers customized self-funded benefit programs. Our commitment and partnership means thinking beyond the typical solutions in the market – to do more for clients – and take them beyond the standard “Point A to Point B.” We have researched the most effective cost containment strategies and are driving down the cost of plans with innovative solutions such as, network and payment integrity, pharmacy benefits and care management. There are many companies with a mission. We are a mission with a company.

Point C is seeking a compassionate and detail-oriented Case Management Nurse to support patients on their journey to better health and well-being. In this role, you’ll serve as a critical liaison between patients, providers, care teams, and community resources—ensuring continuity of care and adherence to treatment plans.

Current standing as a licensed practical nurse (LPN) (required) 5 years of experience in a clinical or community resource setting/care coordination Case Management experience is preferred Highly organized with ability to keep accurate notes and records Evidence of essential leadership, communication, education and counseling skills Proficient computing skills and the ability to learn new systems Exemplary telecommunication skills Maintains high level of professionalism and confidentiality

Create and promote adherence to treatment plans, as developed by patients’ healthcare providers Create and maintain accurate, detailed clinical patient reports for clients and carriers Monitor and document adherence to treatment plans, evaluate effectiveness, monitor patient progress in a timely manner Increase continuity of care by managing relationships with tertiary care providers, transitions-in-care, and referrals Increase patients’ ability for self-management and shared decision making Increase comprehension through culturally and linguistically appropriate education Assist with medication reconciliation Connect patients to relevant community resources, with the goal of enhancing patient health and wellbeing. Serve as the contact point, advocate, and informational resource for patients, care team, family/caregiver(s), stop-loss carrier, and community resources Assess a patient’s unmet health and social needs Acknowledges patient’s right on confidentiality issues, always maintains patient confidentiality and follows HIPAA guidelines and regulations

VA Health Plus

Licensed Practical Nurse

Posted on:

August 27, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

LPN/LVN

State License:

Compact / Multi-State

VA Health Plus, where VA stands for Virtual Assistant. we strives to unlock the full potential of global medical professionals, enabling them to pursue their careers with dignity, highest compensation, and unparalleled benefits available today. The opportunity to work from home has never been more remarkable. VA Health Plus's mission extends beyond business growth; we aim to improve lives. Our passionate advocacy stems from a deep appreciation and respect for global healthcare talent. Recognizing the dedication and skill of medical professionals worldwide, we firmly believe that exceptional talent and hard work should be recognized and rewarded. To this end, we provide industry-leading compensation and benefits packages, including a premium hourly rate and a superior retirement plan for all our virtual assistants.

𝗧𝗶𝘁𝗹𝗲: Licensed Practical Nurse (Work-From-Home) 𝗝𝗼𝗯 𝗗𝗲𝘁𝗮𝗶𝗹𝘀: 𝗘𝗺𝗽𝗹𝗼𝘆𝗺𝗲𝗻𝘁 𝗧𝘆𝗽𝗲: Full-time (Remote) 𝗟𝗮𝗻𝗴𝘂𝗮𝗴𝗲 𝗥𝗲𝗾𝘂𝗶𝗿𝗲𝗺𝗲𝗻𝘁: Candidates must be fluent in English. 𝗦𝗵𝗶𝗳𝘁 𝗧𝗶𝗺𝗶𝗻𝗴𝘀: 9 AM - 6 PM EST (Monday to Friday)

𝗤𝘂𝗮𝗹𝗶𝗳𝗶𝗰𝗮𝘁𝗶𝗼𝗻𝘀: Strong communication skills in English. At least 6 months to 1 year of experience as an LPN. 𝗖𝗲𝗿𝘁𝗶𝗳𝗶𝗰𝗮𝘁𝗶𝗼𝗻𝘀: Must hold an Active Compact State LPN License (required)

Provide remote clinical support and guidance to patients via phone, video, or messaging platforms Monitor patient progress and escalate concerns as needed Collaborate with physicians, RNs, case managers, and other healthcare professionals Document patient interactions and maintain accurate records in EMR systems Assist with care coordination, appointment scheduling, and follow-ups Educate patients on care plans, medications, and self-care techniques Perform virtual assessments and follow-up care under the supervision of an RN or physician

VITAS Healthcare

Call Center Telecare Registered Nurse – OVERNIGHT (Remote)

Posted on:

August 27, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

Compact / Multi-State

The VITAS Telecare RN is a member of the interdisciplinary team who is the pivotal person responsible for identifying the physical, psychological, social, and spiritual needs of those patients and families needing assistance after normal business hours. He or she initiates appropriate interventions to the patients and families by utilizing the nursing process, the VITAS Palliative Care Guide, and Telecare Protocols during alternate hours.

