Health Advocate

Personal Health Advocate (Registered Nurse)

Posted on:

May 4, 2026

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

Compact / Multi-State

Health Advocate is the nation’s leading provider of health advocacy, navigation, well-being and integrated benefits programs. For 20 years, Health Advocate has provided expert support to help our members navigate the complexities of healthcare and achieve the best possible health and well-being. Our solutions leverage a unique combination of best-in-class, personalized support with powerful predictive data analytics and a proprietary technology platform to address nearly every clinical, administrative, wellness or behavioral health need. Whether facing common issues or an unprecedented challenge like COVID-19, our team of highly trained, compassionate experts work together to go above and beyond expectations, making healthcare easier for our members and ensuring they get the care they need.

Registered Nurse - Personal Health Advocate Your Mission: What Success Looks Like Your primary accountability is to deliver high-quality, member-centered clinical advocacy while meeting service, quality, and case management standards. Work Schedule: Monday-Friday 11am-7:30pm EST. OR 12:30pm-9:00pm EST. Pay: $37 per hour

Who You Are: The Leader We’re Looking For You are an experienced nurse who brings clinical judgment, behavioral health expertise, composure, and accountability to every interaction. You naturally demonstrate: Ownership and follow-through You take responsibility for member outcomes and see cases through with care and precision. Empathy grounded in professionalism You listen deeply and respond with compassion while maintaining clarity, confidence, and appropriate boundaries. Strong critical thinking You quickly synthesize clinical information, prioritize what matters, and determine effective next steps. Clear and confident communication You explain complex medical and insurance concepts in a way members can understand and trust. A commitment to quality and results You are motivated by accuracy, meaningful resolution, and delivering an exceptional member experience. Curiosity and continuous learning You stay current on healthcare trends, systems, and procedures to provide thoughtful, informed guidance. You thrive in active environments where your expertise is trusted, your work has visible impact, and excellence is supported. Minimum Qualifications Education: BSN or RN degree from an accredited college or university (required) Licensure: Active and unrestricted State or Multi-State Registered Nurse license (required) Experience: Minimum 5+ years of clinical and/or medical management experience Core Skills: Strong understanding of medical terminology and healthcare systems Excellent verbal communication skills and professional phone presence Ability to explain complex healthcare topics to diverse populations Highly effective listening, problem-solving, and issue-resolution skills Strong organizational and administrative abilities Proficiency with Microsoft Word and Excel Ability to work effectively in a collaborative, remote team environment Team Interface & Customer Service: Establish and maintain professional relationships with internal and external customers Collaborate with team members to meet departmental goals Deliver customer service that consistently exceeds expectations Treat all individuals with dignity, respect, and professionalism Escalate workflow or communication issues to leadership as appropriate Mental and Physical Requirements: This position is fully remote and requires a dedicated, HIPAA-compliant workspace with reliable internet access. The nature of the work is sedentary, involving prolonged sitting and continuous computer and phone use. Essential functions include repetitive motion, typing, concentration, reading, and ongoing verbal and written communication throughout the workday.

Member Advocacy & Clinical Guidance: Receive inbound member calls related to a wide range of healthcare issues (e.g., infertility, chronic disease, medications, diagnoses) Assess needs and determine the best course of action while adhering to established policies, procedures, and performance indicators (KPIs) Take ownership of member cases by going beyond the initial request and encouraging continued engagement Education, Trust & Relationship-Building: Educate members on their medical conditions, diagnostic testing, test results, and available treatment options Explain complex medical and benefit-related information clearly and compassionately Build trusted relationships that empower members to actively participate in their healthcare decisions Care Coordination & System Navigation: Provide members with options for healthcare providers and services based on clinical needs, geographic location, and benefit coverage Research providers through credentialing, education verification, and affiliations with recognized medical centers Facilitate communication between members, treating physicians, and insurance carriers Assist with scheduling and re-scheduling appointments, transferring medical records, resolving access issues, and clarifying benefit provisions Intercede on behalf of members to obtain earlier appointments or remove barriers to care Support members with prescriptions, pre-service fee negotiations, and authorization-related challenges Case Management, Documentation & Follow-Up: Maintain accurate, timely documentation using approved case management systems and procedures Place outbound follow-up calls when issues cannot be resolved during the initial interaction Respond to delegate box, answer service, and after-hours calls as required Escalate cases appropriately and on a timely basis to supervisors or internal clinical resources Strong technical proficiency. You are comfortable navigating multiple systems, documenting in case management platforms, and using technology to work efficiently in a fully remote healthcare environment. You adapt quickly to new tools and maintain accuracy while managing digital workflows. Professional Growth & Team Contribution: Stay current on patient care procedures, diagnoses, authorizations, denials, and evolving healthcare practices Mentor and support new team members as needed Collaborate with colleagues to maintain service excellence and balanced workflows Related Duties as Assigned: This job description describes the general nature and level of work performed and is not intended to be a comprehensive list of all activities, duties, or responsibilities. Job incumbents may be asked to perform other duties as required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions outlined above. Please contact your local Employee Relations representative to request a review of accommodations.

Enlyte

Triage Clinician

Posted on:

May 4, 2026

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

At Enlyte, we combine innovative technology, clinical expertise, and human compassion to help people recover after workplace injuries or auto accidents. We support their journey back to health and wellness through our industry-leading solutions and services. Whether you're supporting a Fortune 500 client or a local business, developing cutting-edge technology, or providing clinical services you'll work alongside dedicated professionals who share your commitment to excellence and make a meaningful impact. Join us in fueling our mission to protect dreams and restore lives, while building your career in an environment that values collaboration, innovation, and personal growth. Be part of a team that makes a real difference.

This is a full-time (40 hours per week), fully remote position with a Sunday through Thursday schedule, 5:00 AM - 1:30 PM CST. Qualified candidates must be located in a Compact state and hold a Compact RN License in the state in which you reside. Bilingual Spanish/English Language Skills Are Preferred. The Worker’s Compensation Telephone Triage Clinician position provides inbound telephone triage services remotely to injured workers while following the individual state Worker Compensation rules and regulations. Uses clinical expertise and communication skills to triage, consult, and provide recommendations for emergent and non-emergent situations. Focuses on conveying compassion and ensuring service excellence is centered on the injured worker.

Unencumbered RN License in state of residence required, compact state strongly preferred Minimum of three years’ recent RN experience in one of the following adult clinical areas: Telephone Triage, ER, Urgent Care, Medical Surgical Unit, Occupational Medicine Bilingual in Spanish Preferred Ability to obtain other state licenses as required with fees reimbursed Ability to function independently and learn in a virtual work environment Experience using Microsoft Office Suite 24 hour work week, schedules and shifts available dependent on the needs of the business, and schedules may include working every Saturday OR every Sunday This is a remote position and the successful candidate must have a safe and HIPAA compliant home office with high speed internet connection, verified by speed test.

Make safe decisions for appropriate care using critical thinking skills Use departmental evidence-based protocols to triage patients Build and maintain solid interdependent relationships within the team Maintain up-to-date knowledge and skill in professional, clinical, and system areas Demonstrate effective written and verbal communication skills

Nuvance Health

Clinical Denials Prevention & Appeals Specialist RN- PART TIME

Posted on:

May 4, 2026

Job Type:

Part-Time

Role Type:

Clinical Operations

License:

RN

State License:

Conneticut

Nuvance Health is a system of award-winning nonprofit hospitals and outpatient healthcare services throughout the Hudson Valley and western Connecticut, including: Danbury Hospital and its New Milford campus, Norwalk Hospital and Sharon Hospital in Connecticut; Northern Dutchess Hospital, Putnam Hospital and Vassar Brothers Medical Center in New York. Nuvance Health offers the latest prevention, diagnostic, medical, surgical and rehabilitation services, including through the Cancer, Heart & Vascular and Neuroscience Institutes; and primary and specialty care services through Nuvance Health Medical Practices. Nuvance Health also provides convenient healthcare through home care, urgent care and telehealth visits.

PART TIME- 20 hours per week- Mon-Fri 8pm- 12am shift- Rotating weekends Hybrid/Remote Summary: The purpose of the Denial Prevention Nurse is to ensure that all patient admissions are appropriately status within the first 12-24 hours and that ongoing communication (electronic and telephonic) with payers ensures timely approval of all hospital days, preventing delays in reimbursement. This role plays a critical part in preventing payment denials by providing timely and accurate clinical information to all payers, while ensuring compliance with CMS requirements, guidelines, and standardized published criteria to support the medical necessity of patient admission and continued hospital stays. This role will require specialized system skills, best practice application of investigating payer practices, successfully challenging payers as they prevent obstacles and deny claims and escalating any egregious payer behaviors to internal leadership for assistance in resolution.

Education Skills Experience Bachelor’s Degree (BSN) is highly preferred. Minimum of Associate’s Degree in Nursing required when accompanied by strong demonstrated competencies and significant experience. Minimum of 5 years experience in acute care Nursing Proficiency in Milliman and InterQual Guidelines required Minimum of 2-3 years experience as Utilization Management Nurse in an acute care setting required, minimum of 4 years experience required for Associate’s Degreed individuals. PREFER: Master’s Degree in related field Required:Current RN License in Connecticut and New York InterQual/MCG proficiency testing completed (preferred); required within 1 year of hire. As certification becomes available, requirement will be revisited. Knowledge of regulatory requirements for CMS Have the positive attitude and aptitude to adapt to the continuing change in payer behaviors Recognizes that education is the responsibility of the individual as well as the organization Seeks external knowledge on payers (such as free email services as Becker’s) Must have analytical abilities to assist in obtaining solutions to problems Self-starter and highly motivated Must be able to work independently in a fast-paced environment, manage workload and prioritize work Must be able to manage multiple competing priorities and maintain calm professional demeanor during peak demand Must possess a high degree of prioritization skills Exceptional interpersonal skills to effectively communicate with the physicians, payers, and other members of the interdisciplinary care team Current working knowledge of utilization management, performance improvement and managed care reimbursement. Working Conditions Manual: Some manual skills/motor coord & finger dexterity Occupational: Little or no potential for occupational risk Physical Effort: Sedentary/light effort. May exert up to 10 lbs. force Physical Environment: Generally pleasant working conditions

Review all inpatient admission and observation cases using InterQual, or Milliman Care Guidelines or CMS 2 Midnight Rule (depending on payer) within 12-24 hours of admission, seven days a week for assigned shifts. Complete an initial screening review within the first few hours of decision to admit from ED and communicate with appropriate Provider if initial status is to be re-considered. Identify incomplete clinical reviews in work queues and complete them within two hours whenever possible. If clinical information is not available by the time the lack of a review may result in a denial, escalate to the appropriate Provider/VPMA. Identify and complete clinical reviews required for submission to specific payers. Validate admission orders for all new admits/observations/outpatients daily. Ensure that the patient status order documented in the chart aligns with the MCG and/or InterQual criteria, or the CMS Two- Midnight Rule, to support the appropriate status and level of care. Prioritize review of all outpatient observation and outpatient bedded cases at least every 8 hours for conversion to inpatient status or discharge opportunities. Participate in daily Observation Huddles. Conduct concurrent reviews for all payers daily for the first three days of admission, then every 2-3 days, or more frequently if criteria are waning. Submit concurrent reviews to payers to ensure authorization of all days for per diem and percentage of charge reimbursement payers. If concurrent inpatient case does not meet medical necessity review criteria during the first level review, discuss with the attending MD to obtain additional clinical information and documentation to support inpatient level of care. If the case still does not meet, send to the Physician Advisor (PA) for a second level review. Forward cases that require secondary physician review to appropriate resource (e.g., Physician Advisor). Resolve any discrepancy at the time of review. If unable to resolve, escalate to the PA and Utilization Review (UR) Leadership. Coordinate with the care team in changing patient status, as needed. � Notify the care team when patient does not meet medical necessity per InterQual or MCG guidelines or 2 MN Rule and escalate appropriately. Document and proactively communicate relevant clinical information to payers for authorizations for treatments, procedures, and Length of Stay � submit clinical information as required by payers. Ensure completion and delivery of required patient notices (by onsite team member). These include but are not limited to: HINNs, Condition Code 44, MOON, Connecticut notice of conversion, etc. Tracking and trending all appeals and communicating on a daily/regular basis with the Denials Management team. Assists with informing Managed Care contracting team with necessary contractual language to protect organization financial position specific to inpatient medical necessity requirements. Employs creative solutions with team members and leadership to prevent denials. Performs other duties as assigned.

Gallagher Bassett

Field Nurse Case Manager - Bakersfield, CA

Posted on:

May 4, 2026

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

California

At Gallagher Bassett, we're there when it matters most because helping people through challenging moments is more than just our job, it’s our purpose. Every day, we help clients navigate complexity, support recovery, and deliver outcomes that make a real difference in people’s lives. It takes empathy, precision, and a strong sense of partnership—and that’s exactly what you’ll find here. We’re a team of fast-paced fixers, empathetic experts, and outcomes drivers — people who care deeply about doing the right thing and doing it well. Whether you're managing claims, supporting clients, or improving processes, you’ll play a vital role in helping businesses and individuals move forward with confidence. Here, you’ll be supported by a culture that values teamwork, encourages curiosity, and celebrates the impact of your work. Because when you’re here, you’re part of something bigger. You’re part of a team that shows up, stands together, and leads with purpose.

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

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

Coordinating medical evaluation and treatment Meeting with physician and injured worker to collaborate on treatment plan and to discuss goals for return to work Keeping employer and referral source updated regarding medical treatment and work status Coordinating ancillary services, e.g. home health, durable medical equipment, and physical therapy. Communicates with employers to determine job requirements and to explore modified or alternate employment. Discusses and evaluates results of treatment plan with physician and injured worker using Evidence Based Guidelines to ensure effective outcome. Documents case management observations, assessment, and plan. Generates reports for referral source to communicate case status and recommendations. Generates ongoing correspondence to referral source, employer, medical providers, injured worker, and other participants involved in the injured worker's treatment plan. May participate in telephonic case conferences. Maintains a minimum caseload of 35 files, and 150 monthly billable hours, with minimum 95% quality compliance.

Molina Healthcare

Care Review Clinician (RN) - Remote in FL

Posted on:

May 4, 2026

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

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

Provides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care.

Required Qualifications: At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience. Registered Nurse (RN). License must be active and unrestricted in state of practice. Ability to prioritize and manage multiple deadlines. Excellent organizational, problem-solving and critical-thinking skills. Strong written and verbal communication skills. Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications: Certified Professional in Healthcare Management (CPHM). Recent hospital experience in an intensive care unit (ICU) or emergency room.

Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines. Analyzes clinical service requests from members or providers against evidence based clinical guidelines. Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. Conducts reviews to determine prior authorization/financial responsibility for Molina and its members. Processes requests within required timelines. Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner. Requests additional information from members or providers as needed. Makes appropriate referrals to other clinical programs. Collaborates with multidisciplinary teams to promote the Molina care model. Adheres to utilization management (UM) policies and procedures.

Abridge

Clinical Success - Nursing (Eastern Time Zone)

Posted on:

May 4, 2026

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

California

Abridge was founded in 2018 with the mission of powering deeper understanding in healthcare. Our AI-powered platform was purpose-built for medical conversations, improving clinical documentation efficiencies while enabling clinicians to focus on what matters most—their patients. Our enterprise-grade technology transforms patient-clinician conversations into structured clinical notes in real-time, with deep EMR integrations. Powered by Linked Evidence and our purpose-built, auditable AI, we are the only company that maps AI-generated summaries to ground truth, helping providers quickly trust and verify the output. As pioneers in generative AI for healthcare, we are setting the industry standards for the responsible deployment of AI across health systems. We are a growing team of practicing MDs, AI scientists, PhDs, creatives, technologists, and engineers working together to empower people and make care make more sense. We have offices located in the Mission District in San Francisco, the SoHo neighborhood of New York, and East Liberty in Pittsburgh.

As the Clinical Success Director/Manager - Nursing, you will be at the forefront of defining, launching, and growing our generative AI platform for nurses. Your work will directly contribute to improving the cognitive burden associated with clinical documentation. You will collaborate with clients, partners, product managers, designers, machine learners, and healthcare professionals to bring to life products that bridge the gap between clinical conversations and actionable data.

3+ years of experience as an RN, preferably in the inpatient setting Experience with electronic record systems (Epic is a definite plus) Passion for deeply understanding nursing workflows and improving inefficiencies Proven track record of leading successful initiatives from conception through launch Ability to build relationships with different layers of an organization, from front-line staff to executives Strong understanding of the healthcare industry, specifically clinical workflows and regulatory requirements Experience working with cross-functional teams in a fast-paced, startup environment This role requires 30% travel*** To be hired you must be based in the Eastern time zone***

Evaluate new product offerings and provide subject matter expertise to our product teams. Build and maintain relationships across customers, including onboarding users, listening to customer feedback, optimizing nursing workflows, and identifying opportunities for improved engagement and success. Design and recruit a council of trusted nurse advisors to guide product strategy and roadmap. Develop a use case-specific end-user survey and a set of success metrics to help communicate impact and value. Evangelize product capabilities and direction to prospective customers by creating sales collateral, conducting product demos, training, and more.

Fulton Montgomery Regional Chamber of Commerce

Supervisor, Utilization Management (remote)

Posted on:

May 4, 2026

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Compact / Multi-State

We are the leading voice of business in the region providing advocacy, resources and solutions for our members. Chamber of Commerce-membership organization, offering programs, events, networking-business support.

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. All applicants must have New York RN licensure*** Position Purpose Supervises Prior Authorization, Concurrent Review, and/or Retrospective Review Clinical Review team to ensure appropriate care to members. Supervises day-to-day activities of utilization management team.

Education/Experience Requires Graduate of an Accredited School Nursing or Bachelor's degree and 4+ years of related experience. Knowledge of utilization management principles preferred. License/Certification RN - Registered Nurse - State Licensure and/or Compact State Licensure required All applicants must have New York RN licensure*** Pay Range $75,300.00 - $135,400.00 per year Centene offers a comprehensive benefits package including competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.

Monitors and tracks UM resources to ensure adherence to performance, compliance, quality, and efficiency standards Collaborates with utilization management team to resolve complex care member issues Maintains knowledge of regulations, accreditation standards, and industry best practices related to utilization management Works with utilization management team and senior management to identify opportunities for process and quality improvements within utilization management Educates and provides resources for utilization management team on key initiatives and to facilitate on-going communication between utilization management team, members, and providers Monitors prior authorization, concurrent review, and/or retrospective clinical review nurses and ensures compliance with applicable guidelines, policies, and procedures Works with the senior management to develop and implement UM policies, procedures, and guidelines that ensure appropriate and effective utilization of healthcare services Evaluates utilization management team performance and provides feedback regarding performance, goals, and career milestones Provides coaching and guidance to utilization management team to ensure adherence to quality and performance standards Assists with onboarding, hiring, and training utilization management team members Leads and champions change within scope of responsibility Performs other duties as assigned Complies with all policies and standards

Fulton Montgomery Regional Chamber of Commerce

Senior RN Clinical Review Nurse (remote)

Posted on:

May 4, 2026

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

New York

We are the leading voice of business in the region providing advocacy, resources and solutions for our members. Chamber of Commerce-membership organization, offering programs, events, networking-business support.

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. ***This position supports our Fidelis state plan and requires NY RN Licensure*** Position Purpose Routinely reviews more challenging prior authorization requests to determine medical necessity of service and appropriate level of care in accordance with national standards, contractual requirements, and a member's benefit coverage. Assesses more complex authorization requests and provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care.

Education/Experience Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 4 – 6 years of related experience. Advanced clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred. Strong knowledge of Medicare and Medicaid regulations preferred. Strong knowledge of utilization management processes preferred. License/Certification LPN - Licensed Practical Nurse - State Licensure required ***This position supports our Fidelis state plan and requires NY RN Licensure***

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

Fulton Montgomery Regional Chamber of Commerce

Clinical Review Nurse (remote)

Posted on:

May 4, 2026

Job Type:

Part-Time

Role Type:

Clinical Operations

License:

RN

State License:

New York

We are the leading voice of business in the region providing advocacy, resources and solutions for our members. Chamber of Commerce-membership organization, offering programs, events, networking-business support.

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. Work Location This is a fully remote role. Candidates must hold active New York State Registered Nurse (RN) licensure and be willing to work Eastern Time (ET/EST) hours. Schedule This position follows a Monday–Friday schedule from 830 AM to 500 PM Eastern Time (ET/EST), with a one‑hour assigned lunch break. Candidates must be able to work during these hours. Position Purpose Analyzes all prior authorization requests to determine medical necessity of service and appropriate level of care in accordance with national standards, contractual requirements, and a member's benefit coverage. Provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care.

Licensure Requirement Active and unrestricted New York State Registered Nurse (RN) licensure is required for consideration. Education/Experience Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience. Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. License/Certification LPN - Licensed Practical Nurse - State Licensure required This position is aligned to support Fidelis Care. NYS RN Licensure required.

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

Mercor

Staff Registered Nurse | Upto $110/hr

Posted on:

May 4, 2026

Job Type:

Contract

Role Type:

License:

RN

State License:

New York

Mercor connects elite creative and technical talent with leading AI research labs. Headquartered in San Francisco, our investors include Benchmark, General Catalyst, Peter Thiel, Adam D'Angelo, Larry Summers, and Jack Dorsey.

Position: Registered Nurses Type: Contract Compensation: $60–$110/hour Location: Remote Duration: 3–4 weeks Commitment: 30–40 hours/week

Must-Have: 4+ years professional experience in nursing. Excellent written communication with strong grammar and spelling skills. Start Date: Immediately

Create deliverables addressing common requests in the nursing domain. Review peer-developed deliverables to enhance AI research. Diagnose and solve real issues in your domain to advance machine learning systems. Work independently and remotely on your own schedule. Contribute expertise to cutting-edge AI research.

Medasource

Post-Service Clinical Nurse

Posted on:

May 3, 2026

Job Type:

Contract

Role Type:

Clinical Operations

License:

RN

State License:

California

Medasource is a leading consulting and professional services firm supporting organizations across the healthcare ecosystem – including Life Sciences, RCM/Payers, Technology, Government and Nursing & Allied Health. Recognized for our commitment to our employees, consultants, and the communities we serve, we deliver solutions that drive meaningful progress across healthcare. With a nationwide footprint of 33 offices and 1,900+ active consultant placements across 120+ clients who are actively engaging Medasource talent, we continue to expand our impact as we advance the future of healthcare, one client at a time.

Title: Post-Service Clinical Review Nurse (RN) Location: Remote – Must Reside in California Type: Full-Time Contract We are seeking an experienced Clinical Review Nurse (RN) to support a high-impact retrospective claims review program. This role is responsible for evaluating medical claims and records to ensure services align with clinical guidelines, medical necessity, and reimbursement policies. This position is ideal for nurses with experience in post-service review, utilization management, or prior authorization, who are comfortable working in a fast-paced, production-driven environment.

Requirements: Active California RN license (required) Experience in post-service review, prior authorization, or outpatient claims review Strong knowledge of CPT, ICD-10, HCPCS coding and billing practices Ability to work independently and apply clinical judgment Experience in a fast-paced, production-based environment Nice to Have: Experience with retrospective claims review programs Background in utilization management or case management Experience reviewing a wide range of outpatient services

Perform retrospective clinical claim reviews and make initial determinations using evidence-based guidelines Evaluate claims for medical necessity, coding accuracy, and policy compliance Review outpatient services including DME, radiology, labs, and genetic testing Prepare cases for Medical Director review when needed and communicate determinations Ensure documentation meets regulatory and accreditation standards Prioritize workload to meet strict turnaround times Identify quality of care concerns and escalate appropriately Collaborate with claims, appeals, and care management teams

Gainwell Technologies

Nurse Reviewer Associate- Remote

Posted on:

May 3, 2026

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you’ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development.

We are seeking a talented individual for the Nurse Reviewer, Associate position. In this role, you will perform clinical reviews to determine whether medical record documentation supports the need for a service, based on clinical criteria, coverage policies, and utilization and practice guidelines as defined by the review methodologies specific to the contract. This involves accessing proprietary systems to audit medical records, accurately documenting findings, and providing policy and regulatory support for determinations. What You Should Expect In This Role Home-based position; you must have a work location within the continental U.S. Must provide a high-speed internet connection and a work environment free from distractions. Full-time schedule during normal business hours is required, as the role involves frequent interactions with the team and other departments. May be required to work extended hours for special business needs. May be required to travel up to 10% of the time based on business needs. This position is for pipeline purposes, and we welcome applications on an ongoing basis.

Active, unrestricted RN licensure from the United States and in your state of primary residence; an active compact multistate RN license as defined by the Nurse Licensure Compact (NLC) is also required. 3+ years of clinical experience in an inpatient hospital setting. 1+ years of experience in utilization review or claims auditing. Experience using Milliman or InterQual criteria is preferred. Demonstrated proficiency in computer skills, including Microsoft Windows, Outlook, Excel, Word, PowerPoint, internet browsers, and typing.

Review and interpret medical records, comparing them against criteria to determine the appropriateness and reasonableness of care. Apply critical thinking and decision-making skills to assess whether the documentation supports the need for the service while maintaining production goals and quality standards. Document decisions and rationale to justify review findings or no findings. Determine approvals or initiate referrals to the physician consultant, processing their decisions while ensuring denials are explained in sufficient detail and completed within contractual deadlines. Perform prior authorization, precertification, and retrospective reviews, and prepare decision letters as needed in support of the utilization review contract. Maintain current knowledge of clinical criteria guidelines and complete required CEUs to maintain RN licensure. Attend training and scheduled meetings to enhance skills and working knowledge of clinical policies, procedures, rules, and regulations. Actively cross-train to perform reviews of multiple claim types, providing a flexible workforce to meet client needs.

EPITEC

Appeals & Utilization Management Nurse

Posted on:

May 3, 2026

Job Type:

Contract

Role Type:

Utilization Review

License:

RN

State License:

Michigan

Why Choose Epitec? Founded in 1978 and headquartered in Southfield, Mich., with regional hubs in Chicago, Central Illinois, and Dallas, Epitec is dedicated to making staffing personal. Our customers include Fortune 500 companies across the United States, providing you access to high demand career opportunities. What Makes Epitec Different? Our flexible workforce model is designed with you in mind. Whether you're looking for contract-to-hire, direct hire, or other employment options, we tailor our services to fit your career goals. We are consistently ranked as a top supplier to our customers, ensuring you have access to premier job placements. How We Support You Our recruiting team focuses on understanding your unique skills and aspirations and we expertly match those to our customer job opportunities. We bring together diverse teams to solve complex problems, ensuring you are placed in roles where you can thrive. By leveraging innovative strategies and technology, we adapt to your evolving needs, providing exceptional support every step of the way. Our Commitment to Your Success Epitec’s dedication to excellence has earned us national recognition as a “Best and Brightest Company to Work For” over 20 consecutive years and MMSDC's Minority Supplier of the Year on four occasions. We are committed to your professional growth and success, making sure you have the resources and opportunities to excel in your career.

Job Title: Appeals & Utilization Management Nurse Location: United States Job Type: W2 Contract Expected Hours Per Week: 40 hours per week Schedule: Monday–Friday, 9:00 AM to 5:00 PM, Remote Pay Range: $38 per hour Position Description: We are seeking an experienced Appeals / Utilization Management Nurse to support the resolution of member and provider appeals in a managed care environment. This role partners closely with Utilization Management, Case Management, and Customer Service teams to ensure appeals are processed in compliance with regulatory, accreditation, and organizational standards while delivering a high level of customer service.

Active RN or LPN/LVN license in good standing. Bachelor’s degree or 4+ years of healthcare experience. 5+ years of utilization management, appeals, claims, and mainframe system experience. Experience in healthcare operations and managed care environments. Strong knowledge of NCQA and URAC accreditation standards. Knowledge of state and federal healthcare and health operations regulations. Strong organizational skills with the ability to manage multiple priorities and deadlines. Excellent verbal and written communication skills with internal teams, members, and providers. Proficiency in Microsoft Word, Excel, and Access.

Collaborate with Utilization Management (UM), Case Management (CM), and Customer Service teams to ensure appeals processes meet established guidelines. Facilitate end-to-end resolution of member and provider appeals in compliance with state and federal regulations. Manage individual appeal inventory using established workflows while meeting required turnaround times. Ensure compliance with NCQA, URAC, DOI, and other regulatory and accreditation standards. Participate in NCQA and URAC audits, DOI audits, correspondence revisions, and departmental process improvement initiatives. Provide data and reporting required for audits, regulatory reviews, and internal stakeholders. Facilitate member or member-designee access to appeal files in accordance with federal guidelines. Work directly with members and providers to resolve appeals while maintaining superior customer service standards. Serve on departmental workgroups and support cross-functional teams. Maintain strong working relationships across organizational lines to achieve operational goals. Communicate professionally with leadership, peers, members, and providers. Maintain strict compliance with HIPAA, Corporate Integrity, Diversity Principles, and all applicable corporate policies. Preserve confidentiality of protected health information and company business. Communicate workflow updates, trends, and development needs to management; complete special projects as assigned.

Trinity Health

Nurse Auditor -RIO (Remote)

Posted on:

May 3, 2026

Job Type:

Full-Time

Role Type:

License:

RN

State License:

Michigan

Trinity Health is one of the largest not-for-profit, Catholic health care systems in the nation. It is a family of 123,000 colleagues and nearly 27,000 physicians and clinicians caring for diverse communities across 26 states. Nationally recognized for care and experience, the Trinity Health system includes 88 hospitals, 135 continuing care locations, the second largest PACE program in the country, 136 urgent care locations and many other health and well-being services. Based in Livonia, Michigan, its annual operating revenue is $21.5 billion with $1.4 billion returned to its communities in the form of charity care and other community benefit programs.

Employment Type: Full time Shift: Day Shift Description Purpose Work Remote Position (Pay Range: $31.8795-$47.8193) The Nursing Support (NS) colleague (uncertified, certified, unlicensed, or licensed) provides safe, quality health care services & / or assistance to patients under the supervision & direction of a registered nurse or other designated health care professional in accordance with level of experience, education, policies & procedures. Note: “patients” refers to patients, clients, residents, participants, customers, members

High school diploma or GED; Completion of an accredited program associated with license. License in the applicable state(s) of engagement. Valid driver’s license where required by assignment. Additional Qualifications (nice to have) Registered Nurse, preferred Training or experience according to assignment area

Our Trinity Health Culture: Knows, understands, incorporates & demonstrates our Trinity Health Mission, Values, Vision, Actions & Promise in behaviors, practices & decisions. Work Focus: Performs clinical care activities (direct or indirect) for patients within the “scope of practice” laws & training received; Cares for patients safely by assisting in clinical care services or engaging in administrative activities (e.g., maintaining records or supplies) that enhance or improve coordination, preparation & flow of the care experience. Process Focus: Knows, understands & incorporates basic or essential area of practice (document, coordinate, communicate) & training standards. Communication: Uses clear, effective, respectful language & communication methods / means. Environment: Performs work in a safe, engaging, & supportive manner; Influences the responsible use of resources; Accountable for continuous self-development & supporting the growth of others. Maintains a working knowledge of applicable federal, state & local laws/regulations, Trinity Health Integrity & Compliance Program & Code of Conduct, as well as other policies, procedures & guidelines in order to ensure adherence in a manner that reflects honest, ethical & professional behavior & safe work practices. Functional Role (not inclusive of titles or advancement career progression) NS IV – licensed: Licensed role (direct or indirect healthcare); Provides nursing interventions or clinical knowledge application in decision-making; Participates in the planning, implementation & / or evaluation of & solutions for care; Performs delegated focused / holistic care autonomously according to care plan; May administer medication & carry out the therapeutic treatment within scope of license (state & TH policy); Performs direct & essential care or supportive activities as part of an interdisciplinary team with a deeper understanding, including theoretical knowledge; Demonstrates a level of independence to perform activities with general oversight, through personal contributions, teamwork & initiatives to safely improve outcomes; Advocates for patients & informs / counsels patients & families about illness & care details; May serve as a knowledge resource, role model & mentor or lead / coordinate / supervise direct & essential care activities or role-based service responsibilities of unlicensed / licensed / certified healthcare professionals within licensed scope of practice.

DataAnnotation

Clinical Appeals Nurse

Posted on:

May 3, 2026

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

None Required

State License:

Compact / Multi-State

Welcome to DataAnnotation! We pay smart folks to train AI. We offer a remote, flexible work model- you choose your own hours and get to work when you want, whenever you want. Apply now through our open Job Listings.

We are looking for a Clinical Appeals Nurse to join our team to train AI models. You will measure the progress of these AI chatbots, evaluate their logic, and solve problems to improve the quality of each model. In this role, you will need to be an expert in healthcare. We are interested in a wide range of expertise, so relevant backgrounds include Clinical Documentation & HIM, Medication Management (PharmD), Laboratory Medicine and Pathology Services (MLS, MD), Quality Improvement & Patient Safety, Regulatory Compliance, Accreditation & Medical Staff, Care Coordination & Case Management, Population Health & Value-Based Care, and Managed Care & Utilization Management. Benefits Full-time or part-time remote position Choose which projects you want to work on Flexible schedule Projects are paid hourly starting at $50+ per hour Bonuses available for high-quality and high-volume work

Fluency in English (native or bilingual level) A current or in-progress medical or healthcare-related degree

Provide AI chatbots with diverse and complex healthcare-related problems Evaluate AI outputs for logic, accuracy, and performance Ensure the medical accuracy and overall quality of model responses

Uniphar | Medical

Medical Information Specialist- RN

Posted on:

May 2, 2026

Job Type:

Full-Time

Role Type:

Informatics

License:

RN

State License:

North Carolina

With a workforce of more than 3500 employees spread across Ireland, United Kingdom, Mainland Europe, MENA, and the USA, Uniphar is a trusted global partner to pharma and MedTech manufacturers, working to improve patient access to medicines around the world. Uniphar provides outsourced and specialized services to its clients, leveraging strong relationships with 200+ of the world’s best-known pharmaco-medical manufacturers across multiple geographies, enabled by our cutting-edge digital technology and our highly expert teams. Uniphar is organized into three key divisions: Supply Chain & Retail, Global Sourcing, and Pharma. This position will support human resources across the US division. Visit our website to learn more: Uniphar.US

Medical Information Specialists are highly trained on the regulatory aspects of communicating with patients, caregivers, and health care professionals, including the handling of AEs, Medical Device Reports, and PQCs. We are looking for an experienced Medical Information Specialist RN in any state with an unrestricted license. The right candidate will have clinical experience, call center experience and have a current or past job title of Medical Information Specialist and enjoy working remotely. As a Medical Information Specialist, you are responsible for providing specific medical information and product support to healthcare professionals and patients. You will offer support services which require substantial knowledge, judgment and nursing skills based upon principles of psychological, biological, physical and social sciences. You will serve as a clinical and educational resource to other departments and health care practitioners. You will document adverse events and product complaints in accordance with FDA regulations and other regulatory agency requirements. You will be working with products with specific indications, complex mechanisms of action and specific administration techniques which will need a strong comprehension of pharmacology. Candidates must have experience as a Medical Information Specialist and answer all questions to be considered for this position.

Education/Experience: Previous experience as a Medical Information Specialist is required. One year clinical experience preferred to ensure proficiency with clinical assessment practices. Previous experience in a call center preferred. Must be able to use dual monitors and technology autonomously. Experience with MIQ, SharePoint, SalesForce and Genesys phone system. Certificates and Licenses: Valid and unrestricted RN license (any state) in good standing required. Additional certifications as may be required by scope of program and client contractual requirements. Knowledge, Skills and Other Abilities: Accomplish goals without creating distractions or disruptions to other employees Must be at work, on time and ready to work at scheduled start times with limited schedule deviations Remain professional even in times of stress or frustration - this is a customer service call center role. Must have strong customer service skills! Strive for thoroughness and accuracy when completing tasks Motivated to perform at your best and assist the team with meeting both internal and external goals Computer proficient, with demonstrated knowledge of Internet navigation and research Positive work attitude Well-established time management skills Professional level oral and written communication skills Ability to provide courteous customer service in a consistently efficient manner Ability to work well with various personalities and within a team Participate in continuous quality improvement activities Experience as a Medical Information Specialist Physical Demands: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to walk, sit and use hands. The employee is occasionally required to stand.

Maintains a working knowledge of program guidelines, FAQ’s, products and therapeutic areas related to assigned programs. Keeps current with existing treatment trends, treatment standards and updated indications related to assigned programs and products. Follows standard operating procedures for all support-related activities. It is essential to maintain compliance with HIPAA at all times when handling protected health information. Maintains company, employee, and customer confidentiality, as well as compliance with all HIPAA regulations. Resolves product issues and provides appropriate scripted responses. Identifies information requests that are within the scope of the program and provides callers with the necessary information. Provides appropriate additional information and/or resources to callers upon request. Recognizes and handles adverse event reports as outlined in the program standard operating procedures. Recognizes and handle product complaint reports as outlined in the program standard operating procedures. Documents each call properly, using the call record form in the program software database. Maintains the knowledge of drug side effects and interactions.

Medical Mutual

Prior Authorization Nurse Reviewer II

Posted on:

May 2, 2026

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Ohio

Founded in 1934, Medical Mutual is the oldest and one of the largest health insurance companies based in Ohio. We provide peace of mind to more than 1.2 million members through our high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement, and individual plans.

Medical Mutual employees must submit their applications through MySource. This is a remote-based role, and we are currently seeking candidates located in Ohio. Job Summary: Under limited supervision, promotes effective use of, and provides appropriate resources and assistance to members managing their health care across the continuum of care. Applies evidence-based criteria and benefit interpretations to make coverage decisions. Collaborates with providers, members, and various internal departments to effectively direct care to quality cost-effective network providers at the appropriate level of care.

Education and Experience: Graduate of a registered nursing program approved by the Ohio State Nursing Board. Bachelor’s degree preferred. 3 years of experience as a Registered Nurse with a combination of clinical and utilization/case management experience, preferably in the health insurance industry. Acute care Medical/Surgical/Critical Care and ambulatory care experience preferred. Professional Certification(s) Registered Nurse with current State of Ohio or multistate unrestricted license. Technical Skills And Knowledge Strong knowledge of health insurance benefits and network plan designs. Knowledge of, and the ability to apply fundamental concepts related to HIPAA compliance and related regulations. Ability to apply knowledge of health plans and industry trends to achieve positive outcomes. Knowledge of clinical practices, members’ specific health plan benefits, and efficient care delivery processes. Intermediate Microsoft Office skills and proficiency navigating windows and web based systems.

Conducts pre-certification of basic to complex outpatient services, surgical and diagnostic procedures, and out of network services to ensure compliance with medical policy, member eligibility, benefits, and contracts. Evaluates clinical information using established national decision support criteria, company policies, and individual patient considerations to ensure the provisions of safe, timely, and appropriately covered healthcare services. Promotes effective resource management by directing member care to accessible cost- effective network providers and coordinates services at appropriate level of care. Coordinates with other Pharmacy and Care Management departments to facilitate the timely provision of covered health care services. Participates in interdepartmental coordination and communication to ensure delivery of consistent and quality health care services. Assists Claims and/or Customer Care Departments as applicable. Keeps up to date on utilization management regulations, policies, and practices, including applicable coding. If assigned to Preceptor/Trainer task: Orients, trains, and provides guidance to more junior or less experienced staff. Supports implementation of new procedures, processes, or clinical systems. Performs other duties as assigned.

Brighton Health Plan Solutions

Clinical Appeals Nurse

Posted on:

May 2, 2026

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

North Carolina

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 of 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™. Company Mission Transform the health plan experience – how health care is accessed and delivered – by bringing outstanding products and services to our partners. Company Vision Redefine health care quality and value by aligning the incentives of our partners in powerful and unique ways.

Clinical Appeal Nurse Brighton Health Plan Solutions REMOTE – 100% FULL TIME About the Role: BHPS provides Utilization Management (UM) services to its clients, ensuring high-quality, clinically sound decision-making. The Clinical Appeal and Grievance Nurse is responsible for conducting daily clinical and benefit reviews in a quality-focused, production-driven environment. The position reports directly to the Clinical Appeal Manager. Note: This job description is not intended to be an exhaustive list of duties. Responsibilities may evolve or change at any time, with or without notice. This is a remote role.

Active and unrestricted RN or LPN license; must maintain licensure throughout employment Minimum of 5 years’ experience in Clinical Appeals and Grievances within a managed care or payor setting Minimum of 5 years’ clinical experience across various care settings (Inpatient Acute, SNF/LTAC/ARU, Outpatient, DME, Complex Care) Strong understanding of UM/Appeals regulatory guidelines including URAC, NCQA, and ERISA Proficiency in Clinical Appeals, Utilization Review, and Grievance processes including benefit interpretation, contract language, and medical policy application Excellent written and verbal communication skills Proficient in Microsoft Office Suite (Outlook, Word, Excel, PowerPoint). Ability to work independently with exceptional accountability Adaptability to a fast-paced and evolving environment. Preferred experience in a Third-Party Administrator (TPA) setting Preferred coding certification

Independently review and analyze pre and post service medical necessity and benefit appeals, post-service clinical claim disputes, and quality of care grievances. Utilize member-specific benefit information, nationally recognized clinical criteria, and internal policies and procedures across multiple care disciplines, including, but not limited to, Inpatient Acute, Post Acute, Outpatient, Specialty Pharmaceutical, and Durable Medical Equipment Prepare and present cases to internal Medical Directors and external Independent Review Organizations (IROs) for timely and accurate decisions Ensure strict adherence to Appeals and Utilization Management (UM) processes and regulatory and accreditation requirements from intake through case closure. Prioritize caseload and other assigned duties to meet clinical accuracy expectations and turnaround time requirements Accurately enter case details in medical management platform Collaborate with team members and other departments to achieve exceptional results and drive continuous improvement

CenterWell Senior Primary Care

Clinical Competency & Quality Nurse

Posted on:

May 2, 2026

Job Type:

Full-Time

Role Type:

Primary Care

License:

RN

State License:

Kentucky

About CenterWell Senior Primary Care: CenterWell Senior Primary Care provides proactive, preventive care to seniors, including wellness visits, physical exams, chronic condition management, screenings, minor injury treatment and more. Our unique care model focuses on personalized experiences, taking time to listen, learn and address the factors that impact patient well-being. Our integrated care teams, which include physicians, nurses, behavioral health specialists and more, spend up to 50 percent more time with patients, providing compassionate, personalized care that brings better health outcomes. We go beyond physical health by also addressing other factors that can impact a patient’s well-being.

Clinical Competency, Remediation, Onboarding and Talent Management The Care Integration Clinical Competency & Quality Nurse is a Center of Excellence (CoE) position responsible for ensuring the clinical quality and provider & patient engagement effectiveness for the Clinical Care RN role through nursing chart and recorded visit audits, competency assessments, remediation oversight and talent management. This role bridges clinical excellence with operational leadership, conducting structured audits, and driving remediation for clinical competency gaps (in partnership with Education team support). You will report to the Director of Physician Strategy. Must reside in designated geographic area, in reasonable commutable distance to CenterWell/Conviva market locations; (market-dependent) quarterly or as-needed travel within market. Role Scope Clinical Competency & Oversight: Conduct and oversee clinical competency audits for nursing staff (Clinical Care RN); support remediation in partnership with Center of Excellence leaders and Education team Clinical Competency & Oversight tooling: Develop audit tools, processes, and remediation approaches in partnership with the Medical Director, Care Integration Team & High Risk Patient Management Program Onboarding & Talent Management: Initial interview and assessment of Clinical Care RN candidates; maintenance of onboarding design and process adherence (in partnership with Center Administrators)

Required Qualifications: Bachelor's Degree in Nursing (BSN) Active, unrestricted RN license 5+ years of clinical nursing experience with experience in transitions of care or population health management Strong clinical judgment and ability to apply evidence-based practices Proficiency with EMR and care management platforms (any system) Preferred Qualifications: Master's degree in Nursing, Business Administration, or Healthcare Management Knowledge of Medicare Advantage Stars, HEDIS, CAHPS, and CMS quality requirements Experience in clinical competency assessment, audit development, or compliance oversight Proficiency with electronic health records (Athena EMR), data analytics platforms (DataHub), and Microsoft Office Suite Familiarity with SalesForce, Genesys, and operational platform tools Experience recruiting, interviewing, and onboarding for clinical roles Strong communication, presentation, and stakeholder engagement skills Commitment to health equity, inclusivity, and patient-centered care Basic Life Support (BLS) certification Working Conditions Workstyle: Hybrid Location: Must reside in designated geographic area, in reasonable commutable distance to market clinics; (market-dependent) quarterly or as-needed travel within market Hours: Monday–Friday, 8:00 AM–5:00 PM; additional time may be required for program improvement projects or strategic initiatives To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. Satellite, cellular and microwave connection can be used only if approved by leadership. Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense. Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information. Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Clinical Competency & Auditing: Develop and maintain clinical competency audit tools and processes aligned with organizational standards and evidence-based best practices Conduct clinical competency audits of RN documentation, clinical decision-making, and patient care practices; perform targeted reviews of charts and recorded successful patient contacts Conducts regular audits on each nurse at prescribed cadence Develop remediation approaches for nurses identified with clinical competency gaps; oversee and monitor remediation execution in collaboration with market operators and Education team. Audit rounds/huddle quality; provide coaching to nurses on case presentation skills. Nursing Staff Development & Recruitment: Support onboarding processes and tools for RNs, in partnership with Stars CoE Program Leads; coordinate with Education team for onboarding activities Develop standard job descriptions and competency frameworks for nursing roles Create and maintain interview guides and recruitment processes; establish guardrails for opening requests (capacity, geography, leader approval) Conduct first-round interviews for Clinical Care RN and project manage talent acquisition process

CareHarmony

Remote - Care Coordinator - LPN - LVN - $21/hr - Day Shift

Posted on:

May 2, 2026

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 Compact/Multi-State license (LPN) (LVN) Technical aptitude – Microsoft Office Suite Excellent written and verbal communication skills Plusses: Epic Experience Bilingual Additional Single State licensures 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.

SSM Health

Mgr-RN, Clinical Documentation Improvement

Posted on:

May 2, 2026

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Compact / Multi-State

SSM Health is a Catholic, not-for-profit, fully integrated health system dedicated to advancing innovative, sustainable, and compassionate care for patients and communities throughout the Midwest and beyond. The organization’s 40,000 team members and 13,900 providers are committed to fulfilling SSM Health’s Mission: “Through our exceptional health care services, we reveal the healing presence of God.” With care delivery sites in Illinois, Missouri, Oklahoma and Wisconsin, SSM Health includes hospitals, physician offices, outpatient and virtual care services, comprehensive home care and hospice services, a fully transparent pharmacy benefit company, a health insurance company and an accountable care organization. It is one of the largest employers in every community it serves. For more information, visit ssmhealth.com

Oversees and manages the daily operations and activities of the regional Clinical Documentation Improvement (CDI) program. Promotes consistent and standardized operations and documentation across the network. Builds and maintains productive inter/intra departmental and vendor work relationships to optimize operations.

EDUCATION: Graduate of accredited school of nursing or education equivalency for licensing EXPERIENCE: Two years' acute hospital experience or surgical area as a clinical nurse Three years' clinical documentation specialist Two years' demonstrated progressive leadership experience PHYSICAL REQUIREMENTS: Frequent lifting/carrying and pushing/pulling objects weighing 0-25 lbs. Frequent sitting, standing, walking, reaching and repetitive foot/leg and hand/arm movements. Frequent use of vision and depth perception for distances near (20 inches or less) and far (20 feet or more) and to identify and distinguish colors. Frequent use of hearing and speech to share information through oral communication. Ability to hear alarms, malfunctioning machinery, etc. Frequent keyboard use/data entry. Occasional bending, stooping, kneeling, squatting, twisting and gripping. Occasional lifting/carrying and pushing/pulling objects weighing 25-50 lbs. Rare climbing. REQUIRED PROFESSIONAL LICENSE AND/OR CERTIFICATIONS State of Work Location: Illinois Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR) State of Work Location: Missouri Registered Nurse (RN) Issued by Compact State Or Registered Nurse (RN) - Missouri Division of Professional Registration State of Work Location: Oklahoma Registered Nurse (RN) Issued by Compact State Or Registered Nurse (RN) - Oklahoma Board of Nursing (OBN) State of Work Location: Wisconsin Registered Nurse (RN) Issued by Compact State Or Registered Nurse (RN) - Wisconsin Department of Safety and Professional Services

Manages the daily operations and resources of assigned Clinical Documentation Improvement (CDI) team, including the development and monitoring of strategic operating goals, objectives, and data analysis; and report operational performance, justification, and/or corrective action. Provides on-going support of CDI with extensive collaboration with physicians, nursing, coding, quality, and leadership. Facilitates improvements to clinical documentation through chart review and educational training sessions (with CDI Educator), which could be performed onsite, with physicians and/or other clinical professionals. Initiates corrective actions to resolve any problem areas identified between CDI and any other areas of the organization. Collaborates with CDI educator for regional education. Provides ongoing clinical documentation management program education for new staff, including new clinical documentation registered nurses, physicians, nurses, and allied health professionals. Participates in the direction and education of all phases of the clinical documentation process. Supports and implements technologies designed to improve and/or ensure the accurate depiction of clinical services, patient’s severity of illness, and risk of mortality. Conducts audits on CDI reviews against quality, coding, and mortality. Provides feedback to staff and CDI educator and director. Reports monthly CDI metrics regarding KPIs and staff productivity. Strengthens technical coding practices and clinician documentation by reviewing patient records with flagged complications to ensure coding accurately reflects the patient’s clinical course and complexity to validate accurate risk-adjustment for administrative metrics used in government incentive/penalty programs. Collaborates with interdisciplinary teams including physicians, nurse practitioners, physicians assistants, and the department managers for revenue integrity, coding and data quality, case management and health information management. Demonstrate leadership and management skills to promote effective and efficient review of physician documentation and the medical record. Communicates with assigned regional/ministry physician leaders. Participates in monthly medical management meetings to report CDI metrics and act as subject matter expert for inquiries. Recruits, engages, develops, leads, and manages assigned staff. ​ Performs other duties as assigned.

SSM Health

RN-Clinical Documentation Specialist Lead

Posted on:

May 2, 2026

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

SSM Health is a Catholic, not-for-profit, fully integrated health system dedicated to advancing innovative, sustainable, and compassionate care for patients and communities throughout the Midwest and beyond. The organization’s 40,000 team members and 13,900 providers are committed to fulfilling SSM Health’s Mission: “Through our exceptional health care services, we reveal the healing presence of God.” With care delivery sites in Illinois, Missouri, Oklahoma and Wisconsin, SSM Health includes hospitals, physician offices, outpatient and virtual care services, comprehensive home care and hospice services, a fully transparent pharmacy benefit company, a health insurance company and an accountable care organization. It is one of the largest employers in every community it serves. For more information, visit ssmhealth.com

We are looking for a candidate with tenured CDS experience and excellent Clinical experience. This is a fully remote role for candidates living in our four state footprint. Eligible states are MO, IL, WI and OK. Schedule - M-F 8 Hour Shifts between 0500 and 1800. Job Summary: Performs duties of a clinical documentation specialist and serves as a mentor and resource to the clinical documentation improvement team. Assists team managers with the query escalation report, mismatch escalations, reconciliation, query impact, and precepting new hires.

EDUCATION: Graduate of accredited school of nursing or education equivalency for licensing EXPERIENCE: Two years' acute care experience and three years' clinical documentation specialist experience PHYSICAL REQUIREMENTS: Frequent lifting/carrying and pushing/pulling objects weighing 0-25 lbs. Frequent sitting, standing, walking, reaching and repetitive foot/leg and hand/arm movements. Frequent use of vision and depth perception for distances near (20 inches or less) and far (20 feet or more) and to identify and distinguish colors. Frequent use of hearing and speech to share information through oral communication. Ability to hear alarms, malfunctioning machinery, etc. Frequent keyboard use/data entry. Occasional bending, stooping, kneeling, squatting, twisting and gripping. Occasional lifting/carrying and pushing/pulling objects weighing 25-50 lbs. Rare climbing. REQUIRED PROFESSIONAL LICENSE AND/OR CERTIFICATIONS State of Work Location: Illinois Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR) State of Work Location: Missouri Registered Nurse (RN) Issued by Compact State Or Registered Nurse (RN) - Missouri Division of Professional Registration State of Work Location: Oklahoma Registered Nurse (RN) Issued by Compact State Or Registered Nurse (RN) - Oklahoma Board of Nursing (OBN) State of Work Location: Wisconsin Registered Nurse (RN) Issued by Compact State Or Registered Nurse (RN) - Wisconsin Department of Safety and Professional Services

Completes initial reviews of patient records and evaluates documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate Diagnosis Review Group (DRG) assignment, risk of mortality (ROM), and severity of illness (SOI). Maintains appropriate productivity level.  Conducts follow-up reviews of patients to support and assign a working or final DRG assignment upon patient discharge, as necessary. Reconciles reviews and ensures correct query impact. Generates and distributes query escalation reports to physician advisors. Queries physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record when needed. Identifies issues with reporting of diagnostic testing proactively. Assists with provider education as needed. Educates physicians and key healthcare providers regarding clinical documentation improvement (CDI) and the need for accurate and complete documentation in the health record. Attends department meetings to review documentation related issues. Trains and mentors new CDI staff on CDI strategy, workflows, and software. Partners with the coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine a working and final DRG, SOI, and/or ROM. ​Reviews and clarifies clinical issues in the health record with the coding professionals that would support an accurate DRG assignment, SOI, and/or ROM. Troubleshoots documentation or communication problems proactively and appropriately escalates. Serves as first line of escalation in the mismatch process. Acts as a resource and first point of contact for front-line clinical documentation staff for workflow or case reconciliation matters. Assists in the mortality review and risk adjustment process utilizing third-party models. Demonstrates an understanding of complications, comorbidities, SOI, ROM, case mix, and the impact of procedures on the billed record. Imparts knowledge to providers and other members of the healthcare team. Maintains a level of expertise by attending continuing education programs. Applies the existing body of evidence-based practice and scientific knowledge in health care to nursing practice, ensuring that nursing care is delivered based on patient’s age-specific needs and clinical needs as described in the department's Scope of Service. As an SSM Health nurse, I will demonstrate the professional nursing standards defined in the professional practice model. Uses the ANA Code of Ethics for Nurses to guide his/her response to the current and evolving health and nursing needs of our patients and our patient populations. Works in a constant state of alertness and safe manner. ​ Performs other duties as assigned.

Maximus

Specialist - Nursing, RN

Posted on:

May 2, 2026

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Virginia

We’re moving people forward by providing transformative technology services, digitally enabled customer experiences, and clinical health services that change lives. Our employees share an authentic desire to make vital services available to the public and support the missions of our customers.

Maximus is currently hiring for a Specialist - Nursing, RN to join our QIC Part A West team. This is a remote opportunity. The Specialist is responsible for completing clinical reviews for Medicare Part A West. These will be second-level appeals that require review of medical documents to determine, using Medicare coverage criteria, how a service should be paid. This is a production-based position.

Bachelor's degree required Active RN license required. Minimum 2 years clinical experience required with RN license. Continuing education courses as required by state to maintain RN license. Ability to redirect work focus, as business need or workload volumes dictate. Ability to work independently in a remote setting. Critical thinking and analytical skills. Excellent written and oral communication skills. Strong organizational skills and attention to detail. Strong computer skills and knowledge of MS Office Suite, Chrome, Microsoft Edge. Ability to work an 8-hour schedule between the hours of 7:30am - 6:00pm EST Monday - Friday required. Preferred Skills & Experience: Clinical experience in an acute or long-term care setting. Certification in ICD-10 billing and coding. Knowledge of Medicare Part A and/or Part B of A. Clinical training, education, or certification. Experience in production-based environment. Please note: For this position Maximus will provide equipment to use. Home Office Requirements: Internet speed of 25mbps or higher required / 50 Mpbs for shared internet connectivity (you can test this by going to www.speedtest.net) Minimum 5mpbs upload speed Connectivity to the internet via Category 5 or 6 ethernet patch cable to the home router Private and secure work area and adequate power source Must currently and permanently reside in the Continental US Must have a smartphone which will be required to log into Maximus systems

Responsible for reviewing favorable and partially favorable determinations in accordance with applicable regulations. Render medical necessity determinations for cases assigned. Resolve all other technical issues within reconsideration assigned. Review cases or sites assigned to determine and summarize facts and assess any issues identified. Perform other special projects not related to a specific case such as general legal research, general medical research, drafting proposal sections, or acting as a liaison for a specific project, when necessary. Perform other duties as assigned by management. Reports directly to QIC Adjudication Manager. Perform technical appeal review under the direction of the professional clinical reviewers and the QIC Adjudication Manager. Review ISO compliant work instruction, process documents, and medical review templates as directed by QIC Adjudication Manager. Assist other projects or departments as directed by QIC Adjudication Manager. Understand workflow process and offer suggestions for improvement. Perform other duties as assigned by QIC Adjudication Manager. Must meet or exceed daily productivity requirements. Must maintain a QA score of 95 – 100%.

Tutera Senior Living and Health Care

Virtual Trainer Orientation Specialist - RN

Posted on:

May 2, 2026

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

Tutera Senior Living & Health Care was founded 40 years ago and currently operates with strong standards, such as compassionate patient care and loyalty to family. Tutera delivers a special brand of hospitality where we truly get to know our residents’ preferences and needs, and then we deliver the care they deserve. Our company principles have not wavered, and today, our employees still proudly embody Tutera’s uncompromising standards. We value our residents’ individual journeys and changing needs, and in response to interacting with residents, we created YOUNITE. It is through this engaging and unifying system that a positive and comprehensive care experience takes place for residents, resulting in overall customer satisfaction. Tutera Senior Living and Health Care's mission is INSPIRED BY YOU. Our vision is to live the YOUNITE philosophy in every decision, every day. YOUNITE is about getting to know our residents and team members on a personal level – using their unique preferences and personalities to guide our actions. Our four core values are INTEGRITY (Do the right thing every time), RESPECT(Treat others as you want to be treated), HOSPITALITY (Help residents, visitors, and team members feel at home), and POSITIVITY (Have a “can-do” attitude).