A minimum of two years’ experience in acute-care hospital nursing in either medical-surgical, oncology, home health, or emergency required. One year of customer service/call center experience preferred. Eligible for licensure in other states VITAS Triage services are located. Excellent verbal, written, and interpersonal communication skills, as well as demonstrated effective telephone skills. Ability to work as a team player and multi-task. Proficient in customer conflict resolution and crisis management. Proficient in telephone techniques including phone etiquette, and handling of calls. Thorough knowledge of professional nursing principles, methods and procedures; anatomy and physiology; medical supplies and equipment used in nursing practice; and the uses and effects of medications including narcotics. Working knowledge of applicable state and federal laws and regulations pertaining to registered nursing and the scope of practice limitations of clinic support staff. Ability to work weekends and holidays as necessary to support the operations of the Care Connection Center. Ability to type 40 WPM. EDUCATION: Graduate from an accredited school with an associate or bachelor’s degree in Nursing. CERTIFICATE & LICENSURE: Current Registered Nurse License(s) (with no current/pending restrictions) required. Telecare RNs that reside in a Nurse Licensure Compact State are required to have or obtain a multistate license designation for their state active nursing license. May be required to obtain additional nursing licenses, based on business needs. ACCOMMODATIONS: Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the job.

Provides clinical assessment and intervention utilizing the nursing process, VITAS Palliative Care Guide, and Triage Protocols. Serves as the patient and family advocate by communicating with the attending physicians, long term care facility staff, case managers, and others external to VITAS as necessary. Provides collaboration with LPN/LVN’s. Coordinates all service delivery after hours including patient and family education, dispatching of interdisciplinary visits, and coordination of services with external vendors and resources as needed. Provides support and collaboration with Telecare staff to ensure favorable patient outcomes. Provides bereavement support to families. Documents interactions with patients, families, contacts, and vendors in the patient record to include the assessment, plan of care, caller agreement to the plan, any actions and interventions and the resolution of each patient/family interaction. Reviews all entries in the record made by Telecare LPN/LVN’s and Patient Care Coordinators and ensures compliance with documentation Standards. Participates in the orientation of new team members as assigned by the supervising manager. Attends regularly scheduled in-services, staff meetings, and educational conferences. Develops and achieves professional growth goals and objectives, and reviews with supervising manager on a monthly basis. Seeks certification in the specialty of hospice nursing when qualified to do so. Instructs and documents appropriate use of medications, home medical equipment and supplies. Appropriately utilizes the resources of contract personnel such as Pharmacy, HME, agency staff, and transportation services. Promotes a customer service-oriented approach to care delivery. Supports and promotes all Care Connection Center cultural platforms. Compliance with all departmental standards, policies, and procedures with training and education, management of the workload, disaster planning, attendance adherence, and quality standards. Performs other job duties as required. This position description in no way states or implies that these are the only duties to be performed by the employee occupying this position. Employees will be required to perform any other job duties assigned by their supervisor or management.

Accolade, Inc.

Full Time Registered Nurse - Triage (Care Navigation) - Remote

Posted on:

August 27, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

Transcarent and Accolade have come together to create the One Place for Health and Care, the leading personalized health and care experience that delivers unmatched choice, quality, and outcomes. Transcarent’s AI-powered WayFinding, comprehensive Care Experiences – Cancer Care, Surgery Care, Weight – and Pharmacy Benefits offerings combined with Accolade’s health advocacy, expert medical opinion, and primary care, allows us to meet people wherever they are on their health and care journey. Together, more than 20 million people have access to the combined company’s offerings. Employers, health plans, and leading point solutions rely on us to provide trusted information, increase access, and deliver care

Accolade is currently Recruiting for a Full Time Registered Nurse supporting our Care Navigation department. We are hiring for a September 8th start date. We are hiring for the applicants to work one of the following shifts of 12:00pm to 8:30pm EST or 2:45pm to 11:15pm EST. This position is Remote for applicants who are not close to our offices. Applicants will be required to work a hybrid schedule who are closer to our offices. As an Accolade Registered Nurse specializing in Care Navigation, you will serve as a trusted resource for our members, providing clinical expertise in triage, healthcare navigation, and advocacy. Leveraging your skills and compassion, you will exercise genuine care by assessing members’ health concerns, prioritizing medical needs, and providing evidence-based recommendations, ensuring members receive timely and appropriate care. Your role is critical in guiding members through their healthcare journey while addressing disparities to support marginalized populations. Together, we work to achieve positive outcomes by empowering members to take the right steps in their healthcare journey. At Accolade, we foster a growth mindset, encouraging continuous learning and collaboration. You will enhance your clinical knowledge while partnering with our care teams to deliver exceptional support, including navigating benefit offerings and specialized programs.

Required: Bachelor's degree in nursing (BSN) or equivalent. Active, unrestricted RN license; Compact (NLC) license. Minimum of 3 years of recent clinical experience in direct patient care. Ability to support Behavioral Health needs as required. Strong clinical acumen, critical thinking, and communication skills. Technological fluency, including the ability to navigate multiple systems simultaneously. Hybrid work expectations for nurses near an Accolade office; occasional travel for remote employees. Preferred: Experience with telephonic triage and related protocols. Knowledge of medical benefits, insurance claims processes, and healthcare coordination. Direct patient care experience in medical/surgical, ER, or homecare settings. Dedication to professional development and staying current in nursing practices. Empathetic, client-focused approach to healthcare advocacy. Additional Information:  This role involves telephonic and digital interactions with members, requiring strong communication skills, organization, and the ability to work collaboratively in a team-oriented environment.   You will be integral in advocating for members' healthcare needs and ensuring they receive personalized care and support throughout their healthcare journey.   Flexibility to work various shifts, including nights, weekends, and holidays as needed.

Empower Members: Provide education to help members confidently navigate the complex healthcare system, building trust and fostering connections to appropriate clinical programs and services. Conduct Assessments: Perform telephonic, holistic clinical assessments to identify and prioritize members’ needs addressing their questions and concerns. Educate and Refer: Offer clear, evidence-based education on healthcare decisions, referring members to Accolade’s internal programs and trusted partnerships, such as virtual primary care, expert second opinions, and complex case management. Leverage trusted partnerships within Accolade's ecosystem to promote optimal clinical outcomes for members. Collaborate with Accolade’s program partners specializing in telemedicine, diabetes management, physical therapy, gender-diverse support, and behavioral health. Guide Next Steps: Prepare members for upcoming healthcare events by educating them on procedures, medications, testing, provider visits, and treatment options. Foster Relationships: Maintain follow-up support to ensure members feel informed and cared for throughout their healthcare journey. Ensure Compliance: Maintain data integrity, compliant to HIPAA guidelines, ensuring accuracy in real time member records, including assessments, interventions, and outcomes.

Cal State Nursing Pathways LLC

Nurse Mentorship

Posted on:

August 27, 2025

Job Type:

Part-Time

Role Type:

Coaching

License:

RN

State License:

California

Cal State Nursing Pathway is an online platform built to help future nurses succeed. We connect students with experienced, licensed nurses for mentorship, guidance, and insight into the nursing profession.

What We Offer You: Set your own pricing for mentorship sessions Fully flexible scheduling – work when you want, from anywhere Platform tools to connect directly with motivated nursing students No long-term commitment Who We’re Looking For: We’re currently seeking licensed, experienced nurses in the following specialties to join our mentorship team: NICU Nurse Surgical Nurse Aesthetics Nurse ICU Nurse ER Nurse

Active, valid RN license (state of California preferred, but open to nationwide). Minimum 2 years of experience in one of the specialties listed above. Professional liability insurance (required for mentors). Passion for teaching and helping future nurses succeed.

Provide educational mentorship and career guidance to nursing students. Share insights from your specialty and help prepare students for real-world nursing. Offer tips on study strategies, clinical skills, work-life balance, and career paths. Sessions are mentorship only – no medical advice, diagnosis, or treatment is allowed.

BreatheSuite

Telehealth Psychiatric-Mental Health Clinical Nurse Specialist (APRN)

Posted on:

August 27, 2025

Job Type:

Contract

Role Type:

Telehealth

License:

RN

State License:

Arizona

BreatheSuite is a leader in virtual pulmonary rehabilitation, helping patients with chronic respiratory diseases improve their quality of life from the comfort of their homes. While our program primarily focuses on respiratory care and physical rehabilitation, we recognize the critical role mental health plays in managing chronic illness. To better support our patients, we are seeking a mental health professional to integrate mental health support into our program.

This is a unique and exciting opportunity for a mental health professional who wants to: Provide Patient Care: Transition into a clinical role, delivering virtual mental health support to patients dealing with the emotional and psychological challenges of living with chronic respiratory diseases. Work Collaboratively: Partner with PTs, NPs, RRTs, and PTAs to provide holistic, patient-centered care. Enjoy Flexibility: Set your own schedule while working remotely.

Licensed in Arizona (considered a bonus if also licensed in Colorado) Experience providing therapy, counseling, or behavioral health interventions (preferably with patients managing chronic illnesses). Comfortable working in a virtual/telehealth setting. Passion for interdisciplinary care and a holistic approach to health and wellness. Strong communication skills and ability to work collaboratively with a multidisciplinary team.