Virtual Orientation Trainer Specialist -RN Tutera Senior Living & Health Care Are you a Virtual Orientation Specialist - RN seeking an exciting new career opportunity? Look no further! Tutera Senior Living & Health Care is searching for a Virtual Orientation Trainer Specialist to join the Corporate Team! This position is a remote position that may require travel to our health care facilities throughout the nation. Travel requirements could be up to 25%. Overnight travel may be required. What Will You Do in This Role? Tutera Senior Living & Health Care is seeking a Virtual Orientation Trainer Specialist -RN to help design and deliver the educational programs to health professionals and other departmental staff. This role ensures that medical teams are proficient in using Electronic Health Record (EHR Systems) like Point Click Care are up to date on the presentations for orientation processes and compliance standards

Associate's degree in healthcare administration, Nursing or a related field of study. Must have intermediate to advanced computer skills, including experience working with an EMR or EHR. Knowledge using Outlooks, Power Point, Microsoft Word and other Microsoft based systems. Must have experience with Zoom, Microsoft Teams, and Learning Management Systems like Relias Must be able to read, write, speak, and understand the English language. Must have outstanding verbal and written communication skills. Possess the ability to make independent decisions when circumstances warrant such action. Must have patience, tact, cheerful disposition and enthusiasm. Must possess educational skills to provide an optimal learning experience. Must be organized and demonstrate time management skills. High Engagement: Ability to maintain energy and inclusivity in a remote setting to keep learners engaged. Detail-Oriented: Precision in updating training documents for compliance as directed

Lead interactive, Virtual Instructor Led Training (VILT) sessions for clinical and operational teams Utilize current Tutera Orientation Program/Learning Modules and Platforms to develop effective and orientation for all Tutera employees Have a clear understanding of Relias, Point Click Care and other platforms to improve outcomes and ensure training success Coordinate and deliver new hire orientation for clinical and admirative staff through remote channels Ensure all training aligns with HIPAA regulations and organizational quality standards Assess training effectiveness through learner feedback

Marshfield Clinic Health System

RN Call Center - Remote - Full Time Nights

Posted on:

May 2, 2026

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

Compact / Multi-State

Marshfield Clinic has served rural communities for more than 100 years. Today, the Health System has clinical locations and hospitals spanning more than 45,000 square miles of northern, central and western Wisconsin and the Upper Peninsula of Michigan. As an integrated Health System, we bring together all the pieces of the health care puzzle to provide excellent, comprehensive care to rural communities.

Department Details: Every third weekend PM shift (3 PM-11 PM). Night coverage (2200-0700) minimally 3 nights a week on rotating weeks. Every third Holiday rotation. 100% remote after 3 days of on site training in Marshfield.

Bachelor’s Degree in nursing preferred. Graduate from an accredited nursing program preferred, including, but not limited to, American Association of Colleges of Nursing (AACN), Accreditation Commission for Education in Nursing (ACEN), and National League for Nursing Commission for Nursing Education Accreditation (NLN CNEA). Currently holds an unencumbered RN license with the State Board of Nursing where the practice of nursing is occurring and/or possess multistate licensure if in a Nurse Licensure Compact (NLC) state. Nurses performing nursing practice over the telephone require licensure in the states where the patients being served reside. Any additional state licensure requirements must be obtained within first 30 days of employment. Needs and maintains Basic Life Support (BLS), Advanced Cardiac Life Support (ACLS), and Pediatric Advanced Life Support (PALS). Obtains and subsequently maintains additional required department specific competencies and certifications.

Responsible for providing telehealth services involving all ages of patients. This includes telephone triage; health information and education; and physician and service referral and other specialty access lines using established protocols, approved references, and specific medical resources. Demonstrates knowledge in decision-making for a diverse client population with a wide range of problems and acuity. Performs effectively in answering caller inquiries and crisis intervention following established protocols with appropriate communication and documentation. Performs ongoing, systematic assessment and data collection, focusing on physiological, psychological and cognitive status. Provides educational and resource referrals based on patient needs. Instructs patients in an articulate and professional manner based on expressed needs and available resources. Demonstrates awareness of legal issues in all aspects of telephone triage. Documents health information accurately.

Molina Healthcare

Behavioral Health- Care Review Clinician (RN- Utilization Manager- NV based)

Posted on:

May 2, 2026

Job Type:

Full-Time

Role Type:

Behavioral Health

License:

RN

State License:

Nevada

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

Provides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care.

At least 2 years MCG experience Behavioral Health Concurrent Review and Prior Authorization experience in an MCO setting Multitasking in a fast-paced environment Ability to operate Microsoft Office Ability to navigate an online SharePoint Fast learner Remote work experience Must obtain NV RN Licensure within 90 days of hire. ASAM certification upon hire

Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines. Analyzes clinical service requests from members or providers against evidence based clinical guidelines. Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. Conducts reviews to determine prior authorization/financial responsibility for Molina and its members. Processes requests within required timelines. Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner. Requests additional information from members or providers as needed. Makes appropriate referrals to other clinical programs. Collaborates with multidisciplinary teams to promote the Molina care model. Adheres to utilization management (UM) policies and procedures.

Molina Healthcare

Clinical Design Specialist ( RN- Pediatrics)

Posted on:

May 2, 2026

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

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

Provides subject matter expertise and leadership in clinical design and population health initiatives, supporting execution/operationalization and implementation, providing evaluation and support for post-implementation process, and ensuring compliance with regulatory and internal standards, practices, policies, and contractual commitments. Contributes to the overarching strategy in providing quality and cost-effective member care to single and multiple member population with a focus on pediatric population health and wellbeing.

Required Qualifications: At least 5 years of health care experience, including experience in clinical operations, and at least 3 or more years in one or more of the following areas: utilization management, care management, care transitions, behavioral health, or equivalent combination of relevant education and experience. Registered Nurse (RN), Licensed Vocational Nurse (LVN), Licensed Practical Nurse (LPN), Advanced Practice Social Worker (APSW), Licensed Clinicians to include backgrounds such as MSW, LCSWs etc. Clinical licensure and/or certification required ONLY if required by state contract, regulation, business operating model, or state board licensing mandates. If licensed, license must be active and unrestricted in state of practice. Strong analytical and problem-solving skills. Strong organizational and time-management skills. Ability to work in a cross-functional, professional environment. Experience working within applicable state, federal, and third-party regulations. Strong verbal and written communication skills. Microsoft Office program proficiency, and ability to navigate online portals and databases. Preferred Qualifications: Certified Case Manager (CCM), Certified Professional in Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ), or other health care or management certification. Experience creating executive summaries and decks as well as comfort presenting to varying stakeholders and audiences, including executive leadership Clinical nursing experience Leadership and change management experience. Medicaid/Medicare/Duals population experience. Six Sigma Green Belt or higher certification Pediatric experience in a children's hospital or specialty medical setting Strong command of writing and editing.

Supports Population Health Transformation and integrated clinical model concept design. Lead clinical design and population health projects: Collaboratively plan and execute initiatives that strengthen care management, transitions of care, and population health strategies across multiple markets. Develop and standardize workflows: Design and implement clinical workflows, tools, and protocols that promote whole-person, timely, and coordinated care. Drive process improvement and change management: Identify opportunities for efficiency and quality improvement, ensuring alignment with organizational goals and compliance requirements. Serve as a clinical subject matter expert: Provide guidance on best practices for care management, including cross functional teams such as utilization management, and quality. Communicate and align strategy: Partner with stakeholders to share clinical and operational needs into actionable requirements, ensuring consistent messaging and adoption. Create supporting documentation: Develop business requirements, test plans, training materials, and other resources to support program execution and sustainability. Collaboratively plans and executes internal healthcare services projects and programs involving department or cross-functional teams of subject matter experts, delivering products from the design process to completion. Provides ongoing communication related to program goals, evaluation, and support to ensure compliance with standardized protocols and processes. May engage and oversee the work of external vendors.

Maximus

Sr. Coordinator – Clinical Ops, LPN

Posted on:

May 1, 2026

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

LPN/LVN

State License:

Compact / Multi-State

We’re moving people forward by providing transformative technology services, digitally enabled customer experiences, and clinical health services that change lives. Our employees share an authentic desire to make vital services available to the public and support the missions of our customers.

Maximus is currently hiring for a Sr. Coordinator – Clinical Ops, LPN to join our QIC Part A West team. This is a remote opportunity. The Specialist is responsible for completing clinical reviews for Medicare Part A West. These will be second-level appeals that require review of medical documents to determine, using Medicare coverage criteria, how a service should be paid. This is a production-based position.

Minimum Requirements: Current Licensed Practical Nurse (LPN) license valid in the state of practice is required High School Degree or equivalent required Minimum 2 years of clinical experience required Continuing education courses as required by state to maintain LPN license. Ability to redirect work focus, as business need or workload volumes dictate. Ability to work independently in a remote setting. Critical thinking and analytical skills. Excellent written and oral communication skills. Strong organizational skills and attention to detail. Strong computer skills and knowledge of MS Office Suite, Chrome, Microsoft Edge. Ability to work an 8-hour schedule between the hours of 7:30am - 6:00pm EST Monday - Friday required. Preferred Skills & Experience: Clinical experience in an acute or long-term care setting. Certification in ICD-10 billing and coding. Knowledge of Medicare Part A and/or Part B of A. Clinical training, education, or certification. Experience in production-based environment. Please note: For this position Maximus will provide equipment to use. Home Office Requirements: Internet speed of 25mbps or higher required / 50 Mpbs for shared internet connectivity (you can test this by going to www.speedtest.net) Minimum 5mpbs upload speed Connectivity to the internet via Category 5 or 6 ethernet patch cable to the home router Private and secure work area and adequate power source Must currently and permanently reside in the Continental US Must have a smartphone which will be required to log into Maximus systems

Responsible for reviewing documentation and/or assessments and applying clinical criteria to complete determinations, approvals or recommendations. Determine need for and obtain any additional information required to complete actions. Determine when escalation or consultation is required with supervisor, physician or related medical or related clinical discipline. Complete reports or documentation in accordance with contract requirements. Performs other related duties as assigned. Reports directly to QIC Adjudication Manager. Perform technical appeal review under the direction of the professional clinical reviewers and the QIC Adjudication Manager. Review ISO compliant work instruction, process documents, and medical review templates as directed by QIC Adjudication Manager. Assist other projects or departments as directed by QIC Adjudication Manager. Understand workflow process and offer suggestions for improvement. Perform other duties as assigned by QIC Adjudication Manager. Must meet or exceed daily productivity requirements. Must maintain a QA score of 95 – 100%.

Intermountain Health

Registered Nurse Triage and Transition

Posted on:

May 1, 2026

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Colorado

Headquartered in Utah with locations in six primary states and additional operations across the western U.S., Intermountain Health is a nonprofit system of 34 hospitals, 400+ clinics, a medical group of more than 4,800 employed physicians and advanced care providers, a health plan division called Select Health with more than one million members, and other health services. With more than 68,000 caregivers on a mission to help people live the healthiest lives possible, Intermountain is committed to improving community health, and is widely recognized as a leader in transforming healthcare. We strive to be a model health system by taking full clinical and financial accountability for the health of more people, partnering to proactively keep people well, and coordinating and providing the best possible care.

The RN Transition and Triage Care Manager offers comprehensive, time-limited services to patients and their families, ensuring continuity of care as they move across healthcare settings and clinicians. This role aims to prevent health complications, connect patients to resources, and guide them to the appropriate level of care. Utilizing clinical expertise, technology, and evidence-based practices, the manager assesses, plans, implements, and evaluates patient care through telephone or digital communication methods. Effective collaboration with patients, families, healthcare providers, payers, community-based providers, and other involved parties is essential to deliver efficient, effective, and patient-centered care management services. The manager operates in various settings, including triage, transitions of care, clinics, communities, and post-acute care environments. Position Details: The RN Triage and Transition is a remote position; however the caregiver must reside in Colorado or Montana and be within close proximity to an Intermountain Health Facility (preferably under an hour). Shift: This position will alternate between two shifts every other week 0700-1530 and 0830-1700. The RN's in the department also alternate these shifts every other week.

Skills: Assessment Care Planning Transitions of Care Motivational Interviewing Critical Thinking Time Management Customer Service Patient Education Communication Prioritization Minimum Qualifications: Current Registered Nurse (RN) license in state of practice. Bachelor of Science in Nursing (BSN) from an accredited institution (degree verification required). RNs hired or promoted into this role must obtain their BSN within four (4) years of hire or promotion date. Demonstrated clinical nursing experience in chronic disease management, and familiarity with chronic disease terminology and processes. Demonstrated understanding of disease management including treatment, length of stay, identifying barriers to delivery of care and any variation. Basic computer skills and knowledge of Microsoft Office software. Preferred Qualifications: Bachelor of Science in Nursing (BSN) from an accredited institution. Care Management Certification. Experience in ambulatory transitional of care or telephonic triage. Intermediate computers skills and knowledge of Microsoft Office software. Physical Requirements: Ongoing need for employee to see and read information, labels, assess patient needs, operate monitors, identify equipment and supplies. Frequent interactions with patient care providers, patients, and visitors that require employee to verbally communicate as well as hear and understand spoken information, alarms, needs, and issues quickly and accurately, particularly during emergency situations. Manual dexterity of hands and fingers to manipulate complex and delicate equipment with precision and accuracy. This includes frequent computer use and typing for documenting patient care, accessing needed information, medication preparation, etc. May be expected to stand in a stationary position for an extended period of time. For roles requiring driving: Expected to drive a vehicle which requires sitting, seeing and reading signs, traffic signals, and other vehicles.

Patient Identification and Assessment: Identifies patients for proactive interventions using specific screening criteria, medical record review, payor models, medical risk scores, or referrals. Assesses patients' medical, functional, and social conditions per department policy/guidelines to develop individualized care plans, care recommendations, or referrals as appropriate. Care Plan Management: Coordinates with internal and external services for social determinants of health (SDoH) needs and care in the community. Evaluates the effectiveness of the patient’s care plan and outcomes. Modifies the plan of care or specific interventions, as appropriate. Acute Symptom Triage: Conducts remote nursing assessments: Utilizes critical thinking skills to assess patient symptoms, medical history, and concerns, applying evidence-based protocols to determine appropriate care recommendations. Patient Support: Supports patient self-management and behavior change through health coaching, care navigation, care coordination, and education of identified patient/caregiver/family to identify and address barriers to optimal health outcomes. Education and Advocacy: Educates healthcare team members about transitions and triage processes, appropriate referrals, and advocate for patient rights. Educates patients about their medical/behavioral health conditions and self-management. Multidisciplinary Collaboration: Collaborates with physicians and other healthcare team members on the patient’s behalf to ensure patient receives quality and timely care and resolve any delays or issues. Participates in rounds or case conferences when necessary. Utilizes team-based care approach referring and consulting with social work, nutrition, pharmacy, rehabilitation, behavioral health, etc. resources as appropriate. Relationship Building: Develops and maintains collaborative partnerships with hospital care management, post-acute providers, and other care managers to ensure seamless transitions and continuity of care. Avoids duplicative care management services/programs. Process Improvement: Actively participates in system and regional initiatives to improve transitions of care and avoid duplicative services. Data Analysis: Conducts root cause analysis of extended post-acute stays, inappropriate utilization, readmissions, and track key data elements or metrics. Identifies, analyzes, and monitors industry, regulatory, technology, and market-based trends that impact ambulatory and post-acute services. Mission and Values driven: Promotes the mission, vision, and values of Intermountain Health, and abides by service behavior standards.

Acentra Health

Clinical Assessor (RN - Mediation and Appeals - Remote in NC)

Posted on:

May 1, 2026

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

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

The Clinical Assessor (Mediations and Appeals) ensures that mediations are scheduled, mediations are performed within timelines and data is entered into QiRePort and the Mediation Tracker within prescribed timelines. The Clinical Assessor (Mediations and Appeals) coordinates with the M&A Manager on decisions and issues, and communicates with the Acentra team as appropriate regarding determinations and other clinical matters.

Required Qualifications: Registered Nurse license by the applicable state (NC and/or Compact). This position requires travel up to a 60 mile radius. Active and current driver’s license required. Bachelor’s degree is required or equivalent experience. 5+ years of clinical experience required. Preferred Qualifications: 2+ years of experience in a home care setting preferred. Demonstrated proficiency in MS Office applications. Ability to maintain a positive attitude and contribute both as an individual and a team member to achieve the goals of the department. Ability to professionally respond to change and handle multiple and changing priorities with sometimes conflicting deadlines. Knowledge and willingness to become a subject matter and thought leader for designated program(s). Experience with stated State Medicaid program (CAP/DA & CAP/C), strongly preferred. Experience working with vulnerable populations is strongly preferred.

Conduct mediations at the request of beneficiaries who have an adverse decision for the CAP programs. Must be able to accurately assess medical conditions and symptoms and functional abilities. Identify and document specific quality indicators for monitoring and tracking the reasons for adverse appeal decisions. Maintain mediation records and reports using a tool that tracks all mediation/appeal requests, dates of the requests, number of requests completed and not completed, and outcomes. Must be able to accurately assess medical conditions and symptoms and functional abilities. Support analysis of the Mediation and Appeals process for quality improvement by maintaining information in database for tracking/trending all decisions, dates, issues and outcomes. Maintain professional relationships with provider community and external customers and identify opportunities for improvement. Communicate and coordinate with OAH and the Attorney General’s Office. Proactively anticipate and work to mitigate problems that could result in customer dissatisfaction or failure to deliver contracted services. Enter appeal results into QiRePort as applicable. Communicate with Mediations Centers to schedule mediations within timelines. Research cases in appeal to prepare for mediation to include PCG records as well as independent assessment(s), supporting docs and comm log notes within QiRePort. Assure contract compliance by meeting all contractual, legal, and regulatory requirements pertaining to this role - Meet expectations in Quality Assurance benchmarks - Meet expectations in Quality Control measures. Is knowledgeable of NC Medicaid Recipient Due Process Rights and Prior Approval Policies and Procedures in order to maintain appropriate systems for implementation. Work to negotiate settlements during mediations. Assist both CAP programs with maintaining SRF and MDT review compliance when needed. Perform other duties as assigned by management. Read, understand, and adhere to all corporate policies including policies related to HIPAA and its Privacy and Security Rules. The list of accountabilities is not intended to be all-inclusive and may be expanded to include other duties that management may deem necessary from time to time.

Mercor

Clinical Nurse Specialist | Upto $300/hr

Posted on:

May 1, 2026

Job Type:

Contract

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

Mercor connects elite creative and technical talent with leading AI research labs. Headquartered in San Francisco, our investors include Benchmark, General Catalyst, Peter Thiel, Adam D'Angelo, Larry Summers, and Jack Dorsey.

Position: Medical Expert - Sanctum Type: Contract Compensation: $180–$300/hour Location: Remote Duration: Ongoing Commitment: 20 hours/week

Must-Have: MD / DO / RN practicing in the United States or Canada. Actively practicing, board-certified or board-eligible in one of the listed specialties. Comfortable reading literature and translating evidence into structured feedback. 6+ hours per week of availability, flexible schedule. Start Date Saturday 4/25/2026 Compensation & Legal Remote, 100% asynchronous. Paid weekly via Mercor.

Design clinically realistic prompts and scenarios in specialties like Internal Medicine, Emergency Medicine, and Cardiology. Write "golden" reference responses at attending-level quality for diagnostic reasoning and treatment planning. Grade AI-generated responses using structured rubrics to ensure adherence to evidence-based standards. Provide written feedback to the research team to improve model behavior and patient care reasoning. Participate in weekly office hours and specialty calibration sessions for continuous improvement.

Nsight Health

Remote Patient Monitoring - LVN

Posted on:

May 1, 2026

Job Type:

Full-Time

Role Type:

Care Management

License:

LPN/LVN

State License:

Compact / Multi-State

Nsight Health is transforming how care is delivered through Remote Patient Monitoring (RPM), Chronic Care Management (CCM), and Behavioral Health Integration (BHI). We empower healthcare providers to manage chronic conditions using real-time data, AI-enabled technology, and 24/7 clinical support. Our HIPAA-compliant platform connects patients and care teams nationwide—improving outcomes, adherence, and peace of mind. Join a fast-growing, mission-driven team that blends healthcare and technology to make a measurable difference in people’s lives. Nsight Health — Where Technology Meets Compassion.

Remote Patient Monitoring - LVN/LPN Clinical | Remote Employment Type: Full-Time Start Date: June 1, 2026 We are seeking a motivated and detail-oriented LVN/LPN to join our Remote Patient Monitoring Department . In this role, you will be responsible for supporting patients with real-time health monitoring, respond to alerts and deliver timely life-improving interventions, and educate and empower patients through ongoing care.

AI Fluency Requirement – Non Negotiable Nsight is an AI-first organization. Every member of our team is expected to actively use AI tools in their day-to-day work — not as a novelty, but as a core productivity multiplier. This role requires genuine curiosity about AI, comfort experimenting with tools like Claude, ChatGPT, and workflow automation platforms to support clinical documentation and care coordination tasks, and the judgment to know when AI helps and when it doesn't. If AI makes you uncomfortable, this is not the right role.

Conduct outbound phone calls to check in on patients and address health concerns (expected call volume ranges from 70 to 90 calls per day) Handle inbound phone calls and route appropriately based on clinical urgency Route non-clinical inbound calls to the appropriate departments across the company Monitor and respond to Remote Patient Monitoring (RPM) alerts, escalating concerns when clinically indicated Collaborate with providers to coordinate timely and effective patient care Perform monthly wellness assessments and complete comprehensive chart reviews Accurately document all patient interactions in our clinical platform in real time Consistently meet or exceed individual and team performance metrics related to care quality, patient engagement, response times, and adherence to protocol standards Maintain compliance with company policies and applicable regulations Perform other duties as assigned

Personify Health

Utilization Review Nurse-LVN/LPN

Posted on:

May 1, 2026

Job Type:

Full-Time

Role Type:

Utilization Review

License:

LPN/LVN

State License:

Compact / Multi-State

Because health is personal. That's why Personify Health created the first and only personalized health platform—bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one place. We serve employers, health plans, and health systems with data-driven solutions that reduce costs while actually improving health outcomes. Together, our team is on a mission to empower people to lead healthier lives.

Under the supervision of a registered nurse the Utilization Review Nurse will provide professional assessment and review for the medical necessity of treatment requests and plans. The standard work schedule is Monday through Friday, 8:00 AM–5:00 PM Pacific Time, with rotating weekend coverage as required.

Education and Experience: Current LVN license in the United States or U.S. territory. 1+ years of clinical experience required. Required Knowledge, Skills, and Abilities: Knowledge of medical claims and ICD-10, CPT, HCPCS coding. Proficiency in software applications including, but not limited to, Microsoft Word, Microsoft Excel, Microsoft PowerPoint and Outlook Excellent verbal and written communication skills Ability to speak clearly and convey complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others. Work Environment: At Personify Health we value and celebrate diversity and we are committed to creating an inclusive environment for all employees. We believe in creating teams made up of individuals with various backgrounds, experiences, and perspectives. Why? Because diversity inspires innovation, collaboration, and challenges us to produce better solutions. But more than this, diversity is our strength, and a catalyst in our ability to change lives for the good. Physical Requirements: Must be able to remain in a stationary position 50% of the time. The person in this job needs to occasionally move about inside the office to access office machinery, filing cabinets and meeting facilities. Constantly operates a computer and other office productivity machinery, such as copy machine, computer printer, calculator, etc. Frequently positions self to maintain files in file cabinets. Frequently moves boxes or equipment weighing up to 25 pounds. Must communicate information and ideas so others understand. Must be able to exchange accurate information in these situations. Must be able to observe details at close range.

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

Connexall

Clinical Informatics Specialist – RN (West Coast)

Posted on:

May 1, 2026

Job Type:

Full-Time

Role Type:

Informatics

License:

RN

State License:

Florida

GlobeStar Systems is a leader in integrated clinical communication. Our cornerstone product, Connexall®, is an award-winning Enterprise grade IoT platform, purpose built for the healthcare industry. Connexall® delivers a customizable suite of integration solutions to meet the unique and specific communications requirements of any organization. Connexall® services over 1,500 healthcare providers around the world, helping customers improve clinical workflow and driving better patient and staff outcomes.

Job Title: Clinical Informatics Specialist - RN Type: Full-Time Start Date: Immediate Location: US (Remote) – Preference will be given to candidates located in Central or Western time zones to support business operations. Job Summary: Reporting to the Director of Clinical Services and Outcomes, the Clinical Informatics Specialist - RN will provide professional services and clinical support to our customers throughout the Connexall project lifecycle. The successful candidate combines clinical workflow design, data analytics, application implementation, and customer relationship skills to successfully excel Connexall Software offerings. They will work cross-functionally to ensure the customer’s business and clinical goals are understood and appropriately considered throughout all project phases. Serving as an internal and external subject matter expert and advisor, the Clinical Informatics Specialist - RN provides support and guidance to sales, solutions delivery and product development teams and initiatives.

Current Registered Nurse BSN degree or higher, Master’s preferred. 5+ years clinical experience providing Clinical Practice, Educational Training, and Project Implementation required. Nursing or Clinical Informatics experience preferred. Previous experience with Connexall is an asset. Proficiency in Microsoft Office Suite including Word, Excel, PowerPoint, and Visio. Excellent interpersonal skills, communication skills, and presentation skills with the ability to speak with individuals at all levels of an organization. Excellent documentation and written skills. Ability to convey product features in clinical environments for varying levels of participants. Ability to work with various internal teams and customers to define the scope and content of assigned projects. Must act as a subject matter expert to assist other members of the company, as necessary. Ability to translate technical information into clinically focused training and educational materials. Strong computer skills and technical aptitude. Ability to work independently and as part of a collaborative team. Ability to lead discussions and drive to consensus. Ability to implement quality and workflow improvements in a clinical setting. Ability to align clinical practices and understanding of products into a customized, consultative program for customers. Flexibility in adapting to a rapidly changing, energetic environment. Ability to multitask, establish priorities, work independently, and proceed with objectives without supervision. Passion for redefining healthcare. Must have a flexible schedule and be able to work Mon–Fri, evenings/weekends as needed. Ability to travel about 50% (including overnight travel).

Provide professional services and clinical support to customers throughout the Connexall project lifecycle, including pre-sales demonstrations, solution design workshops, customer workflow analysis and mapping, user training, go-live support, and post-implementation consulting. Serve as a clinical and educational resource both internally and externally during the sales and implementation process. Participate in key account sales presentations, demonstrations, clinical evaluations, and clinical training. Provides clinical expertise across the sales enablement and customer success lifecycle, serving as a subject matter expert on Connexall solutions. This includes offering consultative guidance on clinical workflow optimization, demonstrating the clinical value of the platform, and supporting sales teams in articulating solution impact to prospective customers. Act as a resource to train internal teams, answer clinical product questions, and facilitate highest possible patient outcomes. Document needs assessment, processes, system requirements, dashboard design requirements, change management, and user training materials to ensure successful communication to both technical team and end user. Provide clinical support to customers during implementation, post-implementation, and into project maturity, working with customers to ensure they are maximizing their use of Connexall. Understand customer’s current clinical workflow by conducting interviews with staff in appropriate units, from admittance to discharge. Evaluate current state of customer’s site to determine bottlenecks and inefficiencies, by making clinical workflow observations and documentations and assessing technology tools and HIS systems in place. Work with customer to design and create a schema outlining an updated clinical workflow design, using Connexall to achieve the customer’s desired future state of clinical workflow. Responsible for clinical stakeholder engagement through all stages of implementation ensuring operational readiness and clinical adoption. Support process improvement projects, address clinical workflow concerns, and identify opportunities for improvement. Collaborate internally to communicate opportunities for product improvement using direct customer feedback. Assist with the development of case studies and use cases to share best practices with other customers. Keep up to date with industry standards thereby making recommendations and sharing information that will result in the best practice and use of Connexall. Other duties as required.

Austin Regional Clinic: ARC

LVN (Specialty Phone Triage, 32 hours) - Remote Opportunity

Posted on:

May 1, 2026

Job Type:

Part-Time

Role Type:

Triage

License:

LPN/LVN

State License:

Compact / Multi-State

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

Under general supervision, provides routine nursing care via telephone within the limits of nursing knowledge, education, licensure, experience and ethical, legal standards of care. Carries out all duties while maintaining compliance and confidentiality and promoting the mission and philosophy of the organization. Work Location: Training and orientation at our Administrative facility. Work-from-home opportunities after ~90 days. Must reside in Texas and be willing to attend on-site training and occasional in-person department meetings in Austin, TX. Work Schedule: Monday-Wednesday and Friday 8:15am-5:15pm

Education and Experience Required: High school diploma or equivalent. Graduation from an accredited school of vocational nursing. Preferred: Previous experience in an ambulatory or acute care setting preferred. Two (2) or more years of clinical experience preferred (within the last five (5) years). Experience working in the related specialty preferred. Telephone triage experience preferred. Previous experience in an ambulatory, hospital, or home health setting preferred. Bilingual in English and Spanish preferred. Certificate/License: Current licensure as a Licensed Vocational Nurse (LVN) in the State of Texas. Required to maintain a current vocational nursing license during employment. Knowledge, Skills And Abilities Ability to utilize computer software and associated programs to triage and send reports to appropriate agencies or clinics. Ability to use nursing judgment as an adjunct to the computer Software Program to reach appropriate dispositions and care advice. Ability to respond appropriately to emergency situations. Ability to apply nursing principles, practices and techniques. Ability to exercise initiative and judgment in selecting proper treatment. Ability to engage others, listen and adapt response to meet others’ needs. Ability to align own actions with those of other team members committed to common goals. Excellent computer and keyboarding skills, including familiarity with Windows. Excellent verbal and written communication skills. Ability to manage competing priorities. Ability to perform job duties in a professional manner at all times. Ability to understand, recall, and communicate, factual information. Ability to understand, recall, and apply oral and/or written instructions or other information. Ability to organize thoughts and ideas into understandable terminology. Ability to apply common sense in performing job. Ability to understand and follow instructions and guidelines. Knowledge of all activities associated with the delivery of quality nursing practices and duties assigned to this role Skill in nursing practices within the scope of responsibilities assigned to this role Skill in organization and efficiency Excellent customer service skills. Excellent interpersonal & problem solving skills. Ability to manage multiple nursing activities simultaneously with frequent interruptions in a fast –paced environment Ability to have excellent attention to detail. Ability to work in a team environment.