Provide virtual therapy, counseling, and/or coaching to patients with chronic respiratory diseases experiencing anxiety, depression, or other psychological barriers to care. Develop individualized mental health strategies to help patients improve adherence to their rehab plans. Utilize telehealth platforms to deliver high-quality, engaging mental health services.

AristaMD

Referral Nurse Navigator (Temporary role, PT to FT)

Posted on:

August 27, 2025

Job Type:

Full-Time

Role Type:

Primary Care

License:

RN

State License:

California

Location: Fully remote (must be in the US and able to work Central Time business hours; applicants do not need to reside in Kansas) Position Purpose & Focus: The RNN (Referral Nurse Navigator) is responsible for all submissions of eConsults for AristaMD. This role is an intermediary between the specialist and provider. This role is critical in optimizing patient care coordination, reducing unnecessary specialty referrals, and improving access to specialist expertise through digital consultation platforms. The successful candidate will bridge the gap between primary care providers and specialists while ensuring seamless patient navigation through the healthcare continuum.

This is a fully remote position. Employee to start 20 hrs/week for first 3 months transitioning to 40hrs/week for the following 3 months. This is a temp position (6 months) with the potential to become a full-time position. Standard Monday-Friday schedule with flexibility for team coverage as needed between 9-5 CST. Some Holiday coverage will be required. Must possess reliable high-speed internet access and a quiet, dedicated workspace. Candidates must be physically located within the United States. Qualifications: Minimum Qualifications Active unrestricted RN or LPN license 2+ years of experience in the nursing field Preferred Qualifications RN license Familiarity with eConsults Experience working in or a multispecialty medical practice/clinic Technical Skills: Proficient in Google Suite and Microsoft Office Experience with VPNs and RDPs Experience with multiple EHR systems (NextGen, EPIC, eCW, Cerner, Athena, Intergy) Expert understanding of referral workflows Success Factors: Excellent customer service skillset Critical thinking and problem-solving abilities with attention to detail Technically savvy Internally motivated Strong organizational skills with ability to manage multiple priorities and competing deadlines Highly self-motivated; takes initiative Proactive - identifies and resolves issues; accountable Has a strong sense of urgency and follow-up with attention to detail Ability to work in a fast-paced growth environment which requires prioritization and the ability to multi-task Ability to collaborate and work effectively as a team Self-starter possessing a can-do attitude

Submits accurate eConsults on behalf of primary care providers. Ensures all assigned sites are continually reviewed for eConsult referrals. Ensure complete and accurate clinical information is available for specialist review Ensures accuracy of grammar and structure of eConsults. Routes referrals once a disposition has been made by a specialist. Triages and processes submittable vs. non submittable referrals in clinic referral inboxes. Notifies primary care providers with any responses from the AristaMD specialist. Provides assistance to other RNN team members when experiencing increased operational demands Covers assigned clinic's eConsult referral in baskets, attaches appropriate documents and submits eConsult to specialist, and communicates the recommendations back to the referring provider. Monitors overdue eConsults and communicates information to RNN Manager. Collaborate to optimize platform functionality and user experience Reviews completed eConsults to submit for review for QA meeting.

AristaMD

Care Coordinator (Temporary Role, Remote)

Posted on:

August 27, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

None Required

State License:

California

The Care Coordinator is responsible for reviewing and routing consult requests created by clients (the primary care provider) to the AristaMD specialist who will respond to the request. The Care Coordinator is responsible for ensuring all consult requests are complete and contain all required pieces of information. Additionally, the Care Coordinator responds to questions and other issues from AristaMD clients, internal AristaMD team members, and AMD specialists. The Consult Routing Specialist is responsible for ensuring that the contract Service Level Agreements (SLA) are met and escalating cases to management if processing is delayed.

Qualifications: Minimum of 2 years of healthcare administrative experience, or an equivalent combination of education and relevant work history. High school diploma or equivalent (required). Medical Assistant certification or higher (preferred). Healthcare or insurance industry experience (preferred). Knowledge of CMS programs or HEDIS measures (not required). Skills & Competencies: Strong medical terminology knowledge. Thorough knowledge of HIPAA regulations and a commitment to compliance. Exceptional organizational skills, meticulous attention to detail, and strong time management abilities. Proficient in data entry, documentation, and the creation of professional templates. Excellent written and verbal communication and interpersonal skills. Adept problem-solving capabilities. Proficiency in Google Workspace (required); Tableau experience (plus). Technically adept with a focus on practical application of digital tools. Ability to work collaboratively and build strong relationships. Ability to adapt and thrive in a dynamic, frequently changing environment, including prioritizing and multitasking effectively in a fast-paced, growth-oriented setting. Comfortable and capable of participating in video meetings with your camera on (required). Success Factors: Highly self-motivated, proactive, and takes initiative with a "can-do" attitude. Self-directed and capable of working independently in a remote environment. Strong sense of urgency, effective follow-up, and commitment to meeting deadlines. Accountable and resourceful in identifying and resolving issues independently. Exhibits a positive, respectful attitude, acting as a role model. Demonstrates excellent customer service. Military veterans, spouses, and affiliates are strongly encouraged to apply. Work Environment: This is a fully remote position. Standard Monday-Friday schedule; candidates can choose between 8am-5pm EST or 8am-5pm PST. Some non-major holiday coverage will be required. Must possess reliable high-speed internet access and a quiet, dedicated workspace. Candidates must be physically located within the United States.

Provide essential support for our eConsult platform and Risk-Bearing Entity (RBE) programs Collaborate closely with clinical teams to ensure timely and effective care coordination Coordinate patient scheduling and facilitate seamless care transitions across our extensive specialty network Conduct targeted provider outreach via phone and email as needed to support operational goals Manage provider outreach and track all interactions in our systems Track and actively resolve failed fax transmissions Accurately track and document all provider interactions within our internal systems Maintain accurate and up-to-date records within our platform systems, including Tableau, HelpScout, and Google Workspace Manage provider outreach and track all interactions in our systems Create and meticulously maintain process documentation and standardized templates Assist with Referral Nurse Navigator (RNN) workflow support Support the successful implementation of pilot programs and new service offerings Actively contribute to process improvements and initiatives aimed at enhancing operational efficiency

Kyyba Inc

RN Utilization Management

Posted on:

August 27, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Michigan

Kyyba, Inc. is a global workforce management and technology solutions firm headquartered in Farmington Hills, Michigan with multiple locations across the globe. Our expertise is in connecting the right people with the right opportunities. We deliver high-quality solutions and top-notch recruiting services, enabling businesses to effectively respond to organizational changes and technological advances. Kyyba offers IT, Engineering, Professional, customized project solutions and Business Consulting Services. Industry areas include but are not limited to Automotive, Education, Financial Services, Public Services, Aerospace & Defense, Insurance, Transportation, Technology, Government, Healthcare & Medical, Manufacturing, and Oil & Energy.

Job Title: RN Review Analyst Location: 100% remote [Office located in Detroit, MI] Duration: 12+ Months License Required: Active & unrestricted Michigan RN license Engagement Description The RN Analyst Reviewer role encompasses the processing of inpatient admission requests utilizing InterQual criteria to determine the medical necessity of an inpatient status. The RN Review Analyst will perform admission approvals, admission denials per MD decision, telephone triage, and benefit interpretation.

Registered Nurse with current Michigan driver's license Associate Degree or nursing diploma required. Two (2) to four (4) years patient care experience which may include acute patient care, discharge planning, case management, utilization review, etc. Expertise in the use of medical terminology Familiar with Microsoft Office Suite including Teams Preferred Skills/Experience: Prior post-acute patient care experience Triage, case management or utilization review experience InterQual knowledge Experience with Clinical Care Advance Education/Certifications: Associate's Degree or Nursing Diploma

Sigma Health

Registered Nurse Case Manager

Posted on:

August 27, 2025

Job Type:

Contract

Role Type:

Case Management

License:

RN

State License:

New Jersey

Title: Registered Nurse Case Manager (Remote) Location: 1700 American blvd. Pennington NJ 08534. Shift : Days 5X8-40hrs/week. Duration: 26 weeks

Requires an associate's or bachelor's degree (or higher) in nursing and/or a health related field OR accredited diploma nursing school. Requires a minimum of two (2) years clinical experience Requires minimum of three (3) years experience in the healthcare delivery system/industry. Requires minimum of two (2) years experience with healthcare payer experience Skills: Critical care experience with a strong understanding of acute care environments. Experience in Level I or Level II trauma centers, including emergency room and ICU settings. Knowledge of geriatrics, pediatrics, behavioral health, infectious disease care, and medical-surgical nursing. Proficient in case management principles including diagnostic evaluation and discharge planning. Familiarity with managed care processes and patient service excellence. Strong understanding of medical terminology, physiology knowledge, vital signs monitoring, and intake procedures. Experience with outpatient clinic operations and post-acute care services is advantageous. Excellent communication skills to effectively liaise between patients, families, and healthcare teams. Join our team as a Registered Nurse Case Manager where you can make a significant impact on patient lives while advancing your career in a supportive environment.

Conduct comprehensive patient assessments to determine healthcare needs and develop individualized care plans. Coordinate and manage patient care across various settings, including inpatient, outpatient, and post-acute care. Collaborate with interdisciplinary teams to ensure continuity of care and optimal patient outcomes. Monitor patient progress and adjust care plans as necessary based on clinical evaluations. Facilitate discharge planning, ensuring patients have the resources needed for successful transitions. Maintain accurate medical records in compliance with HIPAA regulations and organizational policies. Provide education to patients and families regarding treatment options, medication management, and health maintenance. Participate in utilization management activities to optimize resource use while delivering high-quality care.