Assesses and prioritizes medical needs via telephone and directs patients to appropriate and necessary care. Guides evaluation including instructing patient/caller how to evaluate normal/abnormal symptoms, effectiveness of treatment and when to call back. Documents symptoms/complaints, nursing assessment, advice and patient/caller response. Follows policies, procedures, and protocols to ensure consistency and departmental effectiveness as well as improve health care outcomes of patients/callers and their access to appropriate health care. Collects data and make assessments, develops a working diagnosis, determines interventions and disposition per guidelines. Demonstrates best practices and quality care. Assesses the physical, social, and emotional needs of patients and families. Teaches and counsels patients and families concerning heath assessment and care including prevention of disease and health maintenance. Accurately and completely reports and documents status, care rendered, response to care, provider orders, contacts with patient and/or other healthcare providers. Accurately and completely performs patient follow-up activities including laboratory results and diagnostics, appointments, referrals, medications, and call backs. Able to assist in the ordering /re-ordering of prescriptions within the guidelines of the company protocol. Adheres to all company policies, including but not limited to, OSHA, HIPAA, compliance and Code of Conduct. Regular and dependable attendance. Follows the core competencies set forth by the Company, which are available for review on CMSweb. Works holiday shift(s) as required by Company policy. Accurately and completely reports and documents status, care rendered, response to care, provider orders, contacts with patient and/or other healthcare providers. Participates in the orientation of new employees.

CareHarmony

Remote Triage Nurse - Nights - Full Time - LPN or RN

Posted on:

May 1, 2026

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

CareHarmony works comprehensively with providers to deliver value-based care management initiatives for their patients. Our clinicians are driven by their passion for the level of care delivered; experts in assisting patients and caregivers navigate a sometimes-fractured healthcare system and consistently prioritize a high-quality standard so patients may better manage chronic illnesses and improve their Quality of Life.

Under the direction of the Lead Triage RN, the triage nurse will be responsible for providing exceptional patient care for all calls after business hours. This includes telephonic triage of complex patients, assisting with psychosocial needs and business initiatives. Schedule: Full-Time: 36 hours per week with alternating weekends being worked 6pm - 7am CST Example schedule: Week 1 - Tuesday night, Wednesday night, Thursday night Week 2 - Friday night, Saturday night, Sunday night Week 3 - Repeat week 1 Week 4 - Repeat week 2 Pay: $25/hr for LPN / $27/hr for RN

Compact/Multistate Licensure required (additional licensures are a plus) Innovative mindset, driven to change how patients manage their health Robust clinical knowledge Extensive experience in telephonic triage Ability to quickly determine appropriate level of care based off clinical assessment Ability to navigate multiple technological platforms Excellent attention to detail Excellent customer service skills Excellent organizational skills Excellent verbal and communication skills Excellent professional presence when dealing with colleagues, clients and patients Ability to function cohesively within a team Education and Experience: Graduate of accredited School of Nursing Nursing license must be active and in good standing A minimum of five (5) years of professional experience in nursing Experience in Triage required 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

Conduct thorough telephonic assessments with proprietary tools Identify and address patient concerns Address acute clinical concerns with close collaboration with the patient’s providers. Provide telephonic education to patients Participate in Innovation team projects Ensure excellent quality of care provided during on-call and triage interactions Foster relationships within the team to ensure the CareHarmony culture is positive and supportive

OpenLoop

Registered Nurse - Sexual Health

Posted on:

May 1, 2026

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

Compact / Multi-State

OpenLoop is the nation’s top white-label digital health infrastructure provider, powering virtual care delivery for healthcare organizations, employers, retailers, and consumer brands. We make it simple to launch and scale virtual care by delivering the complete clinical and operational backbone behind the scenes—you control your brand, and we handle everything else.

This is a remote position. We are seeking a compassionate and dedicated Telemedicine Registered Nurse (RN) to join our team! You'll have the opportunity to bridge the gap between technology and compassionate care, providing specialized support for gender and sexually diverse communities and addressing STI health needs from anywhere! If this sounds like a mission you want to be a part of - we'd love to connect!

An active Registered Nurse compact state license 3+ years of experience in a clinical nursing role Clinical experience in a semi-independent practice role in medical patient care and/or sexual health Experience providing virtual healthcare Excellent communication skills and empathetic care delivery Experience working in HIV prevention and/or with the LGBTQ2IA+ community Daily availability for asynchronous patient care tasks (reviewing results, providing education, follow-ups), plus 20 hours weekly for scheduled shifts, including live consultations—task volume may vary based on state licensure and patient needs

Providing Compassionate, High-Quality Synchronous Care (20 hours a week) Delivering inclusive, expert, virtual care through scheduled synchronous consultations through our virtual care platform Leading comprehensive initial assessments for those seeking preventative HIV care, including but not limited to: history taking, risk assessment, and psychosocial evaluations Providing comprehensive sexually transmitted and blood borne infection (STBBI) prevention education to clients (with a focus on HIV prevention), including risk reduction strategies and behavioral counseling Championing health education and empowerment, helping patients understand their treatment options, navigate stigma, and take control of their wellness Supporting Seamless Asynchronous Patient Care (hours vary daily based on task availability) Providing asynchronous care to ensure timely and continuous support for patients, including reviewing results, providing education, and clinical follow-ups Maintaining accurate, detailed patient records in our Electronic Medical Record (EMR) system, using a wide variety of virtual tools to chart and connect with patients Collaborating with our team of Nurse Practitioners and support team members to support end-to-end patient care

Molina Healthcare

Medical Review Nurse (RN) -Remote

Posted on:

May 1, 2026

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Illinois

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

Provides support for medical claim and internal appeals review activities - ensuring alignment with applicable state and federal regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Contributes to overarching strategy to provide quality and cost-effective member care

REQUIRED QUALIFICATIONS: At least 2 years clinical nursing experience, including at least 1 year of utilization review, medical claims review, long-term services and supports (LTSS), claims auditing, medical necessity review and/or coding experience, or equivalent combination of relevant education and experience. Registered Nurse (RN). License must be active and unrestricted in state of practice. Experience demonstrating knowledge of ICD-10, Current Procedural Technology (CPT) coding and Healthcare Common Procedure Coding (HCPC). Experience working within applicable state, federal, and third-party regulations. Analytic, problem-solving, and decision-making skills. Organizational and time-management skills. Attention to detail. Critical-thinking and active listening skills. Common look proficiency. Effective verbal and written communication skills. Microsoft Office suite and applicable software program(s) proficiency. PREFERRED QUALIFICATIONS: Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ), or other health care certifications. Nursing experience in critical care, emergency medicine, medical/surgical or pediatrics. Billing and coding experience.

Facilitates clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases in which an appeal has been made, or is likely to be made, to ensure medical necessity and appropriate/accurate billing and claims processing. Reevaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of relevant and applicable state and federal regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of services provided, length of stay, level of care, and inpatient readmissions. Validates member medical records and claims submitted/correct coding, to ensure appropriate reimbursement to providers. Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) issues. Identifies and reports quality of care issues. Assists with complex claim review including diagnosis-related group (DRG) validation, itemized bill review, appropriate level of care, inpatient readmission, and any opportunities identified by the payment integrity analytical team; makes decisions and recommendations pertinent to clinical experience. Prepares and presents cases representing Molina, along with the chief medical officer (CMO), for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings. Reviews medically appropriate clinical guidelines and other appropriate criteria with medical directors on denial decisions. Supplies criteria supporting all recommendations for denial or modification of payment decisions. Serves as a clinical resource for utilization management, CMOs, physicians and member/provider inquiries/appeals. Provides training and support to clinical peers. Identifies and refers members with special needs to the appropriate Molina program per applicable policies/protocols.

Molina Healthcare

RN- Care Review Clinician- Utilization Review (Remote- CA License Req)

Posted on:

May 1, 2026

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

California

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

Provides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care.

Required Qualifications: At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience. Registered Nurse (RN). License must be active and unrestricted in state of practice. Ability to prioritize and manage multiple deadlines. Excellent organizational, problem-solving and critical-thinking skills. Strong written and verbal communication skills. Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications: Certified Professional in Healthcare Management (CPHM). Utilization review, prior authorization, inpatient review desirable. MCG experience, strongly preferred.

Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines. Analyzes clinical service requests from members or providers against evidence based clinical guidelines. Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. Conducts reviews to determine prior authorization/financial responsibility for Molina and its members. Processes requests within required timelines. Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner. Requests additional information from members or providers as needed. Makes appropriate referrals to other clinical programs. Collaborates with multidisciplinary teams to promote the Molina care model. Adheres to utilization management (UM) policies and procedures.

MUSC Health

Patient-Centered Medical Home CMA/LPN Care Coordinator - Midlands/Columbia - MUSCP

Posted on:

May 1, 2026

Job Type:

Full-Time

Role Type:

Care Management

License:

LPN/LVN

State License:

Compact / Multi-State

As the health care system of the Medical University of South Carolina, MUSC Health is dedicated to delivering the highest quality and safest patient care while educating and training generations of outstanding health care providers and leaders to serve the people of South Carolina and beyond. In 2025, for the 11th consecutive year, U.S. News & World Report named MUSC Health the No. 1 hospital in South Carolina. To learn more about clinical patient services, visit muschealth.org.

The role of the Patient-Centered Medical Home (PCMH) Care Coordinator is to work collaboratively with the physicians, staff and other health care professionals to actively facilitate health care delivery and promote care team communication for an assigned patient population ensuring appropriate care is provided. This position will be remotely based, in the Midlands/Columbia area. This position will be required to round in clinics 1-2 days per month.

Education and Work Experience: Certified Medical Assistant: High school diploma or equivalent. Completion of an accredited medical assisting program with one year of patient care experience preferred. Basic computer skills required. Possess ability to understand and implement a variety of detailed instructions in the execution of therapeutic procedures and ability to make accurate physical observation of patients. Employee must possess considerable knowledge of basic medical terminology and human anatomy; ability to understand and implement a variety of detailed instructions in the execution of complex therapeutic procedures; and ability to make accurate physical observation of patients. Must communicate effectively both verbally and in writing. LPN: Completion of a recognized Licensed Practical Nursing program. Ability to demonstrate commitment to patient centered care philosophy as evidenced by effective communications skills, professional demeanor, and excellent interpersonal skills. Ability and motivation to articulate and support departmental philosophy of excellent guest relations. Must communicate effectively both verbally and in writing. Must be computer literate. Degree of Supervision Must be able to work independently under the supervision of the PCMH Clinical Manager. Ability to work with Site Supervisors, Providers and others on the care team along with external stakeholder. Licensures, Registrations, Certifications CMA Required Licensure, Certifications, Registrations: Must be certified through the American Medical Technologist (AMT) or American Association of Medical Assistants (AAMA) or National Health career Association (NHA) or MedCA as a Certified Clinical & Administrative Medical Assistant (MA1), or National Association for Health Professionals (NAHP), or National Center for Competency Testing (NCCT). Current American Heart Association (AHA) Basic Life Support (BLS) certification or American Red Cross BLS for Healthcare Providers certification is required. LPN Required Licensure, Certifications, Registrations: Licensed as an LPN within the state of South Carolina or a compact state. Current American Heart Association (AHA) Basic Life Support (BLS) certification or American Red Cross BLS for Healthcare Providers certification is required. Physical Requirements: Continuous requirements are to perform job functions while standing, walking and sitting. Ability to bend at the waist, kneel, climb stairs, reach in all directions, fully use both hands and legs, possess good finger dexterity, perform repetitive motions with hands/wrists/elbows and shoulders, reach in all directions. Maintain 20/40 vision corrected, see and recognize objects close at hand and at a distance, work in a latex safe environment and work indoors. Frequently lift, lower, push and pull and/or carry objects weighing 50 lbs (+/-) unassisted, exert up to 50 lbs of force, lift from 36” to overhead 25 lbs. Infrequently work in dusty areas and confined/cramped spaces. Ability/willingness to travel frequently to MUSCP-PC clinical locations away from the main campus.

Identifying patients that qualify for care coordination: not meeting clinical goals and quality measures (i.e. hypertension and diabetic control) for patients, overdue for visits, labs, or referrals and arranging for follow-up services as appropriate, identifying gaps in care and respond with appropriate action to correct. TCM coverage as needed. Utilizes Epic registries and reports in accordance with process (i.e. CCM-weekly & daily, quality measures, etc.) to identify patients and needs. Outreach to patients identified for care coordinator services (i.e. CCM, quality measures, etc.) & documents attempt (s) & completion Schedule services and places referrals in accordance with patient needs (i.e. vaccine, labs, appointment, mammogram, etc.) Follow up as appropriate to track data Accurately maintains 100% of data received. Communicates effectively and professionally with patients, care teams and providers to provide support for continuity of care between patient, care team, and assigned providers Compiles and summarize information for quality measures and projects Attend 80 % of staff meetings Maintains communication with providers & care team members (I.e. Epic inbox message, email, phone, office schedule, in person) Identify patient needs and/or barriers (psychosocial and other) to care and coordinate patients/families contact with community resources. Completes & documents accurate information gathering of data Completes Epic & community referrals as needed Communicates & follow up of identified barriers to the appropriate care team member/resource Other duties as assigned

MUSC Health

Clinical Documentation Specialist I-RN

Posted on:

May 1, 2026

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

As the health care system of the Medical University of South Carolina, MUSC Health is dedicated to delivering the highest quality and safest patient care while educating and training generations of outstanding health care providers and leaders to serve the people of South Carolina and beyond. In 2025, for the 11th consecutive year, U.S. News & World Report named MUSC Health the No. 1 hospital in South Carolina. To learn more about clinical patient services, visit muschealth.org.

The RN (Registered Nurse) – Clinical Documentation Specialist I report to their respective Manager, Clinical Documentation. Under general supervision, the RN – Clinical Documentation Specialist I conduct reviews of inpatient electronic medical records to identify missing, vague, and/or incomplete diagnoses and collaborate with and facilitate appropriate provider documentation to accurately reflect appropriate DRG (Diagnosis Related Group) assignment, patient severity of illness and risk of mortality. In addition, the CDI (Clinical Documentation Integrity) specialist risk adjusts for expected mortality/length of stay and clinically validates key diagnoses. Entity: Medical University Hospital Authority (MUHA) Worker Type Employee: Worker Sub-Type​ Regular: Cost Center CC003762 COL - CDI Chart Documentation (DMC) Pay Rate Type Salary Pay Grade Health-28 Scheduled Weekly Hours: 40

Bachelor's degree in nursing from an accredited school of nursing and at least five years' clinical nursing experience preferred. Strong clinical experience and critical thinking skills required. Extensive knowledge of patient care, and knowledge of clinical measurement tools and clinical outcomes; ability to establish cooperative working relationships with diverse groups and individuals, medical staff and other health care disciplines. Licensure as a registered nurse by the South Carolina Board of Nursing or compact state. Position may require extensive walking. May require frequent bending, stooping, or stretching. May require lifting and carrying up to 20 lbs. Requires eye-hand coordination and manual dexterity. Requires the use of office equipment, such as computer terminals, telephones, and copiers. Requires normal vision range and the absence of color blindness. (C) Continuous – 6-8 hours per shift; 2) (F) Frequent – 2-6 hours per shift; 3) (I) Infrequent – 0-2 hours per shift

The RN – Clinical Documentation Specialist I is responsible for a baseline understanding of interpreting quality metrics and participates in appropriate ICCE meetings, QAPIs, and/or other identified educational opportunities across the system.

24-MAG

Remote | Nursing Clinical Review Expert — $65–$95/hour

Posted on:

April 30, 2026

Job Type:

Contract

Role Type:

Clinical Operations

License:

RN

State License:

New York

At 24-MAG, we support emerging AI and consulting platforms by sourcing and connecting qualified professionals with remote, contract-based opportunities. Our work focuses on identifying strong talent, guiding candidates through modern application pipelines, and promoting verified roles in AI evaluation, consulting, project management, and tech-enabled work. We collaborate with platforms and companies that operate in the intersection of AI, digital transformation, and expert-driven problem solving. Our aim is to make high-quality opportunities more accessible while helping organisations tap into skilled global talent.

We are sharing a specialised part-time consulting opportunity for nursing professionals experienced in patient care, clinical monitoring, medication administration, clinical documentation, care coordination, and structured healthcare workflow review. This role supports current and upcoming remote consulting opportunities focused on nursing-related clinical review, patient care workflow evaluation, documentation assessment, medication administration scenarios, clinical data review, and high-quality project execution. Selected professionals will apply their nursing expertise to review realistic healthcare scenarios, evaluate clinical outputs, prepare structured written feedback, and support accurate, evidence-based nursing workflow tasks.

Strong candidates may have: Professional nursing experience in patient care, clinical monitoring, medication administration, documentation, care coordination, or healthcare operations Background in one or more areas such as acute care, primary care, emergency care, long-term care, behavioral health, pediatrics, surgical nursing, oncology, ICU, or community health Familiarity with nursing workflows involving patient assessment, medication administration, clinical documentation, care planning, handoffs, and escalation protocols Comfort reading and preparing nursing artifacts such as patient notes, MAR records, care plans, handoff summaries, discharge instructions, and clinical documentation Strong written communication skills Ability to work independently in a remote, project-based environment Educational Background: Nursing education, RN/LPN/LVN qualification, BSN, MSN, or equivalent clinical training is helpful Active or prior nursing licensure is highly relevant depending on project scope Equivalent practical experience in nursing, clinical documentation, patient care review, healthcare QA, or care coordination is also valuable Nice to Have: Experience in hospital, clinic, long-term care, home health, case management, telehealth, or healthcare quality environments Familiarity with EHRs, clinical documentation standards, medication administration records, care pathways, discharge planning, or patient safety workflows Experience preparing or reviewing nursing notes, care plans, patient summaries, handoff documentation, medication records, or clinical review materials Certifications such as RN, BSN, MSN, CCRN, CEN, CMSRN, or related nursing credentials are helpful Strong attention to detail in clinical, patient-facing, and documentation-heavy healthcare environments

Patient Care & Clinical Monitoring Review: Review nursing scenarios involving patient care, clinical monitoring, vital signs, care plans, escalation pathways, and patient status updates Evaluate clinical outputs against source materials, nursing standards, patient context, and documented review criteria Support structured review of bedside care workflows, triage notes, patient assessments, nursing observations, and follow-up documentation Identify missing clinical context, documentation gaps, care-sequence issues, and expected nursing review outcomes Medication Administration & Documentation Support: Review scenarios involving medication administration, MAR documentation, dosage timing, patient instructions, adverse-event monitoring, and clinical handoffs Evaluate nursing documentation for clarity, accuracy, completeness, and alignment with patient care requirements Support structured review of nursing notes, medication records, care summaries, discharge instructions, and clinical communication materials Prepare clear written feedback based on source materials and verifiable clinical criteria Clinical Workflow Evaluation & Structured Feedback: Review nursing-related tasks and deliverables based on real-world patient care and healthcare documentation workflows Provide domain-specific feedback on clinical accuracy, patient safety, workflow realism, and communication quality Support evaluation workflows involving AI-generated nursing summaries, care recommendations, documentation outputs, and clinical reasoning Maintain accuracy, consistency, and professional judgment across submitted work

ConceiveAbilities

Surrogate Engagement Nurse

Posted on:

April 30, 2026

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Illinois

ConceiveAbilities is the premier gestational surrogacy and egg donation agency in the United States and worldwide. For nearly 30 years, ConceiveAbilities has guided clients through the complex process of family building through assisted reproductive technologies. We are modern family advocates that believe that everyone who wants to become a parent, can. Parents should be able to choose from many family-building options - regardless of marital status, fertility challenges, geopolitical factors, or social motivation. At ConceiveAbilities, we are All In. Our staff is committed to helping our clients from their first meeting, to choosing a surrogate, to the delivery plans for the baby and every step in between.

As a Surrogate Engagement Nurse at ConceiveAbilities, you will own the end-to-end medical record review process for surrogate applicants, working alongside Health Information Specialists and Coordinators to evaluate eligibility with speed and precision. Your clinical eye and process discipline will be a crucial factor in determining which applicants move forward — making your work a consequential step in the surrogate activation process. You will also serve as a key partner to our Match Experts, applying your knowledge of IVF clinic criteria to assess each surrogate's readiness to cycle and optimize match outcomes. In a fully remote, fast-moving environment, you will operate with a high degree of independence, setting the standard for accuracy, timeliness, and clinical rigor across every file you touch.

Experience And Skills: Above-average technical proficiency, including CRM platforms and digital record management — you move fast and learn faster Meticulous attention to detail with a systematic approach to managing high volumes of complex information Clear, direct communicator — your written and verbal work product is precise, professional, and leaves no room for ambiguity Self-directed and accountable; you thrive working independently and hold yourself to a high standard without being managed Equally comfortable operating in structured processes and navigating change — you don't just adapt, you improve what you inherit Sharp problem-solver who sees gaps as opportunities and has the confidence to recommend and implement better ways of working A connector of quality, not quantity — you build relationships with clinic partners that are grounded in credibility and follow-through Personal or professional connection to the fertility field strongly preferred Requirements: Associate's or bachelor's degree in nursing (RN required) Minimum 3 years of clinical experience in IVF or OB/GYN

Own the end-to-end medical record review process, evaluating surrogate applicant eligibility with clinical precision and resolving cases within established timelines Partner with Health Information Specialists to obtain, organize, and assess medical records — prioritizing by applicant lead score Maintain applicant profiles and clinical data in Salesforce with a high degree of accuracy, ensuring records are organized, current, and audit-ready at all times Cultivate and manage relationships with fertility clinic third-party professionals, serving as a reliable and knowledgeable point of contact throughout the pre-approval process Collaborate with fertility clinics to facilitate match acceptance, following up proactively when needed Verify that documentation is complete, accurate, and contains all pertinent medical information before any match advances

Medcor

Call Center Triage RN - Remote (Evenings/Nights)

Posted on:

April 30, 2026

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Illinois

Medcor simplifies the healthcare process for employers. How? By providing the right level of care at the right time and in the right place. When employees get the treatment they need, they avoid unnecessary procedures, labs, prescriptions and referrals. Employers also avoid claims-driven activities that increase costs and recordables. Medcor can provide 24/7 coverage through onsite, mobile, triage and telehealth services. On-demand access thanks to our availability allows early intervention; our use of evidence-based medicine supports prevention and treatment. This holistic approach—and that Medcor operates without claims-driven conflicts of interest—is a win for employers. Medcor is proud to serve clients across the U.S. and Canada, in nearly every industry including Manufacturing; Distribution; Food Processing; OCIP and CCIP Construction; Pharmaceuticals; Retail; Renewables; Insurance; and Hospitality and Entertainment.

Medcor is looking to hire full-time Telephonic Registered Nurses for our remote 24/7 Occupational Health triage call center! The hours for this position include 8 or 10 hour shifts between the hours of 3pm CST - 4a CST. For example, shifts could include 3:00pm - 1:00am or 5:00p - 3:00am. The start date for this triage class will be 6/15//2026. Job Type: Full-time - 40 hours per week Salary: $28 per hour with additional shift differential pay available for evenings, nights & weekends By joining our nursing team, you will be helping thousands of employers better manage their workplace injuries and improve the quality of healthcare for their employees. Nurses who are successful in this position must be able to talk on the phone for long periods while typing and navigating through various software applications simultaneously. Our nurses must be able to visualize an injury while on the phone and clarify details about the injury while following our propriety algorithms to guide the triage of the injured worker. Training: Training for this role will last 5-6 weeks, with 2.5 weeks of classroom instruction and 2.5 weeks of precepting. These first 5-6 weeks of training are held Monday through Friday, from 8a-4p CST. The training schedule is non-negotiable, and all training must be successfully completed within a 6-week time frame. Following training, you will transition to your permanent schedule between the hours of 3p and 4a CST with an every-other-weekend requirement and holiday rotation. Changes to the permanent schedule are not allowed within the first 12 months of employment as these are based on our business needs.

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

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

Nsight Health

Remote Patient Monitoring - LVN (Night Shift)

Posted on:

April 30, 2026

Job Type:

Full-Time

Role Type:

Care Management

License:

LPN/LVN

State License:

Florida

Nsight Health is transforming how care is delivered through Remote Patient Monitoring (RPM), Chronic Care Management (CCM), and Behavioral Health Integration (BHI). We empower healthcare providers to manage chronic conditions using real-time data, AI-enabled technology, and 24/7 clinical support. Our HIPAA-compliant platform connects patients and care teams nationwide—improving outcomes, adherence, and peace of mind. Join a fast-growing, mission-driven team that blends healthcare and technology to make a measurable difference in people’s lives. Nsight Health — Where Technology Meets Compassion.

We are seeking a motivated and detail-oriented LVN/LPN to join our Remote Patient Monitoring Department (Night Shift). In this role, you will be responsible for supporting patients with real-time health monitoring, respond to alerts and deliver timely life-improving interventions, and educate and empower patients through ongoing care.

AI Fluency Requirement – Non Negotiable Nsight is an AI-first organization. Every member of our team is expected to actively use AI tools in their day-to-day work — not as a novelty, but as a core productivity multiplier. This role requires genuine curiosity about AI, comfort experimenting with tools like Claude, ChatGPT, and workflow automation platforms to support clinical documentation and care coordination tasks, and the judgment to know when AI helps and when it doesn't. If AI makes you uncomfortable, this is not the right role. Qualifications Required: Active LVN/LPN license required Proficient with computers, EMRs, and telehealth tools Strong communication and organizational skills Preferred: At least 1 year of nursing experience preferred (RPM, telehealth, or chronic care experience is a plus) Work From Home Requirements Minimum internet speed of 50 Mbps download / 10 Mbps upload Hardwired internet connection required Speed test submission required during the offer process Private, HIPAA-compliant workspace Schedule This position operates on a 4-day work week structure, consisting of 10-hour shifts. Must be available to work overnight hours. Must be available to work rotating holidays throughout the year. Requires mandatory coverage of a minimum of two (2) weekends per month. Training Requirements All new hires must complete a comprehensive training program: Duration: Five weeks Schedule: Monday through Friday, 9:00 AM – 6:00 PM Eastern Time Attendance is mandatory to ensure readiness prior to independently supporting patients.

Conduct outbound phone calls to check in on patients and address health concerns (expected call volume ranges from 70 to 90 calls per day) Handle inbound phone calls and route appropriately based on clinical urgency Route non-clinical inbound calls to the appropriate departments across the company Monitor and respond to Remote Patient Monitoring (RPM) alerts, escalating concerns when clinically indicated Collaborate with providers to coordinate timely and effective patient care Perform monthly wellness assessments and complete comprehensive chart reviews Accurately document all patient interactions in our clinical platform in real time Consistently meet or exceed individual and team performance metrics related to care quality, patient engagement, response times, and adherence to protocol standards Maintain compliance with company policies and applicable regulations Perform other duties as assigned

The Retreat at Cary

Case Management Nurse

Posted on:

April 30, 2026

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

North Carolina

The Retreat at Cary and The Retreat at Cary Corner are sister family care home facilities located in Cary, North Carolina. We are a place where home and care come together with love. Our dedicated staff and owner work around the clock to give you peace of mind that your loved ones are safe and happy. With entertainment, healthful recreation, group outings, and upscale living in a family style residential setting, our mission is simple: there is nothing more important than family. We take care of your loved ones the way we take care of our own families with care, responsibility, and the highest sense of duty.

We are seeking a compassionate and organized Case Management Nurse Specialist to join our team remotely. In this role, you will serve as the clinical hub connecting residents, their families, onsite caregivers, physicians, and community health resources. You will coordinate personalized care plans, oversee chronic disease management, facilitate communication with families, and ensure that each resident's medical, emotional, and social needs are met. Your work will directly support our low guest to staff ratio model by allowing onsite staff to focus on daily hands on care while you manage clinical documentation, physician coordination, and care transitions.

Qualifications: Bachelor of Science in Nursing (BSN) preferred; Associate Degree in Nursing (ADN) with relevant experience accepted. Minimum 1 year of nursing experience in geriatrics, long term care, skilled nursing, home health, or family care home settings. Certification in Case Management (CCM or RN BC) preferred or willingness to obtain within 18 months of hire. Strong knowledge of chronic disease management, fall prevention, polypharmacy, and dementia care. Excellent verbal and written communication skills for speaking with families, physicians, and onsite staff. Proficiency with electronic health records, telehealth platforms, and secure messaging systems. Ability to work independently from a home office with reliable high speed internet and a private workspace for HIPAA compliance. Preferred Qualifications: Experience with Medicare, Medicaid, and long term care insurance documentation. Bilingual proficiency in English and Spanish. Previous remote case management experience.