AnsibleHealth Inc.

Registered Nurse

Posted on:

August 26, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

Ansible Health is a virtual multi-speciality medical group that unites physicians, nurses, respiratory therapists, and tech experts from Columbia, Johns Hopkins, Google, Amazon, and other top institutions to revolutionize care for chronic disease patients. We combine elite clinical expertise with cutting-edge technology to deliver personalized, efficient care at scale. Backed by Bessemer, First Round Capital, AlleyCorp, Breyer Capital, and Inflect Capital, we're a Series A startup partnering with leading healthcare systems nationwide. Our mission is to genuinely improve patient outcomes, not just optimize metrics. If you're passionate about transforming healthcare through technology, join our diverse team in making a real impact.

We are seeking a superstar registered nurse (RN) with a passion for caring for patients with complex chronic medical conditions, focusing on cardiac and respiratory disorders such as congestive heart failure and chronic obstructive pulmonary disease (COPD). We are searching for a compassionate, smart, and slightly rebellious individual who has found their true calling in patient care, and who is pulled towards using their heart, soul, and mind in new and creative ways. If you are a self-driven and intellectually curious learner with a growth mindset, we would love to hear about this in your cover letter. If you make flashcards for self-study when you encounter an unfamiliar medical term or drug name; if you ask a lot of questions (particularly, “why”); if you enjoy brainstorming about patient care with your colleagues; if you have a secret mental list of ideas for care improvement, and are looking for the opportunity to try them out; if you sometimes brush your teeth for too long because you are lost in thought about a patient case; we would love to interview you. We believe in the raw potential of an individual to become the best clinician possible when immersed in a supportive environment with high-quality mentorship. Job Details: Full-time: 40 hours a week (Monday - Friday, 8AM - 5PM EST) Benefits: Flexible PTO Location: Remote

The qualified candidate will possess any combination of Education and Experience that will provide the required knowledge, skills, licenses, and certifications to practice as a competent registered nurse Education: Completion of an accredited program for nursing with a minimum of an Associate's Degree. License /Certification: Current or compact unrestricted Nursing license in the state of Virginia, or Pennsylvania. 5+ years of experience caring for adult patients with medical illness across the acute and chronic spectrum, substantiated by a strong foundation in Primary Care, Internal Medicine, Geriatric, and Urgent Care practice environments. Strong triage skills are a must! 1+ years of experience caring for adult outpatients with chronic cardiopulmonary conditions such as COPD, congestive heart failure, and coronary artery disease Maintenance of license and continuing nursing education Technical: reliable high-speed internet connection (at least 25 Mbps) Preferred Qualifications, Experience & Certifications: The preferred candidate will possess a unique combination of Education and Experience that will likely provide superior knowledge, skills and licenses to practice as a Registered Nurse in the fields of telemedicine, cardiac and pulmonary disease, and polychronic disease management. Education: Must hold an Associate’s Degree or higher in nursing.. Licensed in good standing in Virginia or Pennsylvania 5+ years of experience working with patients with chronic cardiopulmonary diseases such as COPD, interstitial lung disease, lung cancer, pulmonary hypertension, congestive heart failure, ischemic heart disease, and post-cardiothoracic surgery and general internal medicine. Proficiency with telemedicine and/or remote care extension preferred. Prior experience assisting with the coordination of designated health services such as home health, outpatient respiratory care, and DME. Prior experience operating within Cardiac or Pulmonary Rehabilitation programs is a plus but not required. Prior experience/education in exercise science is preferred but not required. This position does include leading patients in home bound exercises over telehealth visits. Strong interest to learn, caring deeply about improving the lives of our patients, ability to work as a strong team player while being self-directed are a must for this position.