Conduct remote intake assessments for new residents by reviewing medical histories, medication lists, physician records, and functional status reports. Develop, implement, and revise individualized care plans in collaboration with onsite staff, the resident's primary care physician, and family members. Coordinate personalized doctors house calls by scheduling visits, communicating resident updates to physicians, and ensuring follow up on lab results or specialist referrals. Serve as the primary remote liaison between the family care home and residents' families, providing weekly updates via phone or secure video calls regarding changes in condition, medication adjustments, or upcoming appointments. Monitor chronic conditions such as diabetes, hypertension, dementia, and heart failure through remote review of vital signs and incident reports submitted by onsite caregivers. Manage transitions of care including hospital admissions, discharges, and emergency room visits by communicating with hospital case managers and arranging follow up services. Oversee medication management by reconciling prescriptions, identifying duplications or interactions, and coordinating with pharmacies for refills. Document all case management activities in electronic health records in compliance with North Carolina family care home regulations. Participate in monthly virtual interdisciplinary team meetings with onsite staff, the recreational coordinator, and the owner to discuss resident progress and quality of life initiatives. Educate families on disease processes, advance care planning, and available community resources such as hospice, palliative care, or home health therapy services.

w3r Consulting

Utilization Review Nurse

Posted on:

April 30, 2026

Job Type:

Contract

Role Type:

Utilization Review

License:

RN

State License:

Compact / Multi-State

w3r Consulting is an award-winning, best-in-class IT consulting and management company that delivers enterprise solutions at the intersection of innovation and ingenuity. Organizations throughout the healthcare payor, financial services, and professionals and business services sectors turn to w3r for a strategic, IT-fueled advantage that elevates their stature and capabilities in competitive global markets. As a minority-owned business, w3r brings diverse and multifaceted people from across different backgrounds and life experiences to the table, unlocking the power of unique perspectives and inventive ideas to help clients achieve their evolving goals.

Registered Nurse responsible for collaborating with healthcare providers, members, and business partners, to optimize member benefits, evaluate medical necessity and promote effective use of resources. Medical necessity reviews may include: drugs and biologics, inpatient admissions, outpatient services, surgical and diagnostic procedures, home health, durable medical equipment and out of network services. Conduct reviews in compliance with medical policy, member eligibility, benefits, and contracts.

Current unrestricted RN license. Multi-State License Preferred Bachelors degree in nursing or health-care related field preferred Minimum of 2 years experience in a regulated environment preferred Minimum of 2-3 years clinical experience Strong customer orientation Strong organizational, planning, and communication skills Working knowledge of insurance industry, medical coding (CPT/HCPCS/ICD-10), and overall claims process a plus Knowledge of National Coverage Determinations, Local Coverage Determinations and MCG criteria are a plus. Excellent time management skills Knowledge, Skills, Abilities Required: Excellent interpersonal and communications skills with nursing staff, physicians, nurse practitioners and other health workers involved in the care of a member Ability to meet deadlines and manage multiple priorities, and effectively adapt and respond to complex, fast-paced, rapidly growing, and results-oriented environments Able to work in a dynamic, fast-paced team environment and to promote team concepts Excellent typing skills. Substantial knowledge of Microsoft Office including SharePoint, Outlook, PowerPoint, Excel and Word.

Responsible for the effective and sufficient support of all Utilization Management activities to include review of inpatient and outpatient medical services for medical necessity and appropriateness of setting according to established policies and compliance guidelines. Uses an established set of criteria to evaluates and authorize the medical necessity of services. Provide notification of decisions in accordance with compliance guidelines. Coordinate with Medical Directors when services do not meet criteria or require additional review. Participation in staff meetings, regular trainings and other collaborative meetings as appropriate. Works with management team to achieve operational objectives and financial goals. Supports teams across UM Department as needed. Active participation and completion of all required trainings. Maintain Required Licensures. Adherence to regulatory and departmental timeframes for review of requests Meet/exceed department Turn Around time, daily established productivity goals, and service levels Proficient knowledge of policies and procedures, Medicare, HIPPA and NCQA standards; Professional demeanor and the ability to work effectively within a team or independently; Flexible with the ability to shift priorities when required Other duties as required

w3r Consulting

Nurse Case Management Senior Analyst

Posted on:

April 30, 2026

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Tennessee

w3r Consulting is an award-winning, best-in-class IT consulting and management company that delivers enterprise solutions at the intersection of innovation and ingenuity. Organizations throughout the healthcare payor, financial services, and professionals and business services sectors turn to w3r for a strategic, IT-fueled advantage that elevates their stature and capabilities in competitive global markets. As a minority-owned business, w3r brings diverse and multifaceted people from across different backgrounds and life experiences to the table, unlocking the power of unique perspectives and inventive ideas to help clients achieve their evolving goals.

Delivers specific delegated tasks assigned by a supervisor in the Nurse Case Management job family. Plans, implements, and evaluates appropriate health care services in conjunction with the physician treatment plan. Utilizes clinical skills to assess, plan, implement, coordinate, monitor and evaluate options and services in order to facilitate appropriate healthcare outcomes for members. Ensures that case management program objectives are met by evaluating the effectiveness of alternative care services and that cost effective, quality care is maintained. Provides clinical assessments, health education, and utilization management to members. Performs prospective, concurrent, and retrospective reviews for inpatient acute care, rehabilitation, referrals, and select outpatient services. Manages own caseload and coordinates all assigned cases. Completes day-to-day Nurse Case Management tasks without immediate supervision, but has ready access to advice from more experienced team members. Tasks involve a degree of forward planning and anticipation of needs/issues. Resolves non-routine issues escalated from more junior team members. RN and current unrestricted nursing license required.

Pain Medicine Physicians - New Jersey

Legal Nurse Consultant

Posted on:

April 30, 2026

Job Type:

Full-Time

Role Type:

License:

RN

State License:

New Jersey

We are seeking a detail-oriented and clinically experienced Legal Nurse Consultant to join our team remotely. In this role, you will bridge the gap between complex medical records and the legal process, supporting cases involving pain management, interventional procedures (e.g., spinal cord stimulators, discectomies, epidurals), personal injury, medical malpractice, and workers’ compensation. You will analyze medical records, identify deviations from standards of care, and provide critical insights to attorneys and clients.

Salary: Full-time W-2: $75,000 – $110,000 annually based on experience and certifications. 1099 Contract: $55 – $85 per hour (project-based or hourly billable). Benefits (for W-2 full-time employees): Health Insurance – Medical, Dental, and Vision (employer pays 75% of premium) Paid Time Off – 15 days PTO + 8 federal holidays Retirement – 401(k) with up to 4% employer match after 6 months Remote Work Stipend – $50/month for internet/phone Continuing Education – Reimbursement for LNC conferences, webinars, and certification renewal (up to $1,000/year) Technology Provided – Laptop, secure VPN, and document management software license Flexible Schedule – Core hours 10am–3pm ET; otherwise flexible Malpractice Insurance – Employer-paid professional liability (errors & omissions) for LNC services Work Environment & Physical Requirements Fully remote – must have private, secure home office space. Reliable high-speed internet and backup power/internet source. Ability to review digital medical records (500+ pages per case) for extended periods – visual concentration required. No direct patient care – entirely desk/computer based.

Education & Licensure (Required): Active, unencumbered Registered Nurse (RN) license in any U.S. state. Associate or Bachelor of Science in Nursing (BSN preferred). Experience (Required): Minimum of 1+ years of clinical nursing experience in one or more of the following areas: Pain management Interventional radiology or procedural areas (epidurals, nerve blocks, stimulator trials) Orthopedics or neurosurgery Physical medicine & rehabilitation (physiatry) Emergency medicine or perioperative nursing Legal Nurse Consultant Certification (LNCC) or completion of an accredited LNC training program (e.g., Vickie Milazzo Institute, AALNC). Skills & Competencies: Strong knowledge of medical terminology, pharmacology, laboratory values, and rehabilitation modalities (e.g., electrical stimulation, therapeutic exercise). Proficiency with remote collaboration tools (Zoom, Microsoft Teams, shared drives). Excellent written communication skills; ability to write clear, objective summaries. High attention to detail, especially with surgical/procedural documentation and medication reconciliation. Preferred (but not required): Experience with personal injury, medical malpractice, or workers’ compensation cases. Familiarity with EMR systems (Epic, Cerner, eClinicalWorks) and medical billing/coding (CPT, ICD-10). Prior deposition or trial experience as a nurse consultant.

Medical Record Review & Analysis: Obtain, organize, and analyze medical records, including operative reports, anesthesia records, EMG/NCV studies, imaging (MRI/CT), physical therapy notes, and medication histories. Identify chronologies, gaps in care, deviations from standards of care, and mechanisms of injury relevant to legal cases. Translate complex medical terminology and procedures (e.g., IDET, Radiofrequency Ablation, SI joint injections, Tenex) into clear, non-medical language for legal teams. Case Support: Prepare comprehensive medical chronologies, timelines, and case summaries. Identify and screen for potential departures from accepted standards of care in pain management and interventional pain medicine. Assist with preparation of deposition and trial questions, exhibits, and demonstrative evidence. Review and summarize depositions of medical experts, treating physicians (e.g., pain specialists, physiatrists, anesthesiologists), and fact witnesses. Expert & Collaboration: Serve as a liaison between attorneys, medical experts (including interventional pain physicians and physiatrists), and healthcare facilities. Identify and locate qualified expert witnesses in pain management, physical therapy, and related specialties. Conduct literature searches to support case strategy (peer-reviewed studies, clinical guidelines, FDA warnings). Compliance & Documentation: Ensure all medical-legal work complies with HIPAA, state regulations, and attorney-client privilege requirements. Maintain secure, organized digital case files using remote document management systems.

CVS Health

Case Manager - Registered Nurse - Southeast Region

Posted on:

April 30, 2026

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

Required Qualifications: Candidates must live in the Southeast Region (States Include- FL, GA, AL, MS, NC, SC, TN, AR, LA) Candidate must have active and unrestricted Compact Registered Nurse (RN) licensure in the state of residence 3+ years clinical practical experience with preference in the following areas: diabetes, Congestive Heart Failure (CHF), Chronic Kidney Disease (CKD), post-acute care, hospice, palliative care, cardiac, home health with Medicare members 2+ years case management, discharge planning and/or home health care coordination experience 2+ years of experience with Microsoft Word, Excel, and Outlook Preferred Qualifications: Previous work from home experience in a healthcare related field Excellent analytical and problem-solving skills Effective communications, organizational, and interpersonal skills Ability to work independently Certified Case Manager National professional certification (CRC, CDMS, CRRN, COHN, or CCM) Efficient and effective computer skills including navigating multiple systems and keyboarding Education: Associate's Degree in Nursing or Nursing Diploma (REQUIRED) Bachelor's Degree in Nursing (PREFERRED) License: Active and unrestricted Compact Registered Nurse (RN) licensure in the state of residence

Acts as a liaison with member/client /family, employer, provider(s), insurance companies, and healthcare personnel as appropriate. Implements and coordinates all case management activities relating to catastrophic cases and chronically ill members/clients across the continuum of care that can include consultant referrals, home care visits, the use of community resources, and alternative levels of care. Interacts with members/clients telephonically or in person. May be required to meet with members/clients in their homes, worksites, or physician’s office to provide ongoing case management services. Assesses and analyzes injured, acute, or chronically ill members/clients medical and/or vocational status; develops a plan of care to facilitate the member/client’s appropriate condition management to optimize wellness and medical outcomes, aid timely return to work or optimal functioning, and determination of eligibility for benefits as appropriate. Communicates with member/client and other stakeholders as appropriate (e.g., medical providers, attorneys, employers and insurance carriers) telephonically or in person. Prepares all required documentation of case work activities as appropriate. Interacts and consults with internal multidisciplinary team as indicated to help member/client maximize best health outcomes. May make outreach to treating physician or specialists concerning course of care and treatment as appropriate. Provides educational and prevention information for best medical outcomes. Applies all laws and regulations that apply to the provision of rehabilitation services; applies all special instructions required by individual insurance carriers and referral sources. Conducts an evaluation of members/clients’ needs and benefit plan eligibility and facilitates integrative functions using clinical tools and information/data. Utilizes case management processes in compliance with regulatory and company policies and procedures. Facilitates appropriate condition management, optimize overall wellness and medical outcomes, appropriate and timely return to baseline, and optimal function or return to work. Develops a proactive course of action to address issues presented to enhance the short and long-term outcomes, as well as opportunities to enhance a member’s/client’s overall wellness through integration. Monitors member/client progress toward desired outcomes through assessment and evaluation.

CVS Health

Case Manager - Registered Nurse

Posted on:

April 30, 2026

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

The Care Manager—Registered Nurse is a key member of our Special Needs Plan (SNP) care team, responsible for coordinating care for members who often face multiple chronic medical and behavioral health conditions, as well as various social determinants of health (SDoH) needs. This role involves conducting comprehensive assessments to evaluate members’ needs and addressing SDoH challenges by connecting them with appropriate resources and support services. The Social Worker provides education and guidance to members and their families on managing chronic conditions and navigating the healthcare system. Additionally, the Care Manager develops and implements individualized care plans, monitors member progress, advocates for necessary services, and collaborates with the interdisciplinary care team to ensure optimal health outcomes. Accurate and timely documentation of assessments and interventions is essential, as is participation in team meetings to discuss member status and care strategies.

Required Qualifications: Candidate must have active and unrestricted Compact Registered Nurse (RN) licensure in the state of residence Proficient in Microsoft Office Suite, including Word, Excel, Outlook, OneNote, and Teams, with the ability to effectively utilize these tools within the context of the Care Manager – Registered Nurse (CM RN) role Access to a private, dedicated space to conduct work effectively to meet the requirements of the position Dependents must have separate care arrangements during work hours, as continuous care responsibilities during shift times are not permitted Confidence working at home / independent thinker, using tools to collaborate and connect with teams virtually 3+ years of nursing experience 2+ years of case management, discharge planning and/or home healthcare coordination experience Preferred Qualifications: Experience providing care management for Medicare and/or Medicaid members Experience working with individuals with SDoH needs, chronic medical conditions, and/or behavioral health Experience conducting health-related assessments and facilitating the care planning process Bilingual skills, especially English-Spanish Education Associate’s of Science in Nursing (ASN) Degree and relevant experience in a health care-related field (REQUIRED) Bachelor’s of Science in Nursing (BSN) (PREFERRED) License Active and unrestricted Compact Registered Nurse (RN) licensure in the state of residence

50-75% of the day is dedicated to telephonic engagement with members and the coordination of their care. Compiles all available clinical information and partners with the member to develop an individualized care plan that encompasses goals and interventions to meet the member’s identified needs. Provides evidence-based disease management education and support to help the member achieve health goals. Ensure the appropriate members of the interdisciplinary care team are involved in the member’s care. Provides care coordination to support a seamless health care experience for the member. Meticulous documentation of care management activity in the member’s electronic health record. Collaborate with other participants of the Interdisciplinary Care Team to address barriers to care and develop strategies for maintaining the member’s stable health condition. Identifies and connects members with health plan benefits and community resources. Meets regulatory requirements within specified timelines. The Care Manager RN supports other members of the Care Team through clinical decision making and guidance as needed. Additional responsibilities as assigned by leadership to support team objectives, enhance operational efficiency, and ensure the delivery of high-quality care to members. This may include participating in special projects, contributing to process improvement initiatives, or assisting with mentoring new team members. Essential Competencies and Functions Ability to meet performance and productivity metrics, including call volume, successful member engagement, and state/federal regulatory requirements of this role. Conduct oneself with integrity, professionalism, and self-direction. Experience or a willingness to thoroughly learn the role of care management within Medicare and Medicaid managed care. Familiarity with community resources and services. Ability to navigate and utilize various healthcare technology tools to enhance member care, streamline workflows, and maintain accurate records. Maintain strong collaborative and professional relationships with members and colleagues. Communicate effectively, both verbally and in writing. Excellent customer service and engagement skills. Work Expectations Access to a private, dedicated space to conduct work effectively to meet the requirements of the position Dependents must have separate care arrangements during work hours, as continuous care responsibilities during shift times are not permitted

CVS Health

Utilization Management Nurse Consultant - Weekends 10-Hour Shifts

Posted on:

April 30, 2026

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Compact / Multi-State

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

Remote Utilization Management RN (Prior Authorization) Full-Time | Remote | Weekend Schedule We’re seeking an experienced Registered Nurse (RN) to join our Utilization Management team in a fully remote role. This position is ideal for nurses who enjoy applying clinical judgment, working collaboratively with providers, and influencing quality healthcare decisions—without bedside demands. Schedule: Saturday & Sunday (CST) with flexible consecutive weekdays to meet business needs 10-hour shifts after training Must be available Monday–Friday during business hours for training UM operates 24/7, with potential evenings, holidays, or on-call coverage

Required: Active, unrestricted Compact RN license in the state of residence, OR Texas RN license 3+ years of clinical nursing experience Proficiency with Microsoft Office and navigating multiple systems Strong critical thinking, communication, and multitasking skills Comfort working in a fast-paced, remote, desk-based environment Preferred: Prior Authorization or Utilization Management experience BSN preferred Education: Associate’s degree in nursing required BSN preferred

Review clinical documentation and apply evidence-based criteria to authorize services or escalate cases to a Medical Director Communicate with providers to gather information and facilitate timely care Support appropriate utilization of healthcare benefits across the continuum of care Identify opportunities for referrals, care coordination, and quality improvement Collaborate with internal and external partners in utilization and benefit management

Insight Global

Nursing Care Manager

Posted on:

April 29, 2026

Job Type:

Contract

Role Type:

Care Management

License:

RN

State License:

Compact / Multi-State

Position: Registered Nurse Care Managers Location: Remote (Must be in a Compact License State!) Duration: 6-month C2H Pay Rate: $33-$40/hr Schedule/ Hours: 40 hours per week, 9:00am – 6:00pm (1 hour lunch) Job Description: Insight Global is looking for a Remote Nurse Care Manager to support a virtual care and healthcare navigation company. This individual will act as a clinical partner helping high-risk and rising-risk members through proactive outreach, post-discharge planning, and care coordination. They will collaborate with a multidisciplinary team to develop and execute holistic care plans while ensuring that each member receives the guidance, education, and support they need throughout their healthcare journey. Day-to-day responsibilities include but are not limited to, coordinating communication with hospital care management teams, supporting medication reconciliation efforts, and navigating members to their employee resources. This is an awesome opportunity to join a tech-enabled care integrator and contribute to a growing Care & Case Management team!

Must Haves: Must be able to work 9 AM – 6 PM in respective time zone Ideal candidates will be located in MST or PST! Must hold compact RN license and reside in the state in which they hold the license 5 years’ experience as a nurse 2 years’ experience as a case manager BSN Ideal candidate will have worked at a TPA (third party healthcare navigator) ir Insurance carrier with remote experience Plusses: CCM (Certified Case Manager) certification

Prestige Leadership Development

Healthcare RN/NP Financial Professional

Posted on:

April 29, 2026

Job Type:

Contract

Role Type:

License:

RN

State License:

Compact / Multi-State

We are a team of driven financial professionals dedicated to empowering individuals and families through financial education and leadership. We believe that financial literacy is the cornerstone of true financial independence and our mission is to equip our clients with the knowledge, tools, and confidence they need to take control of their financial future.

Are you a Registered Nurse or Nurse Practitioner who's passionate about helping families - but seeking a career that offers freedom of time, less burnout and long term financial stability? You're not alone. You'll be trained and supported by a team made up primarily of fellow medical professionals. This is a fully remote, work-from-home opportunity as a Financial Professional ideal for Nurses (RNs/NPs) looking to transition or diversify. Flexible Schedule | Part-Time or Full-Time | Not a Nursing Position High Income Potential | Full Training Provided & Mentorship

Nurses are naturally positioned to succeed in the financial industry because of the qualities and skills they already possess: Leadership Skills - Take initiative in guiding clients through important financial decisions. Lead teams or offices with empathy and confidence. Inspire others by modeling professionalism, consistency, and a genuine desire to help. People Skills - Nurses know how to listen actively and connect emotionally. They have strong interpersonal communication and empathy qualities that make clients feel understood and supported. They can navigate sensitive conversations about health, and that skill applies directly to conversations about finances, family goals, and legacy planning. Assessment Skills - Understanding a client’s financial “symptoms” their goals, challenges, and current financial health. Analyzing details like income, expenses, insurance, and investments to design a personalized plan. Identifying areas of risk or opportunity to provide the right financial “treatment plan.” Education Skills - Educating families about financial literacy, protection, and planning. Simplifying complex concepts like insurance, retirement, and investments. Empowering clients to take ownership of their financial wellness. Documentation Skills - Recording client information, needs, and progress precisely. Maintaining compliance and transparency with every transaction and recommendation. Ensuring clear communication and follow-up through detailed notes and organized systems.

Educate individuals and families on key financial concepts such as income protection, retirement planning, debt management, and wealth building Guide clients through life’s transitions whether it’s protecting a new baby, preparing for college, or planning for retirement Build genuine, trust-based relationships with clients through empathy, education, and integrity Collaborate with a team of professionals (many with medical backgrounds like yours) for ongoing training, mentorship, and support Maintain and grow your own client base with flexible scheduling full-time or part-time

Midi Health

REMOTE Nurse Practitioner - New York (NY) License

Posted on:

April 29, 2026

Job Type:

Full-Time

Role Type:

Primary Care

License:

NP/APP

State License:

Compact / Multi-State

At Midi Health, we're on a mission to revolutionize healthcare for women at midlife—to relieve their symptoms, support their wellbeing, and ensure they feel seen, heard, and cared for. Our care is personalized, evidence-based, and covered by insurance, making it more accessible to women across the country. Wherever they live. Whatever their health story. We’re rapidly growing and looking for passionate full-time Nurse Practitioners to join our dedicated clinical team. You’ll help close the gender health gap by guiding women through perimenopause, menopause, and other midlife transitions with compassionate, evidence-based care.

Mission-Driven Impact: Join us in transforming healthcare for women in midlife—making a meaningful difference every day. Remote (U.S.–Based) Role with Structured Hours: Work fully remote from within the United States with patient-facing hours scheduled between 7:00 AM and 7:00 PM, adjusted by patient location and licensure. This is not a digital nomad role; work may not be performed while you are outside the United States. Continuous Learning: Access weekly clinical education to stay sharp and advance your expertise in women’s midlife health. Purposeful Visits: Our appointments provide you with time to listen, educate, and deliver personalized care that truly supports your patients. Technology + Clinical Support: Benefit from structured onboarding, user-friendly tech, and operational assistance—including elements of logistics, scheduling, and clinical operations—so you can focus on care without being on your own. Community of Care: Be part of a collaborative, respectful team passionate about women’s health and dedicated to your professional growth.

Active, unrestricted, and unencumbered Nurse Practitioner license in at least one U.S. state.*Multiple state licenses are highly preferred. Prescriptive authority as a Nurse Practitioner. Active national board certification (FNP, WHNP, AGNP, or similar). Minimum 3 years of recent experience (within the last 5 years) practicing as a Nurse Practitioner in Primary Care, Women’s Health, or Gynecology. Ability to work independently and make sound clinical decisions. High proficiency and efficiency with technology (telehealth platforms, EMRs, communication tools). A strong passion for caring for women navigating menopause and midlife health transitions.

Quality visits, better conversations: Appointments designed to allow time to listen, educate, and personalize care. Evidence-based protocols: Trained in expert-developed clinical pathways combining hormonal therapy, lifestyle coaching, and medication when appropriate. Care beyond the screen: Patients receive labs, prescriptions, supplements, and referrals as needed—our platform makes it seamless. You’re never alone: Supported by a collaborative team of clinicians, care coordinators, and clinical leaders, with opportunities to grow and specialize over time. Meaningful specialty focus: Practice in women’s midlife health, a critically underserved area where you help close one of the most persistent gaps in care. Mission-aligned, patient-centered culture: Join a team dedicated to empathy, equity, and clinical excellence.

Midi Health

Nurse Practitioner - CA License (Part-Time)

Posted on:

April 29, 2026

Job Type:

Part-Time

Role Type:

Primary Care

License:

NP/APP

State License:

Compact / Multi-State

At Midi Health, we're on a mission to revolutionize healthcare for women at midlife—to relieve their symptoms, support their wellbeing, and ensure they feel seen, heard, and cared for. Our care is personalized, evidence-based, and covered by insurance, making it more accessible to women across the country. Wherever they live. Whatever their health story. We’re growing quickly and looking for passionate part-time Nurse Practitioners to join our dedicated clinical team. You’ll help close the gender health gap by guiding women through perimenopause, menopause, and other midlife transitions with compassionate, evidence-based care.

Why Work With Midi? Mission-Driven Impact: Help us transform healthcare for women in midlife. Remote Role with Set Hours: Enjoy the benefits of remote work with a consistent, structured schedule—adjusted only when business needs require. Purposeful Visits: Our appointments are designed to give you the appropriate time you need to provide meaningful, individualized care. Technology + Support: With structured onboarding, user-friendly technology, and operational assistance—including elements of logistics, scheduling, and clinical operations—you’ll be equipped to focus on delivering great care without being on your own. Community of Care: Join a collaborative, respectful team that shares your passion for women’s health. Scheduling & Time Commitment At Midi, we offer a structured part-time schedule with clearly defined expectations: Core Commitments Minimum of 3 days per week required for part-time status, 20 hours per week Minimum 2 hour block time with a maximum of 6 hour block time per workday allowing for focused, high-quality visits To maintain team and patient continuity, we ask providers to limit time off to no more than three consecutive days within the scheduled work week Patient-Based Scheduling For our part-time NP’s, patient-facing hours are scheduled between 7AM - 4PM in the patient’s local time zone. These hours are designed to align with practice needs and ensure patients have timely access to care. Weekend Availability Weekend shifts become available after completing 80 hours of weekday (Monday–Friday) patient-facing care

Active, unrestricted, and unencumbered Nurse Practitioner license in at least one U.S. state. Multiple state licenses highly preferred Prescriptive authority as a Nurse Practitioner Active national board certification as a Nurse Practitioner (FNP, WHNP, AGNP, or similar) Minimum of 3 years of recent experience (within the last 5 years) practicing as a Nurse Practitioner in Primary Care, Women’s Health, or Gynecology Ability to work independently and make sound clinical decisions High level of proficiency and efficiency with technology (telehealth, EMRs, communication tools) A strong, demonstrated passion for caring for women navigating menopause and midlife health transitions

Quality visits, better conversations: Our appointments allow time to listen, educate, and personalize care. Evidence-based protocols: You’ll be trained in expert-developed clinical pathways that combine hormonal therapy, lifestyle coaching, and medication when appropriate. Care beyond the screen: Patients receive labs, prescriptions, supplements, and referrals as needed—our platform makes it seamless. You’re never alone: Supported by a collaborative team of clinicians, care coordinators, and clinical leaders, with opportunities to grow and specialize over time. Meaningful specialty focus: Practice in women’s midlife health—a critically underserved area—helping close one of the most persistent gaps in care. Remote, part-time hours: Work comfortably from home with a schedule that fits your life. Mission-aligned, patient-centered culture: Join a team dedicated to empathy, equity, and excellence. Support that respects you: We value your autonomy and wellbeing, providing the backing you need to thrive.

PatientPAL

Nurse Practitioner

Posted on:

April 29, 2026

Job Type:

Full-Time

Role Type:

Primary Care

License:

NP/APP

State License:

Compact / Multi-State

Patient PAL is dedicated to making your healthcare a piece of cake. We provide patient advocacy and healthcare claims negotiation services through compassionate healthcare professionals who understand the challenges faced when desiring to provide the best health care treatment available for someone in need. Our flagship patient advocacy program empowers thousands of members to navigate their healthcare journey with support and confidence.

We are seeking a compassionate and clinically skilled Nurse Practitioner Specialist to join our remote team. In this role, you will serve as a clinical advocate for Patient PAL members. You will review complex medical cases, interpret clinical data, communicate with treating physicians, and support claims negotiation efforts by providing expert clinical perspectives. Your goal is to ensure members receive appropriate, timely, and high quality care while helping them navigate insurance denials, treatment authorizations, and medical billing disputes.

Degree in Nursing (MSN or DNP) from an accredited program. Active and unrestricted Nurse Practitioner license in at least one U.S. state; compact license or multi state licensure preferred. National board certification as a Family Nurse Practitioner (FNP), Adult Gerontology Primary Care Nurse Practitioner (AGPCNP), or similar. Minimum 1 year of clinical experience as a Nurse Practitioner in primary care, internal medicine, or a related specialty. Strong understanding of health insurance processes including prior authorization, medical necessity determinations, appeals, and claims denial reasons. Excellent written and verbal communication skills to explain complex medical information clearly to patients and insurance representatives. Proficiency with telehealth platforms, electronic health records (EHR), and secure document sharing. Ability to work independently in a remote environment with strong time management and organizational skills. Preferred Qualifications: Experience in patient advocacy, case management, or utilization review. Familiarity with Medicare, Medicaid, and commercial insurance appeal processes. Bilingual proficiency in English and Spanish.

Conduct remote clinical assessments of Patient PAL members by reviewing medical records, diagnostic test results, and treatment histories. Communicate directly with members via secure telehealth platform to understand their health concerns, treatment goals, and barriers to care. Collaborate with the claims negotiation team to provide clinical justification for appealed insurance denials, prior authorization requests, and out of network coverage exceptions. Identify gaps in care, potential misdiagnoses, or alternative treatment options that align with evidence based practice. Serve as a liaison between members, their families, and treating physicians to clarify treatment plans and coordinate second opinions when needed. Educate members on their health conditions, prescribed medications, and recommended procedures to empower informed decision making. Document all clinical findings, recommendations, and advocacy actions in the Patient PAL electronic system. Stay current on clinical guidelines, insurance coverage policies, and healthcare regulations affecting patient access to care. Participate in weekly virtual team meetings to discuss complex cases and improve advocacy strategies.

Pegasus Knowledge Solutions, Inc.

Nurse - Medical Bill Reviewer

Posted on:

April 29, 2026

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Illinois

Founded in 1997, PKSI [Pegasus Knowledge Solutions, Inc.] is an independent, advanced analytics software and services organization, that partners with the industry leading providers to help customers create value from their data, bringing a range of talents, including data integration and preparation, big data environments, data mining, predictive analytics, machine learning and text mining, as well as dashboarding and visualization. PKSI is focused on quality, speed of execution, value and above all, customer satisfaction. Our global solution delivery centers are ISO 9001-2008 and ISMS 27001-2013 Certified. Leading Organizations are harnessing the power of Advanced Analytics today to address business challenges. Our Analytics solutions and services utilize statistical techniques, predictive modeling, text and social data mining to provide customer and operational insights. Our Data scientists can help you sift through customer data (including web and social data) and syndicated data sets to build statistical models to improve business outcomes, like customer and employee retention, fraud reduction, increased sales and many other areas. These models seamlessly integrate into visualization tools which can be accessed on any device to enable collaborative sharing and improved decision making. Our industry-leading technology and platform partnerships enables us to bring best-in-class solutions to you.

ob Title : Nurse - Medical Bill Reviewer Location : Remote Type : Full-time Position Summary: We are seeking a detail-oriented and knowledgeable Medical Bill Coder who can review, validate, and apply appropriate coding to medical bills in compliance with state-specific regulations and industry standards. The ideal candidate will ensure billing accuracy, improve claims efficiency, and reduce compliance risk.

Qualifications License Requirement: Candidates must have either an LPN or RN license (Temp or FTE). Minimum 3-5 years of experience in medical coding, preferably in a workers’ compensation or physical medicine environment. Strong understanding of state-specific billing guidelines and medical coding compliance. Proficiency with EHR systems and coding software (e.g., EncoderPro, Availity). High attention to detail, strong analytical skills, and ability to meet deadlines. Preferred Skills: Experience working with workers’ compensation claims. Familiarity with NCCI edits and payer-specific rules.

Review incoming medical bills for completeness and accuracy. Assign proper CPT, ICD-10, and HCPCS codes based on medical records and documentation. Ensure coding aligns with state regulations, payer-specific rules, and client's policies. Identify and correct coding discrepancies, unbundled codes, or documentation gaps. Collaborate with billing, claims, and compliance teams to resolve coding-related issues. Stay updated with coding changes, fee schedules, and relevant state legislation. Support audits and internal reviews as needed.

Penguin Ai

UM Policy Review Nurse - Utilisation Management

Posted on:

April 29, 2026

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Compact / Multi-State

We’re not your average AI company - and we don’t want average teammates. Penguin Ai was founded by healthcare veterans who knew the system needed more than hype and half-baked algorithms. We built an AI platform that actually works in healthcare - across Prior Auth, HCC Coding, and all those soul-crushing workflows no one brags about. Our platform is fast to implement (think: 60 days), reduces administrative costs up to 40%, and makes payers look like heroes without writing a line of code. This is AI for the real world of healthcare. And just to put a fine point on it: powerhouses like Snowflake and AWS don't just partner with anyone. Their trust in our platform speaks volumes about our robust, scalable, and secure technology. Our audacious vision was first ignited by our CEO Fawad Butt, whose leadership as Chief Data Officer at both Optum and Kaiser Permanente gave him oversight of healthcare data representing nearly 75% of American lives. So, he didn't just see the problem; he lived it. Fawad understood that healthcare AI couldn't be a bandage - it had to be a purpose-built, battle-ready solution, meticulously crafted for the intricate, human-first world of medicine, not some hastily retrofitted industry software. So with Fawad, who else is steering this iceberg? A dream team boasting over 150 years of combined, hard-won healthcare experience! We're talking about heavy hitters like Kishore, Mark, Peter and Terry… who all bring different successes & expertise from AI & healthcare. These aren't just impressive resumes; they're the architects and masterminds behind a platform that doesn't just process data – it genuinely understands healthcare's pulse. We're growing faster than a penguin on a waterslide and we’re always on the hunt for customer-obsessed problem-solvers to help our clients unlock the full potential of their AI investments. This isn’t some futuristic sci-fi movie set, this is AI for the real, gritty, essential world of healthcare where speed & data matter.

You are the clinical source of truth for how Penguin Ai turns health plan UM and medical policy text into structured, machine‑readable logic. This is not chart review - you validate the AI’s decomposition of policies into discrete questions, answers, decision points, and data facts so our UM Agent Suite can act reliably and audibly at scale. Your judgment is the gateway between narrative policy and production logic.

Active, unrestricted RN license in the United States (compact license preferred) Minimum 5 years clinical nursing experience, with ≥2 years in utilization management, medical policy interpretation, appeals/grievances, or policy development at a health plan or UM vendor Demonstrated fluency reading and applying health plan medical policies, coverage determinations, and national criteria (InterQual, MCG, CMS NCDs/LCDs) Strong analytical/logical reasoning - able to decompose narrative policy into discrete, testable decision points without losing nuance Precise written communication - able to document persuasive, defensible clinical rationale. Comfortable in structured, software‑based review environments and providing clear feedback on AI output Bonus Points: Your Secret Weapons! BSN or MSN Background in clinical informatics, structured data, ontologies, or terminology standards (SNOMED CT, ICD‑10, CPT, LOINC) Prior exposure to AI/ML‑assisted clinical workflows, CDS, or ambient documentation tools Familiarity with URAC AI in Healthcare Accreditation, CMS‑0057‑F, or NCQA UM frameworks Prior experience at a health plan, UM/PA vendor, or healthcare technology company at payer scale

Validate AI policy decompositions: Confirm that AI‑generated questions, answers, decision points, and data facts reflect the clinical intent, scope, inclusions/exclusions, and decision logic of source policies Surface clinical nuance: Identify comorbidities, contraindications, sequencing, timing windows, documentation thresholds, edge cases, ambiguous language, and latent assumptions the AI may miss Approve, edit, or reject: Take definitive clinical positions in PolicyVault™ and related tooling; rewrite items to be unambiguous and answerable from typical documentation Document durable rationale: Produce concise, audit‑grade explanations for every validation decision to support URAC/CMS transparency and payer audits Close the loop with product & engineering: Partner to convert recurring patterns into upstream fixes in prompting, taxonomy, and validation workflows Keep the source of truth current: Track updates to client policies, InterQual/MCG, CMS NCDs/LCDs, and specialty guidelines; ensure structured representations remain aligned Raise the clinical bar: Build playbooks, validation standards, and onboarding materials for future policy reviewers

Gainwell Technologies

Nurse Reviewer Appeals and Hearings- Remote

Posted on:

April 29, 2026

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

For 50 years, our nation’s federal Medicaid program has worked to improve the health, safety and well-being of America’s most vulnerable populations: low-income families, women and children, seniors, and those with disabilities. With positive health and cost outcomes that pierce inequities and impact economies, the success of these programs is inextricably tied to the prosperity of communities, individual states and the nation as a whole. We think that demands respect and, more importantly, is deserving of a lifetime commitment from innovators who can help those who operate within and around health and human services evolve — in any market at any stage. At Gainwell Technologies, that’s our sole focus. Built across more than five decades, Gainwell has intentionally seized opportunities to advance its digitally enabled services to meet agencies, health plans and MCOs where they are on their modernization journeys and propel them into the future of public health. Our commitment to innovation, deep experience and ability to leverage insights from customers across 50 states has allowed us to expand on next-generation, cloud-enabled technologies. Today, Gainwell offers one of the most comprehensive suites of scalable services and solutions on the market — all proven to deliver cost savings, better patient outcomes and an improved provider experience. Equally important to our expanding technologies and results: We bring ideas that bring policies to life.

It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you’ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development. Summary: We are seeking a talented individual for a Nurse Reviewer Appeals and Hearings to coordinate and perform all appeal related duties including analyzing and responding appropriately to appeals from providers; reviewing documentation to ensure all aspects of the appeal have been addressed properly and accurately; prepare case files and case summaries for hearings; and participate in in virtual and on-site hearings.

Active, Unrestricted RN license from the United States and in the primary home residency, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), 5+ years clinical experience or 5+ years medical record coding experience required 3+ years utilization review experience or claims auditing required Working knowledge of the appeals and hearings process Experience using MCG or InterQual criteria preferred Excellent written communication skills including ability to write clear, concise, accurate, and fact-based rationales in support of appeal determinations. Excellent oral communication skills with particular emphasis on verbally presenting case summaries and decisions. Ability to multi-task in a fast-paced production environment. What you should expect in this role Work Location: Remote within the United States Travel Requirement: Up to 25% Travel for onsite hearing testimony

Reviews provider appeals and redeterminations using approved clinical and coding guidelines and documents appeal determinations clearly and concisely. Analyzes and reviews appeal documentation to ensure all aspects of the appeal have been addressed properly and accurately while maintaining production goals and quality standards. Prepares case files and case summaries for hearings and actively participates in hearings in conjunction with the Medical Director. Assist management with training new reviewers to include daily monitoring, mentoring, feedback and education. Maintains current knowledge of clinical criteria guidelines and/or coding guidelines; successfully completes required CEUs to maintain RN license and/or coding certification. Responsible for attending training and scheduled meetings to enhance skills and working knowledge of clinical policies, procedures, rules, and regulations. Actively cross-trains to perform reviews of multiple claim types to provide a flexible workforce to meet client needs.

Gainwell Technologies

DRG Nurse Reviewer Appeals and Hearings- Remote

Posted on:

April 29, 2026

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

For 50 years, our nation’s federal Medicaid program has worked to improve the health, safety and well-being of America’s most vulnerable populations: low-income families, women and children, seniors, and those with disabilities. With positive health and cost outcomes that pierce inequities and impact economies, the success of these programs is inextricably tied to the prosperity of communities, individual states and the nation as a whole. We think that demands respect and, more importantly, is deserving of a lifetime commitment from innovators who can help those who operate within and around health and human services evolve — in any market at any stage. At Gainwell Technologies, that’s our sole focus. Built across more than five decades, Gainwell has intentionally seized opportunities to advance its digitally enabled services to meet agencies, health plans and MCOs where they are on their modernization journeys and propel them into the future of public health. Our commitment to innovation, deep experience and ability to leverage insights from customers across 50 states has allowed us to expand on next-generation, cloud-enabled technologies. Today, Gainwell offers one of the most comprehensive suites of scalable services and solutions on the market — all proven to deliver cost savings, better patient outcomes and an improved provider experience. Equally important to our expanding technologies and results: We bring ideas that bring policies to life.

It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you’ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development. Sign-on bonuses are available for highly qualified candidates. Summary We are seeking a talented individual for a DRG Nurse Reviewer Appeals and Hearings to coordinate and perform all appeal related duties including analyzing and responding appropriately to appeals from providers; reviewing documentation to ensure all aspects of the appeal have been addressed properly and accurately; prepare case files and case summaries for hearings; and participate in in virtual and on-site hearings.

Active, Unrestricted RN license from the United States and in the primary home residency, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), required Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or Certified Professional Medical Auditor (CPMA) required 5+ years clinical experience or 5+ years medical record coding experience preferred Working knowledge of the appeals and hearings process Excellent written communication skills including ability to write clear, concise, accurate, and fact-based rationales in support of appeal determinations. Excellent oral communication skills with particular emphasis on verbally presenting case summaries and decisions. Ability to multi-task in a fast-paced production environment. What You Should Expect In This Role Remote (Work from Home) Up to 25% Travel for onsite hearing testimony

Reviews provider appeals and redeterminations using approved clinical and coding guidelines and documents appeal determinations clearly and concisely. Analyzes and reviews appeal documentation to ensure all aspects of the appeal have been addressed properly and accurately while maintaining production goals and quality standards. Prepares case files and case summaries for hearings and actively participates in hearings in conjunction with the Medical Director. Assists management with training new reviewers to include daily monitoring, mentoring, feedback and education. Maintains current knowledge of clinical criteria guidelines and/or coding guidelines; successfully completes required CEUs to maintain RN license and/or coding certification. Responsible for attending training and scheduled meetings to enhance skills and working knowledge of clinical policies, procedures, rules, and regulations. Actively cross-trains to perform reviews of multiple claim types to provide a flexible workforce to meet client needs.

ForHealth Consulting at UMass Chan Medical School

Nurse Reviewer II-Case Management

Posted on:

April 29, 2026

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Massachusetts

ForHealth Consulting partners with purposeful organizations, including state Medicaid agencies and health and human services organizations, to make the healthcare experience better for all – more equitable, effective, and accessible. We know that to do this, we need to address every aspect of the system – how we pay for it, how we manage information, and how we deliver quality care to everyone. As part of UMass Chan Medical School, we leverage world-class expertise to create transformational solutions across the health and human services system. ForHealth Consulting believes in the power of collaboration and a shared purpose – together, we can make healthcare better.

Under the general supervision of the Associate Director, Clinical Coordinator, or designee, the Nurse Reviewer II is responsible for providing administrative case management as part of the Community Case Management Program. This position is responsible for the authorization, coordination and facilitation of long term services and supports (LTSS) for program Members. As a member of a multidisciplinary team, the Nurse Reviewer II is responsible for assessing, planning, organizing, reviewing and evaluating the care needs of Members requiring community-based services. This position fosters and promotes continuity of care and cooperative partnerships by liaising with nursing providers, state agency staff, acute care hospitals and other programs/organizations involved in the provision of services.

Required Qualifications: RN licensed to practice in Massachusetts 5-7 years of work experience with at least 3 recent years providing direct service or case management to the pediatric, young adult, or adult medically complex population Ability to travel statewide to Member homes and service providers places of business Experience with Office Application and database Valid Drivers license required Preferred Qualifications: Experience with home care Knowledge of applicable state regulations Experience with prior authorization and/or eligibility determinations Experience with the care of medically complex individuals Supervision Supervision Received Supervision received from Clinical Coordinator Supervision Exercised None Environmental Working Conditions Remote/desk work with statewide travel required

Serve as the clinical manager for an assigned caseload of Members. Contribute as an active member of a multi/inter-disciplinary team to assess, plan, organize, review and evaluate the care needs of Members requiring health care services, to include outpatient and home based therapy services. Conduct on-site reviews and assessments of Members community long term care needs to determine medical necessity and clinical eligibility for Community Case Management and Continuous Skilled Nursing Services Determine and authorize services for Members in accordance with program guidelines and regulations, meeting all established deadlines. Prepare and implement Member service records. Coordinate, facilitate and monitor the delivery of services to members. Review and document all relevant information into data system applications in accordance with program guidelines and regulations. Conduct routine and ad-hoc evaluations and re-evaluations of Members services. Contact and engage providers, state agency offices, and Members to obtain information and records needed to conduct a comprehensive clinical review of the case and final determination. Evaluate and document the appropriateness of Members services and make modifications, as required. Maintain individual records documenting all Member encounters and contacts; write clinical summaries. Foster and promote continuity of care and cooperative partnerships by liaising with health care providers, acute care hospitals and other programs/organizations involved in the provision of services. Prepare and respond to inquiries related to appeals on clinical determinations. Maintain positive working relationships with peers, leadership, Members, relevant informal supports, provider organizations, and state agencies. Maintain the confidentiality of all business documents and correspondence per UMass Chan Medical School/ForHealth Consulting procedures and HIPAA regulations. Participate in performance improvement initiatives and demonstrates the use of quality improvement in daily operations. Participates in training and onboarding of new clinical staff Comply with established departmental policies, procedures and objectives. Perform other duties as required.

ForHealth Consulting at UMass Chan Medical School

Nurse Rev II-Case Mgt (Home Based with Client Visits)

Posted on:

April 29, 2026

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Massachusetts

At ForHealth Consulting, part of UMass Chan Medical School, we are dedicated to advancing health and well-being across Massachusetts communities. Youll be part of a mission-driven organization that values collaboration, innovation, and compassion in care management. The University of Massachusetts Chan Medical School welcomes all qualified applicants and complies with all state and federal anti-discrimination laws.

ForHealth Consulting at UMass Chan Medical School is seeking a detail-oriented Nurse Reviewer II with experience caring for individuals with complex medical needs to join our Community Case Management Program. In this role, you will manage a caseload of members, ensuring they receive the long-term services and supports (LTSS) they need to thrive in the community. This position combines the flexibility of remote work with meaningful field interactions through home and site visits. Youll play a key role on a multidisciplinary team - assessing, planning, coordinating, and authorizing care for individuals with complex medical needs, while collaborating closely with providers, state agencies, and other healthcare partners to ensure continuity and quality of care.

Required Qualifications: RN licensed to practice in Massachusetts 5-7 years of work experience with at least 3 recent years providing direct service or case management to the pediatric, young adult, or adult medically complex population Ability to travel statewide to Member homes and service providers places of business Experience with Office Application and database Valid Drivers license required Preferred Qualifications: Experience with home care Knowledge of applicable state regulations Experience with prior authorization and/or eligibility determinations Experience with the care of medically complex individuals

Serve as the clinical manager for an assigned caseload of Members. Contribute as an active member of a multi/inter-disciplinary team to assess, plan, organize, review and evaluate the care needs of Members requiring health care services, to include outpatient and home based therapy services. Conduct on-site reviews and assessments of Members community long term care needs to determine medical necessity and clinical eligibility for Community Case Management and Continuous Skilled Nursing Services Determine and authorize services for Members in accordance with program guidelines and regulations, meeting all established deadlines. Prepare and implement Member service records. Coordinate, facilitate and monitor the delivery of services to members. Review and document all relevant information into data system applications in accordance with program guidelines and regulations. Conduct routine and ad-hoc evaluations and re-evaluations of Members services. Contact and engage providers, state agency offices, and Members to obtain information and records needed to conduct a comprehensive clinical review of the case and final determination. Evaluate and document the appropriateness of Members services and make modifications, as required. Maintain individual records documenting all Member encounters and contacts; write clinical summaries. Foster and promote continuity of care and cooperative partnerships by liaising with health care providers, acute care hospitals and other programs/organizations involved in the provision of services. Prepare and respond to inquiries related to appeals on clinical determinations. Maintain positive working relationships with peers, leadership, Members, relevant informal supports, provider organizations, and state agencies. Maintain the confidentiality of all business documents and correspondence per UMass Chan Medical School/ForHealth Consulting procedures and HIPAA regulations. Participate in performance improvement initiatives and demonstrates the use of quality improvement in daily operations. Participates in training and onboarding of new clinical staff Comply with established departmental policies, procedures and objectives. Perform other duties as required.

Harris Computer

Nurse Care Manager (RN/LPN) - REMOTE MICHIGAN

Posted on:

April 29, 2026

Job Type:

Part-Time

Role Type:

Care Management

License:

RN

State License:

Michigan

Harris provides mission-critical software solutions for the Public Sector, Healthcare, Utilities, and Private Sector verticals throughout North America, Europe, Asia, and Australia. Harris is a wholly-owned subsidiary of Constellation Software, Inc (CSI), a publicly-traded company on the Toronto Stock Exchange. Trading symbol CSU.

Location: MICHIGAN - 100% REMOTE (NOT A COMPACT STATE) Join our mission to help transform healthcare delivery from reactive, episodic care to proactively managed patient care that prevents live-changing problems before they happen for patients with two or more chronic conditions. We believe every patient with chronic disease deserves consistent check-ins, follow-up, and support. The position of the Remote Chronic Care Coordinator will perform telephonic encounters with patients on behalf of our partners each month and develops detailed care plans within our care plan templates in the electronic health record. This begins as an Independent 1099 Contractor position but offers the potential to reach full-time W2 employment (with employee benefits). Esrun Health is seeking nurses to work part-time from their home office as independent contractors while complying with HIPAA privacy laws. You will set your own hours and will not be held to a daily work hour schedule. Esrun Health wants its team members to have the flexibility to balance their work-life with their home life. Part-time team members will typically need to dedicate an average of 20-30 hours per week to care for their assigned patients. This unique business model allows you to choose what days and what hours of the day you dedicate to care for your patients. The Care Coordinator will be assigned a patient panel based on skill and efficiency level and is expected to carry a patient panel of a minimum of 100 patients per calendar month within the first three months of assignment. Care Coordinators will be expected to complete encounters on 90 percent of the patients they are assigned each month unless patients are unable to participate due to current health conditions. Compensation Structure Esrun Health utilizes a productivity-based pay structure: $10.00 per completed patient encounter up to 99 encounters/month. $10.25 100-149 encounters/month $12.00 150-199 encounters/month, $14.00 200-249 encounters/month $16.00 >250 encounters/month. Payment tier increases require 3 months consistency to achieve. There is a $1/encounter incentive compensation for bilingual nurses equal to $3/hr. A patient encounter will take a minimum of 20 minutes (time is cumulative to include chart review time, time spent during call attempts and the non-face-to-face encounter, time for care coordination, and time spent for documentation/billing time).

Graduate from an accredited School of Nursing (LPN, LVN, RN, BSN, etc.) Current active license to practice as an RN/ LVN/LPN held in the state of MICHIGAN (NOT A COMPACT STATE) with no disciplinary actions noted or licensed in the non-compact state where the applicable practice is located. A minimum of two (2) years of clinical experience in a Med/Surg, Case Management, and/or home health care. Hands-on experience with Electronic Medical Records as well as an understanding of Windows desktop and applications (MIcrosoft Office 365, Teams, Excel, etc), also while being in a HIPAA compliant area in home to conduct Chronic Care Management duties. Ability to exercise initiative, judgment, organization, time-management, problem-solving, and decision-making skills. Skilled in using various computer programs (If you don’t love computers, you won’t love this position!) High Speed Internet and Desktop or Laptop computer (Has to be operation system of Windows or Mac) NO Chromebooks OR iPads Excellent verbal, written and listening skills are a must. What will make you stand out: Quickly recognize condition-related warning signs. Organized, thorough documentation skills. Self-directed. Ability to prioritize responsibilities. Demonstrated time management skills. Clear diction. Applies exemplary phone etiquette to every call. Committed to excellence in patient care and customer service. Ability to troubleshoot minor technological issues related to remote working environment.

The role of the Care Coordinator is to abide by the plan of care and orders of the practice. Ability to provide prevention and intervention for multiple disease conditions through motivational coaching. Develops a positive interaction with patients on behalf of our practices. Improve revenue by creating billable Chronic Care Management episodes, increasing visits for management of chronic conditions. Develops detailed care plans for both the doctors and patients. The care plans exist for prevention and intervention purposes. Understand health care goals associated with chronic disease management provided by the practice. Attend regularly scheduled meetings (i.e., Bi-Monthly Staff Meetings, monthly one on one's, etc.). These “mandatory” meetings will be important to define the current scope of work.

Harris Computer

NON-COMPACT STATE - PT Remote CCM/RTM Care Management Nurse (CA)

Posted on:

April 29, 2026

Job Type:

Part-Time

Role Type:

Care Management

License:

RN

State License:

Virginia

Harris provides mission-critical software solutions for the Public Sector, Healthcare, Utilities, and Private Sector verticals throughout North America, Europe, Asia, and Australia. Harris is a wholly-owned subsidiary of Constellation Software, Inc (CSI), a publicly-traded company on the Toronto Stock Exchange. Trading symbol CSU.

Join our mission to help transform healthcare delivery from reactive, episodic care to proactively managed patient care that prevents live-changing problems before they happen for patients with two or more chronic conditions. We believe every patient with chronic disease deserves consistent check-ins, follow-up, and support. The position of the Nurse Chronic Care Coordinator, Remote will perform telephonic encounters with patients on behalf of our partners each month and develops detailed care plans within our care plan templates in the electronic health record. This begins as an Independent 1099 Contractor position but offers the potential to reach full-time W2 employment (with employee benefits). Esrun Health is seeking Nurses to work part-time from their home office while complying with HIPAA privacy laws. You will set your own hours and will not be held to a daily work hour schedule. You will be contracted to work a minimum of 20hrs/wk. Esrun Health wants its team members to have the flexibility to balance their work-life with their home life. Part-time team members will typically need to dedicate an average of 20-30 hours per week to care for their assigned patients. This unique business model allows you to choose what days and what hours of the day you dedicate to care for your patients. The Care Coordinator will be assigned a patient panel based on skill and efficiency level and is expected to carry a patient panel of a minimum of 100 patients per calendar month. Care Coordinators will be expected to complete encounters on 90 percent of the patients they are assigned. Esrun Health utilizes a productivity-based pay structure and pays $10.00 per completed patient encounter up to 99 encounters/month, $10.25/encounter from 100-149 encounters/month, $12/encounter from 150-199 encounters/month, $14/encounter from 200-249 encounters/month, and $16/encounter for >250 encounters/month. Payment tier increases require 2 months consistency to achieve. A patient encounter will take a minimum of 20 minutes (time is cumulative including chart review, call times/attempts/texts, care plan development, care coordination, and documentation time).

Graduate from an accredited School of Nursing. (LPN, LVN, RN, BSN, etc.) Current license to practice as an RN/ LVN/LPN with no disciplinary actions noted A minimum of two (2) years of clinical experience in a Med/Surg, Case Management, and/or home health care. Hands-on experience with Electronic Medical Records as well as an understanding of Windows desktop and applications (Microsoft Office 365, Teams, Excel, etc.), also while being in a HIPAA compliant area in home to conduct Chronic Care Management duties. Ability to exercise initiative, judgment, organization, time-management, problem-solving, and decision-making skills. Skilled in using various computer programs (If you don’t love computers, you won’t love this position!) High Speed Internet and Desktop or Laptop computer (Has to be operation system of Windows 10 or higher or Mac) NO Chromebooks and no iPad. Excellent verbal, written and listening skills are a must. What Will Make You Stand Out: Quickly recognize condition-related warning signs. Organized, thorough documentation skills. Self-directed. Ability to prioritize responsibilities. Demonstrated time management skills. Clear diction. Applies exemplary phone etiquette to every call. Committed to excellence in patient care and customer service.

The role of the Care Coordinator is to abide by the plan of care and orders of the practice. Ability to provide prevention and intervention for multiple disease conditions through motivational coaching. Develops a positive interaction with patients on behalf of our practices. Improve revenue by creating billable CCM episodes, increasing visits for management of chronic conditions. Develops detailed care plans for both the doctors and patients. The care plans exist for prevention and intervention purposes. Understand health care goals associated with chronic disease management provided by the practice. Attend regularly scheduled meetings (i.e., Bi-Monthly Staff Meetings, monthly one on one's, etc.). These “mandatory” meetings will be important to define the current scope of work.

J.S. Held LLC

Legal Nurse Consultant (Part Time)

Posted on:

April 28, 2026

Job Type:

Part-Time

Role Type:

License:

RN

State License:

Georgia

J.S. Held is a global consulting firm that combines technical, scientific, financial, and strategic expertise to advise clients seeking to realize value and mitigate risk. Our professionals serve as trusted advisors to organizations facing high stakes matters demanding urgent attention, staunch integrity, proven experience, clear-cut analysis, and an understanding of both tangible and intangible assets. The firm provides a comprehensive suite of services, products, and data that enable clients to navigate complex, contentious, and often catastrophic situations.

The ideal candidate will bring established client relationships and a proven track record of generating revenue. This role is designed for professionals who can leverage their network to drive immediate impact and accelerate the growth of our practice. In addition to business development, you’ll enjoy high visibility across the organization, opportunities to shape strategy, mentor emerging talent, and contribute to thought leadership initiatives.

Bachelor Nursing degree or associate nursing degree with a bachelor’s degree. 5+ years of LNC experience, defense preferred Active, non-restrictive RN license 10+ Years of Acute Care Experience; orthopedics, trauma, ICU, neurosurgery, ED is preferred Entrepreneurial mindset with a passion for building teams, developing services, and growing a business. Functional in Microsoft Office, Adobe Acrobat, file sharing/email programs, Zoom/Teams Works independently with minimal supervision Excellent written communication and research skills. Exhibits critical thinking, meticulous organizational/time management skills Highly motivated, self-reliant and can function independently yet collaborative when necessary. Preferred Qualifications: Legal Nurse Certification (AALNC) or equivalent LNC certification. Physical and Mental Job Qualifications Ability to travel as needed

Maintain competency within the Legal Nurse Consulting field through participation in ongoing educational activities. Continue knowledge base of medical, chiropractic, pharmaceutical practices, care, treatment, etc. Exhibit writing skills through the production of professional, clear, concise, grammatically correct, easily readable, and informative reports. Capable of taking large and or medically complex files. Can create a chronology/summary as well as in-depth analysis of claim information Possess proficiency in the suite of Microsoft Office, Adobe Acrobat, file-sharing software & email programs, to produce professionally drafted narrative reports and tables. Ability to navigate electronically generated/scanned medical records. Perform medical research related to case issues and standards of care/practice. Exhibit exceptional organizational and time management skills, prioritizing assignments to meet deadlines, and ensuring completion of assignments. Analysis and complete general liability review with creation of written reports generate reports in all report formats. Expanded knowledge of medical practices across multiple disciplines. Exhibit’s ability to obtain research data to support critical thinking, analyzes case information effectively. Generation of work product that eventually requires no more than 1-3 edits. Review/analysis simple to moderately complex general liability files. Performs position duties consistently and meets all assignment deadlines. Works independently and manages time/assignments well.

Providence Health & Services

Utilization Review RN - Remote

Posted on:

April 28, 2026

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Oregon

At Providence, our strength lies in Our Promise of “Know me, care for me, ease my way.” Working at our family of organizations means that regardless of your role, we’ll walk alongside you in your career, supporting you so you can support others. We provide best-in-class benefits and we foster an inclusive workplace where diversity is valued, and everyone is essential, heard and respected. Together, our 120,000 caregivers (all employees) serve in over 50 hospitals, over 1,000 clinics and a full range of health and social services across Alaska, California, Montana, New Mexico, Oregon, Texas and Washington. As a comprehensive health care organization, we are serving more people, advancing best practices and continuing our more than 100-year tradition of serving the poor and vulnerable.