You will be part of a team led by a nurse practitioner with a mix of respiratory therapists and registered nurses to provide direct care via telemedicine to patients suffering from advanced chronic lung and heart disease. We treat an elderly patient population that is medically complex, very ill at baseline, frequently hospitalized, and often burdened by psychosocial challenges. You will collaborate closely with your medical team members, often speaking multiple times per day with the supervising nurse practitioners, physicians, and medical directors. Examples of patient care tasks include: Performing telemedicine visits with our patients to provide education specific to their conditions Leading exercise sessions with your team for your patients over telehealth. Assessing/triaging adult outpatients with multiple chronic medical conditions, with an emphasis on lung disease/heart failure. Coordinating care with primary care providers, specialists, and external care agencies Advocating for patients who are experiencing major social stressors by activating community resources to improve access to medications, transportation, healthy nutrition, and safe housing Working with your NP led team to serve as the continuous point of contact for patients and families across the entire care spectrum, ranging from transitional post-acute care, to medical stabilization, to rehabilitation, to advanced care planning and dying with dignity Engaging with our interdisciplinary team of physicians, engineers, designers, and other care team members to continuously optimize the care we deliver to our patients Intimately related to patient care, you will also play a role in promoting our program and answering questions from referring providers and practices as we become more established in your local community. This versatile role requires you to wear many different hats throughout the week, blending aspects of medical care, education, case management/social work, marketing, and advocacy. We believe in nurturing these transferable skills within one individual, rather than creating silos of expertise across rigid professional categories. This is an unorthodox approach that challenges the current trend in healthcare, which has moved towards more and more specialization, leading to further care fragmentation. We believe that the future of healthcare rests in the hands of a new kind of cross-functional clinician. Here a few examples of our recent success stories: A socially isolated 50-year-old woman with COPD and several overlapping anxiety disorders was frequently seen in the ED with dyspnea related to panic attacks and psychological distress. Multiple psychotropic medications were added over time, leading her to feel like a “zombie” and drink 10 caffeinated soft drinks per day to compensate, which fueled a vicious cycle of anxiety. The patient’s Ansible clinician connected her to a psychotherapist, convinced her to adopt a dog, and collaborated with her providers to discontinue and taper off several medications. The patient is now doing well at home, no longer going to the ED, and on a much safer medication regimen. A 67-year-old man with very severe COPD and pulmonary cachexia (BMI 17.3 kg/m2) was declined for lung transplantation due to being severely underweight and unable to access a pulmonary rehabilitation facility. The patient lived in a rural Appalachian town with no cellular or internet service. The patient’s Ansible clinician found a public library 3 miles from the patient that housed a WiFI-enabled conference room for telemedicine. The clinician coordinated transportation with his church, provided guidance on nutritional supplementation, and supervised the patient through pulmonary telerehabilitation. The patient’s functional status improved, his BMI increased to 21.5 kg/m2, and he was listed for transplantation. A 59-year-old woman with very severe COPD, HFpEF, and ischemic cardiomyopathy was admitted to the hospital 13 times within the last year for various acute issues including COPD exacerbations, pulmonary edema, and unstable atrial fibrillation. Our clinical team pursued multiple avenues of medical optimization and rehabilitation but the patient continued to deteriorate. Throughout the patient’s journey in the medical system, her Ansible clinician was the most stable contact point, and was able to use the therapeutic rapport to initiate a discussion about end-of-life care. The patient entered into a home hospice program and her symptoms were effectively managed. Responsibilities: You will join a diverse, talented, and meritocratic team of clinicians from all walks of life who are excited about working at the frontier of healthcare. This is a challenging role that will involve a very steep learning curve, feeling more like a training program for the first year. As with any innovation, a degree of organized chaos is expected. Changing the culture of healthcare is hard. It will often feel like it is “us against the world”, but you will be in good company. You bring your energy, wisdom, and passion for learning. We will bring intensive mentorship to grow your skills and help you to become the best clinician possible. This is a fantastic opportunity for an entrepreneurial and self-directed registered nurse who is excited to be at the absolutely leading edge of the future of healthcare.

Urology America, MSO

Triage Clinician

Posted on:

August 26, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Texas

At Urology Austin, our mission is committed to improving the lives of patients and their families through compassionate, quality, and ethical care. In choosing a career with Urology Austin, you are choosing to improve the lives of patients and their families through a collaborative team-driven approach in an innovative, quality-driven, community-based setting. Better Medicine. Better Care.

The Triage Clinician plays a critical role in Urology Austin’s centralized triage and contact center, serving as the first clinical point of contact for patients seeking assistance. This position is responsible for evaluating patient needs via phone and electronic systems, collecting and documenting clinical information, and executing delegated non-licensed clinical tasks under appropriate supervision. Certification is required to ensure competency and alignment with scope-of-practice expectations under Texas law Reporting: Reports to the Triage and Scheduling Manager

Required: High school diploma or equivalent Certification as a Medical Assistant (AAMA, AMT, NCCT, or NHA). Minimum of 2 years’ experience in ambulatory clinical care, call center, or specialty practice setting Strong knowledge of medical terminology, clinical protocols, and urologic conditions Excellent documentation, communication, and follow-through skills Preferred: LVN or RN degree. Previous triage or care coordination experience Familiarity with HIPAA-compliant remote work standards (if remote) Knowledge, Skills, and Abilities: Knowledge of urologic terminology and outpatient care practices Familiarity with call handling, care coordination, and triage protocols Strong written and verbal communication skills Ability to remain composed in high-volume or emotionally charged interactions Time management and multitasking in a remote or multi-clinic setting