Utilization Review RN - Remote Providence Health Plan caregivers are not simply valued – they’re invaluable. Join our team at Providence Health Plan Partners and thrive in our culture of patient-focused, whole-person care built on understanding, commitment, and mutual respect. Your voice matters here, because we know that to inspire and retain the best people, we must empower them. This position offers 100% remote work for candidates residing in Oregon .

Required Qualifications: Upon hire: Oregon Registered Nurse License 5 years clinical nursing experience. Experience working with physicians in collaboration and management of patient care. Preferred Qualifications: Bachelor’s Degree in Nursing or health care. Utilization review, discharge planning and/or managed care experience.

The RN Care Coord-Qual Med Mgmt will provide administration of medical management programs for prior authorization. These programs are developed to manage medical expense, determine medically appropriate services and define clinical criteria for decision making.

IntellaTriage

Remote Hospice Triage RN PT 3:30p-11p Compact & CA license needed

Posted on:

April 28, 2026

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 remote 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 are seeking a compassionate registered nurse (RN) to join our growing team! In this role, you will provide critical after-hours support, triaging hospice patients and family needs over the phone wit professionalism and empathy. You will help ensure timely interventions and coordination of care for patients receiving hospice services.

Active multistate Registered Nurse (RN) license Hospice, palliative, or end-of-life care is strongly preferred Must be comfortable with technology and electronic medical records (EMR) utilized for documentation of calls Ability and comfort with typing documentation and notes in a fast-paced environment 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) Strong communication and critical thinking skills Ability to work independently in a remote environment This is a remote position that requires consistent attendance, active communication, and reliable internet connectivity during all scheduled shifts to support timely patient care coordination

Provide telephone triage for hospice patients and families Assess patient conditions and determine appropriate next steps Collaborate with on-call teams to coordinate care and resources Accurately document all communications and interventions Maintain a calm and professional demeanor while handling urgent calls.

CVS Health

Utilization Management Nurse Consultant - Medical Review (Remote)

Posted on:

April 28, 2026

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Compact / Multi-State

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.

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Information Schedule: Monday–Friday 8:00am-5:00pm EST Location: 100% Remote (U.S. only) Position Summary 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, 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.

Oscar Health

Utilization Review Nurse

Posted on:

April 28, 2026

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Compact / Multi-State

Hi, we're Oscar. We're hiring a Utilization Review Nurse to join our Utilization Review team. Oscar is the first health insurance company built around a full stack technology platform and a relentless focus on serving our members. We started Oscar in 2012 to create the kind of health insurance company we would want for ourselves—one that behaves like a doctor in the family.

You will perform frequent case reviews, check medical records and speak with care providers regarding treatment as needed. You will make recommendations regarding the appropriateness of care for identified diagnoses based on the research results for those conditions. You will report into the Supervisor, Utilization Review. Work Location: This is a remote position, open to candidates who reside in: Texas, Georgia, Arizona, and Florida. While your daily work will be completed from your home office, occasional travel may be required for team meetings and company events. Pay Transparency: The base pay for this role is: $35.00 - $45.94 per hour. You are also eligible for employee benefits and monthly vacation accrual at a rate of 15 days per year.

Active, unrestricted RN licensure from the United States in [state], OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC) Associate Degree or Bachelors Degree - Nursing or Graduate of Accredited School of Nursing MCG or InterQual tooling experience Ability to obtain additional state licenses to meet business needs 1+ year of utilization review experience in a managed care setting 1+ years of clinical experience (including at least 1+ year clinical practice in an acute care setting, i.e., ER or hospital) Bonus Points BSN Previous experience conducting concurrent or inpatient reviews for a managed care plan

Complete medical necessity reviews and level of care reviews for requested services using clinical judgment and Oscar Clinical Guidelines, Milliman Care Guidelines Obtain the information necessary (via telephone and fax) to assess a member's clinical condition, and apply the appropriate evidence-based guidelines Meet required decision-making SLAs Refer members for further care engagement when needed Compliance with all applicable laws and regulations Other duties as assigned

Brigham and Women's Hospital

CPE / PreOp Eval Nurse - Remote - Faulkner

Posted on:

April 28, 2026

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham. Schedule: Per-diem - Remote

The Preoperative Evaluation Registered Nurse is responsible for conducting comprehensive preoperative assessments to ensure patients are medically optimized and fully prepared for their scheduled surgical or procedural care. This role involves patient education, coordination with interdisciplinary teams, and meticulous review of medical histories, diagnostics, and perioperative requirements. The Pre-Op Eval RN promotes patient safety, supports evidence-based practice, and contributes to a positive patient experience throughout the surgical pathway.

Current Registered Nurse (RN) license in good standing. Bachelor of Science in Nursing (BSN) preferred. PACU/PreOp or PreOP eval nursing experience required Strong critical thinking, assessment, and clinical judgment skills. Excellent communication, patient education, and interdisciplinary collaboration abilities. Proficiency with electronic medical record systems and strong organizational/documentation skills. Adheres to all C.A.R.E. standards. Staff RN, Psychiatry, Ambulatory/Float: Adheres to all I.C.A.R.E standards. The RN must show evidence of the basic analytic thinking necessary to care for a group of patients. Must demonstrate observational skills and the ability to set priorities. Must be able to function under stress with good interpersonal and communication skills. Must demonstrate effective skills in applying hospital standards in area of service, team work, communication, respect for others, and time/priority management.

Perform thorough preoperative nursing assessments, including medical history review, medication reconciliation, allergy verification, and evaluation of comorbid conditions. Review and ensure completion of all required preoperative testing (laboratory work, imaging, EKGs, consults) according to established clinical guidelines. Identify potential risk factors and collaborate with anesthesia, surgery, and other providers to address concerns and optimize patient readiness. Provide clear, comprehensive patient education regarding preoperative instructions, medication management, NPO guidelines, and perioperative expectations. Document all assessments, interventions, and communications accurately within the electronic medical record (EMR). Communicate effectively with surgeons’ offices, anesthesia teams, and ancillary departments to clarify orders, missing documentation, or patient-specific needs. Triage and respond to patient inquiries related to preoperative preparation and coordinate follow-up as needed. Participate in continuous quality improvement initiatives, ensuring compliance with regulatory standards and institutional policies. Support patient safety initiatives, including infection prevention, accurate patient identification, and confirmation of surgical readiness. Maintain current knowledge of clinical best practices, surgical protocols, and perioperative guidelines.

Mercy Health

Registered Nurse (RN) - Triage Specialist - Conduit Health Partners

Posted on:

April 28, 2026

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

At Mercy Health, we understand that every family is a universe. A network of people who love, and support, and count on one other to be there. Everybody means the world to someone and we are committed to care for others so they can be there for the ones they love. With nearly 35,000 employees across regions of Ohio and Kentucky, we’re one of the largest health care systems in the country. At each of our more than 600 points of care, we deliver high-quality, compassionate care with one united purpose: to help our patients be well in mind, body and spirit.

​​The RN Triage Specialist provides telephonic triage to assist callers to determine the most appropriate level of care needed for the current situation expressed or assessed, following workflows and utilizing protocols/resources to provide supportive service to patients and customers. The RN Triage Specialist will maintain a performance standard that prioritizes safety, quality and experience and coincides with the organization's mission and identified key strategic or performance initiates. Please note the following details prior to apply: This position REQUIRES an active Compact RN license. This position REQUIRES a HIPAA compliance at home workspace. (Secure physical areas with a lock on door to office space and ensuring screens are not visible to unauthorized individuals.) This position REQUIRES home office space equipped highspeed internet of 100mbps download speed and 20mbps upload speed. If your current internet does not meet expectations, we will ask that you upgrade prior to your interview. You will need the speeds to be able to participate in the job shadowing, during the last 30 minutes of the one hour and fifteen-minute interview. This position REQUIRES a secondary workspace with access to highspeed internet private access, within :30 minutes of their home office. 4 Week Orientation/Training schedule is Monday thru Thursday 8:00am ET - 4:30pm ET. We offer opportunities across all shifts - days, afternoon/evenings, and nights - with full-time and on occasionally part-time and PRN positions. Schedules are set and follow a six-week rotation, which includes an every-other-weekend requirement. There is also an on-call component and a rotating holiday requirement for all positions. Once you're placed into a schedule, you'll be expected to work that set schedule for at least six months before any schedule change request is considered. Please note that while schedule change requests are reviewed every six weeks, they are not guaranteed and are evaluated based on our established standard operating procedures. *Hours subject to change based on need of operations

Licensing/Certification: RN license required in applicable state(s). ​​Multistate/Compact RN Licensure​  required. Education: ADN or Diploma​  Nursing  required ​​BSN​  preferred Work Experience 1 year of acute care nursing experience required. Triage experience preferred. Training EPIC Electronic Health Record (preferred) IT Requirements Minimum internet speed of primary and secondary work locations is: Download speed of 100Mpbs Upload speed of 20Mbps Office Setting Must have a designated workspace with a locked door, per HIPAA regulations. Associates are encourages to also identify a secondary work location, meeting HIPAA regulations in case of power outages as well. Working Conditions Periods of high stress and fluctuating workloads may occur. General office environment. May have periods of constant interruptions. Required to car travel to off-site locations, occasionally in adverse weather conditions. Prolonged periods of working alone. Skills Inform medical professionals regarding patient conditions and care Assessment of condition via telephone or video ​Attention to detail Critical thinking Communication Teamwork Conflict resolution Active listening Relationship building Agility and adaptability

Provides telephonic triage or requested support and / or virtual monitoring. Offers subsequent recommendations, education or care advice using decision making tools, clinical judgement, and defined workflows. Participates in care coordination, by partnering with customers to reduce readmissions, enhance chronic disease management, manage health risk and injury reporting. Schedules provider appointments and facilitates provider communication. ​​Ensures accurate, timely documentation in the EMR (Electronic Medical Record) according to best practice, guidelines, or workflows. Participates in virtual monitoring and subsequent reporting and escalation to support services identified by customer. Provides additional support to Conduit Health Partners business functions as identified to ensure all patient needs are being met and continuity of Conduit Health Partners business operations is maintained.  Participates in process improvement, professional development, peer development and peer review This document is not an exhaustive list of all responsibilities, skills, duties, requirements, or working conditions associated with the job. Employees may be required to perform other job-related duties as required by their supervisor, subject to reasonable accommodation and appropriate within the scope of practice for the registered nurse.

ExamWorks

Clinical Quality Assurance Coordinator (31899)

Posted on:

April 28, 2026

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

The ExamWorks Group platform, family company services, applications and portals for the management of independent medical claim review are the assets of choice among claims professionals. Our global service network and private cloud-based computing platform connects medical professionals, case managers, and claimants to property, casualty, and disability insurers, third-party administrators, and legal professionals so they can provide evidence-based independent expert medical opinions and analysis for claims resolution. Secure, streamlined, automated, customized, independently audited and accredited workflows assist clients to manage costs by verifying the validity, nature, cause, and extent of claims, identifying fraud and providing fast, efficient and quality IME services.

Are you a Nurse (LPN, LVN or RN) seeking a role that challenges you, helps you grow, and lets you work from the comfort of your own home? ExamWorks has the perfect opportunity for you! We’re looking for a Clinical Quality Assurance Coordinator to join our team! In this role, you’ll ensure Peer Review case reports meet the highest standards of quality, integrity, and compliance with client agreements, regulatory guidelines, and federal/state mandates. Why This Role Rocks 100% Remote - Enjoy the flexibility of working from home! Impactful Work - You’ll play a key role in ensuring the quality and compliance of critical reports. Schedule - Monday to Friday; 8:30am-5:00pm EST

High school diploma or equivalent required with a minimum of two years clinical or related field experience; or equivalent combination of education and experience. Experience in peer review, clinical documentation review, or medical necessity assessments. Familiarity with CMS guidelines, InterQual, Milliman/MCG, or payer policies. Prior employment with insurance carriers, TPAs, or managed care organizations. Must have strong knowledge of medical terminology, anatomy and physiology, medications and laboratory values. Must be able to add, subtract, multiply, and divide in all units of measure, using whole numbers and decimals; Ability to compute rates and percentages. Must be a qualified typist with a minimum of 40 W.P.M Must be able to operate a general computer, fax, copier, scanner, and telephone. Must be knowledgeable of multiple software programs, including but not limited to Microsoft Word, Outlook, Excel, and the Internet. Must possess excellent skills in English usage, grammar, punctuation and style. Ability to follow instructions and respond to upper managements’ directions accurately. Demonstrates accuracy and thoroughness. Looks for ways to improve and promote quality and monitors own work to ensure quality is met. Must demonstrate exceptional communication skills by conveying necessary information accurately, listening effectively and asking questions where clarification is needed. Must be able to work independently, prioritize work activities and use time efficiently. Must be able to maintain confidentiality.

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

Mercor

Registered Nurse - AI Trainer

Posted on:

April 28, 2026

Job Type:

Contract

Role Type:

License:

RN

State License:

California

Mercor connects elite creative and technical talent with leading AI research labs. Headquartered in San Francisco, our investors include Benchmark, General Catalyst, Peter Thiel, Adam D'Angelo, Larry Summers, and Jack Dorsey.

Position: Registered Nurses Type: Contract Compensation: $60–$110/hour Location: Remote Duration: 3–4 weeks Commitment: 30–40 hours/week

4+ years professional experience in nursing. Excellent written communication with strong grammar and spelling skills.

Create deliverables addressing common requests in the nursing domain. Review peer-developed deliverables to enhance AI research. Diagnose and solve real issues in your domain to advance machine learning systems. Work independently and remotely on your own schedule. Contribute expertise to cutting-edge AI research.

Devoted Health

Triage Clinical Guide (Registered Nurse) – Night Shift

Posted on:

April 28, 2026

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

At Devoted Health, we’re on a mission to dramatically improve the health and well-being of older Americans by caring for every person like family. Founded in 2017, we've grown fast and now serve members all across the United States. We've gathered smart, diverse, and big-hearted people to create a new kind of all-in-one healthcare company — one that combines compassion, health insurance, clinical care, service, and technology -- to deliver a complete and integrated healthcare solution that delivers high quality care that everyone would want for someone they love. We're only just getting started!

We want to help members navigate the healthcare system in a better and safer way. This means getting the right care at the right place, at the right time. As a Triage Clinical Guide (Registered Nurse), you’ll be responsible for providing telephonic advice and clinical triage when Devoted Health members call us for support. You'll serve as a fierce advocate, helping them achieve better health outcomes and connecting them with the necessary resources. Our ideal Triage Clinical Guide is caring, compassionate, solution-oriented, and enthusiastic about providing an outstanding member experience. You possess excellent clinical judgment, are ready to innovate, and are excited about changing the way healthcare is delivered. You will be joining a team of adaptable, scrappy, and resilient professionals who are proud to be part of the Devoted family, creating a revolution in care delivery. Schedule Details: This is a full-time, night shift role. You will work three (3) scheduled clinical shifts per week on a rotating basis, including weekends and holidays. Shifts are scheduled based on business needs and may include: 8:00 PM – 8:30 AM ET (current primary shift) or 6:00 PM – 6:30 AM ET (alternate shift). The remaining 2.5 hours per shift are reserved for administrative work, training, and team meetings. Shift assignments are subject to change based on operational needs, and candidates must be flexible to work either schedule as required.

Required Skills & Experience: Licensure: An active, unencumbered Compact RN license OR a willingness to obtain additional state licenses as needed (for non-compact states). Experience: A minimum of 5 years of direct patient care experience. Triage Expertise: Prior clinical triage experience in an Emergency Department, Intensive Care Unit, Primary Care, or Telephonic Triage setting. Telehealth: Prior telehealth experience is required. Technical Agility: Eager to learn and able to quickly master electronic medical records (EMR), remote telephone software, and virtual video systems. Work Style: Exceptional communication and active listening skills. You enjoy fast-paced work, are eager to task-switch, and are always happy to help colleagues. Desired Skills & Experience: BSN (Bachelor of Science in Nursing) degree preferred. Experience caring for older adult populations. Experience working within population health or value-based care programs. Attributes to Success: Curious & Compassionate: You listen to others, lead with empathy, and aren't afraid to be wrong or change your mind. Detail-Oriented: You hold high standards for patient care, are well-organized, and possess meticulous attention to detail. Happy Warrior: As long as you’re in a great environment with smart, caring people working toward a common aim, you’re comfortable working hard and tackling tough challenges. Innovative: You are wired for learning and change. You want to make a difference by testing new ways of doing things to build a better care system. Agile: Agility and collaboration are critical. We are a growing organization with a start-up mentality—you believe we can do hard things together!

Clinical Triage: Engage with members via telephone and the patient portal to provide clinical advice, educational materials, answer questions, and direct patients to the appropriate level of care. Care Coordination: Connect members with the exact care they need, whether routing them to providers within Devoted Medical, primary care, urgent care, or emergency services. Telehealth Support: Deliver exceptional support to patients with urgent complaints across multiple geographies, leveraging video telehealth visits to keep them safely at home whenever possible. Interdisciplinary Collaboration: Work seamlessly alongside a multidisciplinary team—including other RNs, NPs, PAs, MDs, and medical assistants—safeguarding our collaborative, team-based culture. Continuous Growth: Enthusiastically participate in learning sessions and be eager to grow your own skills while teaching others. Patient Advocacy: Fiercely promote our model of treating and caring for patients like they are our own family members.

CircleLink Health

Registered Nurse Care Coach

Posted on:

April 28, 2026

Job Type:

Contract

Role Type:

Coaching

License:

RN

State License:

Compact / Multi-State

CircleLink Health’s AI-enabled SphereCM platform accelerates compassionate, intelligent care management at scale. 
We pair dedicated tele-RNs with the latest in supervised, agentic AI, augmenting and extending the reach of your care teams across CCM, RPM, RTM, and APCM programs.

This is a remote role. CircleLink Health is looking for passionate, tech savvy registered nurses to work remotely and serve patients enrolled in Medicare’s Chronic Care Management Program. In this part time role (about 20-25 hrs. per week), an RN Care Coach will be assigned a group of patients that they will be following and calling each month. In these monthly calls you will provide education, coordinate care, close preventive care gaps, and coach on strategies for self-management to keep them out of the hospital. This Role Requires Precision, Discipline, and Accountability Role The Care Manager role is not a step back from bedside nursing — it’s a step into a more complex, structured, and performance-driven environment. To succeed, you must bring more than clinical knowledge: Excellent documentation skills — Your charting must be complete, timely, and accurate. Strong time management — Case tasks must be prioritized and closed on schedule. Ownership of outcomes — Each case is closely tracked for quality, compliance, and effectiveness. Expectations are high, and performance is regularly reviewed. This is not a role where details can be missed or timelines pushed — we need professionals who take initiative, stay organized, and consistently deliver. If you’re ready for a challenging, fast-paced environment where your work is held to high standards and makes a real difference, we encourage you to apply.

Requirements: Fluent in English Self-directed, able to work independently with little supervision while meeting performance metrics Passion for nursing and improving patient outcomes Good with technology and eager to learn and use new software Excellent organizational and time management skills Timely communication is essential, and nurses are expected to respond to all messages and emails within 24–48 hours. Strong critical thinking and problem-solving skills Education And Experience: Current, unrestricted Compact License / multistate RN license Proficiency with electronic health records and web-based applications 3+ years' experience as a Registered Nurse Preferred Education And Experience, But Not Required: Spanish fluency Case Management or Chronic Disease Management experience highly preferred Certified Diabetes Educator Experience with Motivational Interviewing or other behavior change communication techniques Scheduling And Other Requirements: RN needs a STRONG internet-connected computer Minimum of 20 hours of availability per week required You will commit to your own schedule using our software. This is a 1099 contract position with no end date. Care coaches are responsible for their own taxes and insurance.

Utilize our specialized care management software to call Medicare patients with 2 or more chronic conditions (Diabetes, CHF, Chronic Pain, COPD, etc.) on a monthly basis Build and maintain rapport with patients to help coach them to improved health through SMART goals and education on self-management strategies Implement and improve the Plan of Care by updating medications, appointments due, biometrics, symptoms, and interventions made Connect the patient with community resources as needed, including transportation, personal care needs, prescription/DME assistance, social services, etc. Conduct Transitional Care Management activities to high risk patients discharged from the hospital and the ER to reduce unnecessary readmissions. Close care gaps by encouraging and assisting with preventive care measures, i.e. annual well visits, vaccines, cancer screens, follow-up/specialist appointments, etc.

Insight Global

Remote Nurse Case Manager (Payer/Insurance Experience Required)

Posted on:

April 27, 2026

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

Insight Global is an international talent and consulting company that delivers business outcomes in an ever-changing world. We obsess over solving problems and building solutions that move our customers further, faster. With access to top talent in more than 50 countries, our tech-enabled recruiters can build teams quickly. Our technical experts across Cloud, AI, Data, Enterprise Operations, and Applied Engineering deliver solutions tailored to each customer’s needs. As those needs evolve, so do we. As we evolve, though, we stay true to our purpose: to develop people personally, professionally, and financially so they can be the light to the world around them. It shows up in everything we do, from investing in our people to delivering results for our customers to making a meaningful impact in our communities.

We're seeking a passionate and highly motivated Nurse Care Manager to join our dynamic Care and Case Management team. In this telephonic role, you'll play a crucial part in holistically guiding our members through their healthcare journey, ensuring their needs are met with industry-leading interventions. This position places a special emphasis on proactive engagement with high-risk and rising-risk members, particularly around discharge planning and care transitions. You will partner with a multidisciplinary clinical team that includes a variety of healthcare professionals, care coordinators, and records specialists, to deliver integrated remote care in an innovative way. The ideal candidate will enjoy spending time on the phone, actively listening to members’ needs, answering questions, and serving as a dedicated advocate. You should excel at creating cohesive care plans and possess the clinical acumen to guide members through complex situations, leveraging available benefits and resources. Schedule: Monday-Friday, 9:00 AM-6:00 PM local time zone

Bachelor of Science in Nursing (BSN) Compact Nursing License and must reside in the state in which you hold the license. 5+ years of experience in clinical nursing 2+ years of experience working in care management, case management, and/or disease management, preferably within a health plan, health navigator, or third-party administrator (TPA) environment. Remote care or case management experience Comfortable discussing a wide variety of medical conditions and experienced working with populations across all age ranges. Strong comfort with technology and high competence in using multiple computer/medical record systems.

Engage in high-value Care Management outreach calls for Included Health members with the primary goal of clinically engaging high-risk and rising-risk members, fostering strong relationships and promoting proactive health management. Make proactive calls to members once their hospital discharge is confirmed, conducting thorough intake assessments if the member is reached. Collaborate with hospital-based case managers to understand & support members' specific discharge needs and actively encourage members to engage with our Care Management program. Perform initial assessments encompassing activities of daily living, cognitive functions, social determinants of health (SDOH), health beliefs and behaviors, and life planning activities to develop truly holistic care strategies. Deliver coordinated, patient-centered virtual Care Management by telephone and/or video that consistently improves members’ health outcomes. Generate impactful care plans collaboratively with members and our multidisciplinary care team, empowering members to achieve their desired health goals. Coordinate necessary resources that holistically address members’ problems, whether clinical or social.

Trillium Health Resources

Complex Transitional Care Nurse (Mis-State)

Posted on:

April 27, 2026

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

North Carolina

Trillium Health Resources is a Tailored Plan and Managed Care Organization (MCO) serving 46 counties across North Carolina. We manage services for individuals with serious mental health needs, substance use disorders, traumatic brain injuries, and intellectual/development (IDD) disabilities. Our mission is to help individuals and families build strong foundations for healthy, fulfilling lives. Why Work for Us? Trillium believes that empowering others begins with supporting our team. We offer our employees: A collaborative, mission-driven work environment Competitive benefits and work-from-home options for most positions Opportunities for professional growth in a diverse inclusive culture Every day, our work changes lives – from children thriving through early intervention and school-based therapies, to adults with severe mental illness living independently and contributing to their communities.

Trillium Health Resources has a career opening for a Complex Transitional Care Nurse to join our team! The Complex Transitional Care Nurse is responsible for providing Complex Care Coordination targeting those with chronic, unresolved or complex physical, behavioral health and social determinant needs. This includes providing care planning with foundations in national evidence based and informed standards to do whole person care. The Complex Transitional Care Nurse completes required documentation/paperwork/tasks in a software platform according to timelines. Typical working hours: 8:30 am – 5:00 pm; flexible work schedules with some roles with management approval. Work-from-home options available for most positions Health Insurance with no premium for employee coverage Flexible Spending Accounts 24 days of Paid Time Off (PTO) plus 12 paid holidays in your first year NC Local Government Retirement Pension (defined-benefit plan) https://www.myncretirement.gov/systems-funds/local-governmental-employees-retirement-system-lgers/lgers-handbook 401k with 5% employer match and immediate vesting Public Service Loan Forgiveness (PSLF) qualifying employer Quarterly stipend for remote work supplies

Required: Fully licensed by the North Carolina State Board of Nursing as a Registered Nurse (RN) with a minimum of one (1) year experience as a Registered Nurse. Must have a valid driver’s license. Must reside within Trillium’s Mid State Region, which includes the following counties: Anson, Guilford, Montgomery, Randolph, and Richmond. Must be able to travel within catchment as required. Preferred: Experience working with BH/MH/SU/IDD population. Knowledge of QM, UM procedures as well as experience in using data analytics for population health management. Experience assessing and coordinating care for members in adult care homes, family care homes, home residence or other settings.

Complex care coordination to assigned individuals who may have identified needs with mental health, physical health, co-occurring, co-morbid or multi-morbid conditions. Collaborate with Internal Staff across discipline/teams (Care Coordinators, Clinicians, OT, COTA, Housing Specialists, Peers, etc.) to facilitate integrated care. Monitor the Care Plan (physical, behavioral health and social determinant concerns), service delivery and health and safety of the members. Perform clinical functions of discharge/transition planning and diversion including clinical interviewing; obtaining and reviewing clinical records; identifying potential treatment needs; assessing barriers to treatment and recommending solutions; and assessing general health needs and recommending referrals. Provide education about all available services and natural and community supports, treatment options, diagnosis, etc.

CircleLink Health

Registered Nurse Care Coach

Posted on:

April 27, 2026

Job Type:

Contract

Role Type:

Coaching

License:

RN

State License:

Compact / Multi-State

CircleLink Health is a company of passionate clinicians, technologists and businesspeople tackling the $600B problem of preventable chronic and post-acute complications. We’re building a world-class Care Management platform to enable providers while accelerating the shift to preventative care instead of status quo reactive care. Learn more about us here.

This is a remote role. CircleLink Health is looking for passionate, tech savvy registered nurses to work remotely and serve patients enrolled in Medicare’s Chronic Care Management Program. In this part time role (about 20-25 hrs. per week), an RN Care Coach will be assigned a group of patients that they will be following and calling each month. In these monthly calls you will provide education, coordinate care, close preventive care gaps, and coach on strategies for self-management to keep them out of the hospital. This Role Requires Precision, Discipline, and Accountability Role: The Care Manager role is not a step back from bedside nursing — it’s a step into a more complex, structured, and performance-driven environment. To succeed, you must bring more than clinical knowledge: Excellent documentation skills — Your charting must be complete, timely, and accurate. Strong time management — Case tasks must be prioritized and closed on schedule. Ownership of outcomes — Each case is closely tracked for quality, compliance, and effectiveness. Expectations are high, and performance is regularly reviewed. This is not a role where details can be missed or timelines pushed — we need professionals who take initiative, stay organized, and consistently deliver. If you’re ready for a challenging, fast-paced environment where your work is held to high standards and makes a real difference, we encourage you to apply.

Fluent in English Self-directed, able to work independently with little supervision while meeting performance metrics Passion for nursing and improving patient outcomes Good with technology and eager to learn and use new software Excellent organizational and time management skills Timely communication is essential, and nurses are expected to respond to all messages and emails within 24–48 hours. Strong critical thinking and problem-solving skills Education And Experience: Current, unrestricted Compact License / multistate RN license Proficiency with electronic health records and web-based applications 3+ years' experience as a Registered Nurse Preferred Education And Experience, But Not Required Spanish fluency Case Management or Chronic Disease Management experience highly preferred Certified Diabetes Educator Experience with Motivational Interviewing or other behavior change communication techniques Scheduling And Other Requirements RN needs a STRONG internet-connected computer Minimum of 20 hours of availability per week required You will commit to your own schedule using our software. This is a 1099 contract position with no end date. Care coaches are responsible for their own taxes and insurance.

Utilize our specialized care management software to call Medicare patients with 2 or more chronic conditions (Diabetes, CHF, Chronic Pain, COPD, etc.) on a monthly basis Build and maintain rapport with patients to help coach them to improved health through SMART goals and education on self-management strategies Implement and improve the Plan of Care by updating medications, appointments due, biometrics, symptoms, and interventions made Connect the patient with community resources as needed, including transportation, personal care needs, prescription/DME assistance, social services, etc. Conduct Transitional Care Management activities to high risk patients discharged from the hospital and the ER to reduce unnecessary readmissions. Close care gaps by encouraging and assisting with preventive care measures, i.e. annual well visits, vaccines, cancer screens, follow-up/specialist appointments, etc.