Clinical Communication - Delegated and Supervised: Answer and triage incoming calls using Patient Sync and EMR in accordance with approved protocols Log into phone systems daily and remain available to receive incoming calls during scheduled shifts Communicate provider-reviewed test results to patients as directed without interpretation Relay provider-approved medication orders to pharmacies per documented instructions Document all patient communication accurately and completely in the EMR and triage system Coordinate follow-up on labs, imaging, procedures, or referrals based on provider orders Data Collection and Charting: Collect and update medical history, allergies, medications, and urologic symptoms via phone Document patient history and responses without interpretation or diagnosis Prepare and maintain accurate EMR documentation prior to upcoming visits or consults. Administrative and Operational Support: Schedule appointments, tests, and procedures per provider with instructions and/or protocols. Request and organize outside medical records, imaging, or prior authorizations Support cross-functional communication with site clinics, billing, and clinical staff Maintain daily availability and responsiveness across all assigned work applications Patient Education: Provide standardized patient instructions (pre-procedure prep, catheter care guidance) Reinforce previously given provider instructions without creating or altering instructions independently Clarify what to expect during upcoming appointments or procedures Triage QA and Escalation: Identify recurring call or symptom patterns and escalate to clinical leadership Immediately escalate urgent symptoms per triage protocol (fever, catheter issues, retention) Participate in peer review, audit feedback, and protocol improvement sessions Compliance and Professional Standards: Maintain strict adherence to HIPAA and all applicable clinical privacy regulations Participate in regular in-service education and policy updates Maintain a professional, supportive, and team-oriented work environment

Cadence Health

Care Management Registered Nurse, RN Compact License Required

Posted on:

August 26, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Compact / Multi-State

Cadence Health was built around a simple promise: patients always come first. Our technology-enabled remote care model pairs continuous health insights with a highly skilled clinical Care Team, empowering seniors to stay healthier, avoid complications, and live more independent, fulfilling lives, all without the limits of a traditional office visit.

In the U.S., 60% of adults – more than 133 million people – live with at least one chronic condition. These patients need frequent, proactive support to stay healthy, yet our care system isn’t built for that level of attention. With rising clinician shortages, strained infrastructure, and reactive care models, patients too often end up in the ER or the hospital when those outcomes could have been prevented. At Cadence, we’re building a better system. Our mission is to deliver proactive care to one million seniors by 2030. Our technology and clinical care team extend the reach of primary care providers and support patients every day at home. In partnership with leading health systems, Cadence consistently monitors tens of thousands of patients to improve outcomes, reduce costs, and help patients live longer, healthier lives. The Cadence Health team seeks a Registered Nurse to support patients in our care management programs and help patients better manage their conditions.

Multi-state RN Compact State Licensure Associate Degree in Nursing Science 5+ years of clinical experience as an RN in an ICU/ER setting. Prior experience supporting patients in a chronic care management program is a plus. To ensure that our clinicians have the necessary tools for a successful remote work environment, home office setups must have consistently stable wifi with strong upload and download speeds. A wifi speed test is required before participating in the interview process to verify that these standards are met. Skilled in nursing processes. Excellent clinical acumen. Exceptional written, verbal, and interpersonal communication skills. EMR experience, preferably in Athena and EPIC. Works effectively with minimum supervision. Strong collaboration with cross-functional partners. Ability to support the delivery of health care to patients by performing a variety of activities and procedures that are prescribed by and performed under the direction of the Cadence Nurse Practitioner and Cadence clinical policies and procedures. Patient assessment competency. Technical fluency with the ability to work in multiple platforms and systems, including Notion, Athena, EPIC, Zendesk, and G Suite.

Continuously monitor patient vitals, symptoms, and lab results to proactively identify care gaps and patients requiring clinical intervention. Create and manage personalized care plans to address patients' specific health needs, ensuring alignment with treatment goals and physician recommendations. Address patient concerns and escalations via phone and text, providing timely and empathetic responses. Conduct virtual follow-up appointments to guide patients through program enrollment, update treatment plans, support medication adherence, and achieve lifestyle and health goals. Document clinical interactions thoroughly and prepare detailed care summaries to share with patients’ physicians, ensuring seamless care coordination. Assist in developing workflows and processes to enhance our care management programs, ensuring efficiency, scalability, and patient-centered care. Ensure every patient interaction reflects Cadence’s commitment to delivering exceptional care and aligns with the goals of partnering health systems. Collaborate with the team to scale care delivery for patients with chronic conditions, including CHF, hypertension, and type 2 diabetes, as Cadence grows.