Clearlink Partners

Utilization Management RN - Behavioral Health (OR Licensed)

Posted on:

April 27, 2026

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Compact / Multi-State

Clearlink Partners is an industry-leading managed care consultancy specializing in end-to-end clinical and operational management services and market expansion initiatives for Managed Medicaid, Medicare Advantage, Special Needs Plans, complex care populations, and risk-adjusted entities. We support organizations as they navigate a dynamic healthcare ecosystem by helping them manage risk, optimize healthcare spend, improve member experience, accelerate quality outcomes, and promote health equity.

Other Information: Expected Hours of Work: Monday - Friday 8 am – 5 pm PST; with ability to adjust to Client schedules as needed Travel: May be required, as needed by Client Direct Reports: None Salary Range: $70,000 – $100,000

Competencies: Ability to translate member needs and care gaps into a comprehensive member centered plan of care Ability to collaborate with others, exercising sensitivity and discretion as needed Strong understanding of managed care environment with population management as a key strategy Strong understanding of the community resource network for supporting at risk member needs Ability to collect, stage and analyze data to identify gaps and prioritize interventions Ability to work under pressure while managing competing demands and deadlines Well organized with meticulous attention to detail Strong sense of ownership, urgency, and drive The ability to effect change, perform critical analyses, promote positive outcomes, and facilitate empowerment for members/families. Excellent analytical-thinking/problem-solving skills. The ability to work effectively in a fast-paced environment with frequently changing priorities, deadlines, and workloads. The ability to offer positive customer service to every internal and external customer Experience: Current unencumbered Oregon RN license required; Compact license preferred in addition to Oregon Minimum of 5+ years of acute clinical experience Minimum 2 years’ experience in a managed care environment across multiple lines of business (Medicare Advantage, Managed Medicaid, Dual SNP, Commercial, etc.) 2+ years of utilization management experience Strong knowledge of utilization management processes and industry best practice In-depth knowledge and experience with the application of standard medical criteria sets (MCG, InterQual) Detailed knowledge and demonstrated competency in all types of medical-necessity decisions, including inpatient care, sub-acute/skilled care, outpatient care, hospice care and home health care. HMO and risk contracting experience preferred In-depth knowledge of current standard of medical practices and insurance benefit structures. Excellent oral and written interpersonal/communication, internal/external customer-service, organizational, multitasking, and teamwork skills. Proficiency in Microsoft Office Physical Requirements: Must be able to sit in a chair for extended periods of time Must be able to speak so that you are able to accurately express ideas by means of the spoken word Must be able to hear, understand, and/or distinguish speech and/or other sounds in person, via telephone/cellular phone, and/or electronic devices Must have ample dexterity which allows entering of text and/or data into a computer or other electronic device by means of a keyboard and/or mouse Must be able to clearly use sight so that you are able to detect, determine, perceive, identify, recognize, judge, observe, inspect, estimate, and/or assess data or other information types Must be able to fluently communicate both verbally and in writing using the English language Time Zone: Mountain or Pacific

Specific: Determine appropriateness of services through the application and evaluation of medical guidelines, benefit determinations and compliance with state mandated regulated based on approved criteria (MCG, InterQual, etc.) Perform 15-30 reviews per day Performs initial and concurrent review of inpatient admissions Performs reviews for outpatient surgeries, and ancillary services Concludes medical necessity and appropriateness of services using clinical review criteria Collaborate with Medical Director(s) for appropriate referrals, complex cases and adverse determinations to ensure timely access to medically necessary/ appropriate services Accurately documents all review determinations, contacting providers and members according to established requirements and timeframes General: Perform daily work with a focus on the core principles of managed care: Patient Education, Wellness and Prevention Programs, Early Screening and Intervention and Continuity of Care Work proactively to expedite the care process Identify priorities and necessary processes to triage and deliver work Empower members to manage and improve their health, wellness, safety, adaptation, and self-care Assess and interpret member needs and identify appropriate, cost-effective solutions Identify and remediate gaps or delays in care/ services Advocate for treatment plans that are appropriate and cost-effective Work with low-income/ vulnerable populations to ensure access to care and address unmet needs Gather and evaluate clinical information to assess and expedite referrals within the healthcare system including consideration of alternate levels of care and services Facilitate timely and appropriate care and effective discharge planning Work collaboratively across the health care spectrum to improve quality of care Leverage experience/ expertise to observe performance and suggest improvement initiatives Ensure understanding of industry standard competencies and performance metrics to optimize decisions and clinical outcomes Ensure individual and team performance meets or exceeds the performance competencies and metrics Contribute actively and effectively to team discussions Share knowledge and expertise, willingly and collaboratively. Provide outstanding customer service, internally and externally Follow and maintain compliance with regulatory agency requirements

Akkodis

Utilization Review Nurse

Posted on:

April 27, 2026

Job Type:

Part-Time

Role Type:

Utilization Review

License:

RN

State License:

Georgia

Akkodis is a global digital engineering company and Smart Industry leader. We enable clients to advance in their digital transformation with Talent, Academy, Consulting, and Solutions services. Our 50,000 experts combine best-in-class technologies, R&D, and deep sector know-how for purposeful innovation. We are passionate about Engineering a Smarter Future Together. With a shared passion for technology and talent, 50,000 engineers and digital experts deliver deep cross-sector expertise in 30 countries across North America, EMEA and APAC. Akkodis offers broad industry experience, and strong know-how in key technology sectors such as mobility, software & technology services, robotics, testing, simulations, data security, AI & data analytics. The combined IT and engineering expertise brings a unique end-to-end solution offering, with four service lines – Consulting, Solutions, Talents and Academy – to support clients in rethinking their product development and business processes, improve productivity, minimize time to market and shape a smarter and more sustainable tomorrow.

Akkodis is seeking an Appeals Professional III (Weekend Only) for a 100% remote, contract‑to‑hire opportunity supporting Medicare appeals across the United States. This is for EST Shift, Schedule: Saturday & Sunday only Hours: 8–10 hours per day Start Time: Flexible (preference for 10:00 AM ET or earlier) Pay Range: $36–$44/hour, negotiable based on experience, education, geographic location, and other factors. Job Summary: This senior‑level role supports Medicare appeals and medical necessity reviews through independent clinical review of medical records and issuance of well‑supported reconsideration decisions in compliance with CMS and Medicare regulations. The workload and case complexity are equivalent to full‑time AP III roles.

Required Qualifications: Associate’s degree or higher in Healthcare (or equivalent experience) 3+ years of experience in Medicare appeals, utilization review, medical review, or clinical review Clinical background as RN, PT, RT, or OT Experience with medical necessity decision‑making Strong written and analytical skills Preferred: Medicare Advantage or managed care experience Knowledge of CMS regulations and medical review processes Additional Details: Candidates may maintain another role, subject to no conflict of interest

Review medical records and Medicare appeal case files Prepare clear, concise, and impartial reconsideration decision letters Make independent medical necessity determinations using clinical evidence and Medicare guidelines Research CMS regulations, coverage manuals, and medical literature Participate in case discussions, quality reviews, and special projects Serve as a subject matter expert; mentor or support team members as needed

EmblemHealth

Registered Nurse - Transition of Care/Case Manager (New York RN License)

Posted on:

April 27, 2026

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

New York

EmblemHealth is one of America’s largest not-for-profit health insurers. With an 85-year legacy of serving New York communities, EmblemHealth offers a full range of commercial and government-sponsored health plans to employers, individuals, and families. We started back in the 1930s, at the height of the Great Depression. Out of hard times, the idea of health insurance was born — a system that would protect everyday people from financial misfortune if they had an accident or illness. Two companies from those early days of health insurance, Group Health Incorporated (GHI) and Health Insurance Plan of Greater New York (HIP), would later merge and become EmblemHealth. And after 85 years, our purpose as a not-for-profit is still the same — to provide quality, affordable health insurance for New Yorkers and their families. We believe in what we’re doing. And we’re looking for passionate people to join us.

Provide care management, as part of a multi-disciplinary care team, that includes care coordination, performing telephonic or face-to-face assessments of members’ health care needs, identifying gaps in care and needed support, administering/coordinating implementation of interventions. Support and enable members to manage their physical, environmental and psycho-social concerns, understand and appropriately utilize their health plan benefits and remain safe and independent in their home or current living environment in collaboration with health care providers. Provide Care Management services to identified high risk members within the community, including but not limited to Physician Practices, Retail Centers/Neighborhood Care Centers, and members’ homes. Coordinate and provide care that is safe, timely, effective, efficient and member-centered to support population health, transitions of care, and complex care management initiatives. Engage with the most complex members of the health plan with the goal of improving health care outcomes and appropriate and timely utilization of services across the continuum of care. Assist the entire Care Management interdisciplinary team in managing members with Care Management needs.

Bachelor’s degree RN required, with current active RN license - New York State CCM certification preferred Certification in utilization or care management preferred 4 – 6 years of clinical experience Organization/prioritization ability; and the ability to effectively manage a caseload of highly complex members Support an integrated care model tapping into appropriate resources both internally and external to the organization Experience in case management/care coordination, managed care, and/or utilization management Strong communication skills (verbal, written, presentation, interpersonal) Trained in the use of Motivational Interviewing techniques Experience working in medical facility or practice and/or with electronic medical records Computer proficiency: MS Office (Word, Excel, PowerPoint, Outlook); mobile technology (wireless phone/laptop, etc.) System user experience in a highly automated environment Bilingual ability (verbal, written) Strong cross-group collaboration, teamwork, problem solving, and decision-making skills Ability to work a flexible schedule (evenings, weekends and holidays) to meet member and/or caregiver and departmental scheduling needs

Assess and evaluate the needs of our most complex members, acting as the clinical coordinator collaborating with members, caregivers, providers, multi-disciplinary team, and health care and community resources through a variety of assessments to identify areas of (medical, financial, environmental, health insurance benefit, psycho-social, caregiving) concerns and potential gaps in care utilizing the most appropriate resources to support members’ needs. Identify appropriate goals, strategies and interventions that may include referrals, health education, activation of community-based resources, life planning, or program/agency referrals based on areas of concern. Develop, communicate and evaluate medical management strategies and interventions including potential for alternative solutions to ensure high quality, cost effective continuum of care with the member, caregiver, provider(s) and multidisciplinary team. Include member and family as appropriate. Engage actively with the member PCP / designee. Engage with the member in support of their treatment team to identify and establish attainable goals that positively impact clinical, financial, and quality of life outcomes for member. Work collaboratively with all stake holders to ensure knowledge of the action plan, including participation in telephonic and face-to-face case conferences when appropriate. Assess the needs of members and align them with the appropriate member of the care team (wellness team, registered dietitian, social worker, community health workers). Act as the member’s advocate and liaison by completing or facilitating interventions with providers and/or private,non-profit, and governmental agencies. Ensure that all Care Management processes and reporting are compliant with all applicable federal and state regulations, and NCQA and company standards. Participate in delegation collaboration activities, as required. Research evidence-based guidelines, medical protocols, provider networks, and on-line resources in making care management recommendations. Enter and maintain documentation in the Electronic Medical Records System (EMR), meeting defined timeframes and performance standards. Maintain an understanding of Care Management principles, program objectives and design, implementation, management, monitoring, and reporting. Actively participate on assigned committees. Attend and complete all department-mandated training as well as satisfy educational in-service requirements. Perform other related projects and duties as assigned. Provide ongoing monitoring, evaluation, support and guidance to the coordination of the member's health care. Develop, implement and coordinate plan of care and facilitate members’ goals. Coordinate interdisciplinary team tasks and activities, with the goal of maintaining team performance and high morale.

Insight Global

Remote Nurse Case Manager

Posted on:

April 26, 2026

Job Type:

Contract

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

Insight Global is an international talent and consulting company that delivers business outcomes in an ever-changing world. We obsess over solving problems and building solutions that move our customers further, faster. With access to top talent in more than 50 countries, our tech-enabled recruiters can build teams quickly. Our technical experts across Cloud, AI, Data, Enterprise Operations, and Applied Engineering deliver solutions tailored to each customer’s needs. As those needs evolve, so do we. As we evolve, though, we stay true to our purpose: to develop people personally, professionally, and financially so they can be the light to the world around them. It shows up in everything we do, from investing in our people to delivering results for our customers to making a meaningful impact in our communities.

Duration: 6 month contract to hire Schedule: Monday - Friday, 9 AM - 6 PM (MST or PST work hours) Start Date: June 1st 2026 (Cannot have any major absences during the first 8 weeks due to training period) Insight Global is looking for a Remote Nurse Care Manager to support a virtual care and healthcare navigation company. This individual will act as a clinical partner helping high-risk and rising-risk members through proactive outreach, post-discharge planning, and care coordination. They will collaborate with a multidisciplinary team to develop and execute holistic care plans while ensuring that each member receives the guidance, education, and support they need throughout their healthcare journey.

Must hold compact RN license and reside in the state in which they hold the license 5 years’ experience as a nurse 2 years’ experience as a case manager Bachelors Degree in Nursing (BSN)

Day-to-day responsibilities include but are not limited to, coordinating communication with hospital care management teams, supporting medication reconciliation efforts, and navigating members to their employee resources. This is an awesome opportunity to join a tech-enabled care integrator and contribute to a growing Care & Case Management team!

Guardian Life

Appeals Case Manager II

Posted on:

April 26, 2026

Job Type:

Full-Time

Role Type:

Case Management

License:

None Required

State License:

New York

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.

As the Appeals Case Manager II, Group Disability Claims you are responsible for adjudicating assigned appeals for Group Life and Disability claims. The ACM 2 provides a full and fair reconsideration review, as required under the Employee Retirement Income Security Act (ERISA), by thoroughly assessing the claim file and applying plan provisions in accordance with applicable state and federal regulations. This role supports Group Short-Term Disability, Long-Term Disability and Life Waiver of Premium appeals. You are: A highly motivated and reliable individual who is able to work with varying levels of supervision – independently or collaboratively. You are detail-oriented and a decisive decision maker who is able to manage multiple priorities at the same time with a positive attitude. Location: Remote/Flexible – work primarily from home. May be expected to come into a Guardian work location occasionally, as determined by their people leader. 0-10% possible travel.

A minimum of 5 years of Group Disability and/or Life claims experience. A minimum of 3 years of experience handling appeals or complex claims (preferred). Bachelor’s Degree (preferred) or equivalent professional experience. A client focus with excellent verbal and written communication skills. Strong problem-solving, analytical, math aptitude and information research skills. Demonstrated ability to manage multiple tasks in accordance with regulatory requirements. The ability to remain flexible due to changing business needs.

Utilize effective claim management skills to plan, implement and execute the investigation of disputed claims; ensure timely and compliant appeal resolution. Identify and interpret relevant plan language and thoroughly investigate all claim issues to make an accurate and non-biased appeal determination. Evaluate medical, financial and other claim information in consultation with clinical/vocational professionals for the purpose of resolving disputes. Utilize proactive outreach to provide superior customer service to all internal and external customers. Identify legal and/or compliance scenarios that require additional research; facilitate resolution. Maintain current knowledge of all ERISA and Department of Labor guidelines. Independently prioritize workload based on individual and departmental deadlines. Readily share insights and learnings with claims colleagues.

Guardian Life

Senior RN Clinical Consultant, Disability Appeals

Posted on:

April 26, 2026

Job Type:

Full-Time

Role Type:

Behavioral Health

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.

The Senior RN Clinical Consultant will work in partnership with Clinical and Vocational Leaders to provide ongoing coaching and oversight to Clinical Consultants and will serve as clinical subject matter expert in all lines of business (STD/LTD/Appeals) and products, action planning management, and Guardian systems. This incumbent will have a strong clinical and client focus to assist in ensuring the fair and accurate assessments of medically supported functional abilities. They will assist in cultivating talent and foster an environment of continuous learning. They will promote organizational excellence by demonstrating leadership, problem-solving behaviors, and viewing challenges as opportunities. This individual will work with the Clinical Team Manager to drive performance and ensure the team meets their goals. They will effectively communicate & explain departmental initiatives and changes as they relate to organizational goals & strategies. They will assist the Clinical Team Manager in managing and resolving issues that come up related to clinical processes, claim management activities, customer inquiries, and quality. You are: A highly motivated and reliable individual who can work with varying levels of supervision – independently or collaboratively. You are diligent and a decisive decision maker who can prioritize multiple tasks simultaneously with a positive attitude. Location: This is a remote position with occasional travel as needed for department meetings determined by the people leader.

A minimum of 3+ years of (STD, LTD, Appeals) claim experience, minimum of 2 years disability experience A minimum of 5 years in direct patient care settings RN REQUIRED, BSN and CCM preferred Demonstrated proficiency in verbal and written communication, as well as strong presentation abilities Ability to exercise independent & sound judgment in decision making Strong problem-solving, analytical, clinical, and information research skills Excellent time management & organizational skills Demonstrated ability to multi-task with the ability to manage continually changing priorities and the ability to prioritize work based on customer service needs and departmental regulations The ability to remain flexible due to changing business needs Proven track record to mentor and coach Proficiency in MS Word, Excel, PowerPoint, DCMS, Claim Facts, and iProcess

Train and mentor, all new Clinical Consultants Provide ongoing training, coaching and development to all Clinical Consultant members Organize and present at least one Clinical Training session for the Claims teams over the course of a year Work with Team Manager to delegate, distribute, and monitor workloads within the department to meet departmental regulations, improve efficiency and reduce or eliminate backlogs Assist Team Manager when needed to monitor caseloads, productivity, and participate in calibration sessions with our Clinical CMA and provide feedback to leadership and team members Oversee external vendor utilization within team Leverage knowledge and skills to flex and assist the overall team meet its goals, (i.e., assist with STD/LTD/ Appeals, flex and assist if needed) Collaborate with claims partners to resolve conflicts and establish procedures that promote clinical claim management accuracy and improved customer service Address escalated customer inquiries and formal complaints. Senior BHCM will also be first point of contact for SI or mental health crisis calls Support training initiatives by identifying knowledge gaps and providing ideas for improvement Support Clinicians in developing efficient desk & time management skills Collaborate with peers and leadership to ensure consistency with mentoring and coaching Co-facilitate team meetings to share best practices, workflow changes, trends, and insights in alignment with Group benefits strategies Provide desk coverage for leadership as needed

Blue Cross Blue Shield of Arizona

Integrated Care Manager - Remote AZ

Posted on:

April 26, 2026

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Compact / Multi-State

Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy. AZ Blue offers a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions. At AZ Blue, we have a hybrid workforce strategy, called Workability, that offers flexibility with how and where employees work. Our positions are classified as hybrid, onsite or remote. While the majority of our employees are hybrid, the following classifications drive our current minimum onsite requirements: Hybrid People Leaders: must reside in AZ, required to be onsite at least twice per week Hybrid Individual Contributors: must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per week Hybrid 2 (Operational Roles such as but not limited to: Customer Service, Claims Processors, and Correspondence positions): must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per month Onsite: daily onsite requirement based on the essential functions of the job Remote: not held to onsite requirements, however, leadership can request presence onsite for business reasons including but not limited to staff meetings, one-on-ones, training, and team building Please note that onsite requirements may change in the future, based on business need, and job responsibilities. Most employees should expect onsite requirements and at a minimum of once per week.

This remote work opportunity requires residency, and work to be performed, within the State of Arizona. PURPOSE OF THE JOB Responsible for promoting continuity of care through a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates care options and services available to members through their benefit plan that meet the individuals' health care needs while promoting quality, cost effective outcomes. This job description is primary for case management functions but can assist with utilization management if a business need arises.

Required Work Experience 2 year(s) of experience in full-time equivalent of direct clinical care to the consumer Required Education Associate’s Degree in general field of study or Post High School Nursing Diploma or Master’s Degree in a behavioral health field of study (i.e., MSW, MA, MS, M.Ed.), Ph.D. or Psy.D Required Licenses Active, current, and unrestricted license to practice in the State of Arizona (or an endorsement to work in Arizona) as a behavioral health professional such as LCSW, LPC, LISAC LMFT, or licensed psychologist (Psy.D. or Ph.D.), OR an active, current, and unrestricted license to practice nursing in either the State of Arizona or another state in the United States recognized by the Nursing Licensure Compact (NLC) as an RN. Required Certifications Within 4 years of hire as a Care Manager employee must hold a certification in case management from the following certifications; Certified Case Manager (CCM), Certified Disability Management Specialist (CDMS), Case Management Administrator, Certified (CMAC), Case Management Certified (CMC), Certified Rehabilitation Counselor (CRC), Certified Registered Rehabilitation Counselor (CRRC), Certified Occupational Health Nurse (COHN), Registered Nurse Case Manager (RN, C), or Registered Nurse Case Manager (RN,BC). PREFERRED QUALIFICATIONS Preferred Work Experience 3 year(s) of experience in full-time equivalent of direct clinical care to the consumer (managed care CM experience preferred) 1-2 year (s) of experience working in a managed care organization Preferred Education Bachelor's Degree in Nursing or Health and Human Services related field of study Preferred Licenses N/A Preferred Certifications Active and current certification in case management from the following certifications; Certified Case Manager (CCM), Certified Disability Management Specialist (CDMS), Case Management Administrator, Certified (CMAC), Case Management Certified (CMC), Certified Rehabilitation Counselor (CRC), Certified Registered Rehabilitation Counselor (CRRC), Certified Occupational Health Nurse (COHN), Registered Nurse Case Manager (RN, C), or Registered Nurse Case Manager (RN,BC). Required Job Skills: Intermediate PC proficiency Intermediate skill in use of office equipment, including copiers, fax machines, scanner and telephones Intermediate skill in word processing, spreadsheet, and database software Required Professional Competencies: Maintain confidentiality and privacy Advanced and current clinical knowledge Practice interpersonal and active listening skills to achieve customer satisfaction Interpret and translate policies, procedures, programs, and guidelines Capable of investigative and analytical research Demonstrated organizational skills with the ability to priortize tasks and work with multiple priorities Follow and accept instruction and direction Establish and maintain working relationships in a collaborative team environment Apply independent and sound judgment with good problem solving skills Navigate, gather, input, and maintain data records in multiple system applications Required Leadership Experience and Competencies Conflict Resolution Represent BCBSAZ in the community PREFERRED COMPETENCIES Preferred Job Skills Advanced PC proficiency Knowledge of CPT 2018 and ICD-10 coding Preferred Professional Competencies Knowledge of managed care, utilization management, and quality management Working knowledge of McKesson InterQual, MCG, ASAM, or other nationally recognized criteria Knowledge of a wide range of matters pertaining to the organizations services and operations Knowledge of health and/or patient education and behavior change techniques Preferred Leadership Experience and Competencies N/A

Assess and collect data related to the member from all care settings. Interview and collaborate with case-related providers, member and family to implement the care plan. Answer a diverse and high volume of health insurance related customer calls on a daily basis. Explain to customers a variety of information concerning the organization’s services, including but not limited to, contract benefits, changes in coverage, eligibility, claims, BCBSAZ programs, provider networks, etc. Analyze medical records and apply medical necessity criteria and benefit plan requirements to determine the appropriateness of benefit requests. Present status reports on all cases to the manager/supervisor and, when indicated, to the medical director. Consult and coordinate with various internal departments, external plans, providers, businesses, and government agencies to obtain information and ensure resolution of customer inquiries. Meet quality, quantity and timeliness standards to achieve individual and department performance goals as defined within the department guidelines. Maintain all standards in consideration of state, federal, BCBSAZ, URAC, and other accreditation requirements. Maintain complete and accurate records per department policy. Demonstrate ability to apply plan policies and procedures effectively. When indicated to assist with team/project functions: Collaborate with team to distribute workload/work tasks; Monitor and report team tasks; Communicate team issues and opportunities for improvement to supervisor/manager; Support/mentor team members. Participate in continuing education and current development in the field of medicine, behavioral health and managed care at least annually. The position has an onsite expectation of 0 days per week and requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements. Perform all other duties as assigned.

A&G Infusion Nursing Services, Inc.

Experienced IVIG Registered Nurse (RN) - On the Road / Per Diem

Posted on:

April 26, 2026

Job Type:

Part-Time

Role Type:

License:

RN

State License:

California

A&G INFUSION SERVICES INC. is the most reliable and trustworthy Home Infusion service in Southern California — providing excellent home infusion solutions to patients who are dealing with injury or illness. We are committed to meeting all of your health needs, and go above and beyond to ensure you get the best care available. Our experienced medical professionals put your healing needs first. We are proud to provide a high-quality level of customer service, medical experience, and commitment to health and wellness to all our patients. Our goal is to make you feel better as quickly as possible.

We are seeking an experienced and compassionate IVIG Infusion RN to provide high-quality, in-home infusion therapy services. The ideal candidate will deliver safe, efficient, and patient-centered care while supporting patients with chronic conditions requiring IVIG and other specialty infusions.

Active RN license in CA. Minimum 1 year of experience in infusion therapy, including IVIG administration. Proficiency in peripheral IV insertion, central line management, and infusion protocols. Strong clinical assessment and patient education skills. Reliable vehicle and valid driver’s license required. Excellent communication and interpersonal skills. Work Location: On the road Employment Type: Contract, Per diem This is a remote position.

Administer IVIG, antibiotics, TPN, and other specialty medications in patients’ homes. Insert and manage peripheral IVs, PICC lines, port-a-caths, and other central lines. Perform blood draws and monitor patient response during infusion therapy. Provide patient education on self-administration, medication management, and infusion safety. Collaborate with the healthcare team to develop and follow individualized care plans. Maintain accurate and timely documentation of nursing interventions and patient progress.

Galileo

Population Health Registered Nurse

Posted on:

April 26, 2026

Job Type:

Full-Time

Role Type:

Primary Care

License:

RN

State License:

Compact / Multi-State

Galileo is a team-based medical practice working to improve the quality and affordability of health care for all. Operating across 50 states, Galileo offers high-touch, data-driven, multi-specialty, longitudinal care to diverse and complex patients—on the phone, in the home, and everywhere in between. Regional and national health plans, employers, and Fortune 500 organizations trust Galileo as the leading solution to improve population health. Founded by Dr. Tom X. Lee, the healthcare pioneer behind One Medical and Epocrates, Galileo is a team of leading innovators from healthcare, technology, and human-centered design. Our mission is to apply that talent and scientific thinking to transform society by solving our largest, toughest healthcare problems, while at the same time bringing patient and provider closer.

Are you a Registered Nurse who thrives on connecting with patients and making a real difference in their health outcomes? Do you want to leave behind rigid, cookie-cutter systems and join a dynamic, patient-centered organization that values your creativity and clinical expertise? If you are passionate about improving patient outcomes and enjoy making meaningful connections, we want you to be part of our team at Galileo! At Galileo, we’re transforming healthcare by delivering personalized, comprehensive care to those who need it most—underserved patients and patients with complex medical needs. Our focus is on patient engagement and outcomes, and we’re looking for someone just like you to join our growing team of healthcare heroes. This is a remote, full-time position at 40 hours/week. We're currently hiring for a schedule of Monday-Friday from 10am-6:30pm ET, with one weekend per month.

About You: You’re a “people person”. You love to connect with others and have an innate ability to build rapport and quickly engage with new patients. Your curious nature and creativity comes through in conversations with others. You’re looking for a new environment where your natural ability can shine and you’re given the ability to thrive. We look for passionate Registered Nurses who are invested in solving complex problems that impact millions of lives and are excited about fixing what’s broken to improve care quality and health outcomes for everyone. We believe in a culture that fosters teamwork, excellence, and sound decision-making—one that is based on mutual respect and trust. We would love to hear from you if you have the following or equivalent experience: 2+ years of experience in case management in insurance organizations or VBC health care startups OR as a primary care RN with population health experience Engaging with Medicare and Medicaid populations with complex chronic conditions Nurse Licensure Compact (NLC) required Active RN license(s) in NY, NV, MI, MN, OR, CA, MA, CT and/or IL a plus Ability to leverage your motivational interviewing skills to encourage patients to make behavioral changes Excellent written and verbal communication skills Familiarity with Population Health and HEDIS quality gaps in care preferred Well versed with operating in an Mac iOS and Google Suite technology environment Physical Requirements: Employee must be able to meet the following requirements with or without a reasonable accommodation: This is primarily a sedentary position. Physical requirements may include lifting up to 10 pounds, manual dexterity, near/far visual acuity, keyboarding, the ability to hear, understand, and distinguish speech, sitting, standing, walking, and screen usage 8 or more hours per day.

Telephonic outreach, including cold calls, to patients for post discharge assessments of clinical symptoms, barriers to medication adherence, safety concerns, social needs Educate and coordinate preventative health screenings Perform chronic disease management and medication adherence education Navigate conversations with patients seeking insight on Galileo’s care model Facilitate the coordination of care between health care services, including hospital/ED care, pharmacies and community providers to improve patient outcomes Develop an understanding of various health plan contracts / goals, Galileo markets, and needs of various patient populations Be accountable to performance targets as an individual contributor Collaborate internally with Engagement and Population Health leadership to improve population outcomes

Rasmussen University

Online Adjunct Instructor - Adult-Gerontology Primary Care Nurse Practitioner Practicum II and Clinical

Posted on:

April 26, 2026

Job Type:

Part-Time

Role Type:

Primary Care

License:

NP/APP

State License:

Minnesota

This course and practicum experience provide an opportunity for students to apply newly acquired knowledge and skills as they participate in the evaluation, treatment, and management of patients seeking primary care services. Although practicum experiences may include a variety of adult patients, there is a focus on caring for adolescent, young adult, and adult patients. Students apply the knowledge of advanced assessment and diagnostic reasoning to formulate treatment plans for primary care patients within the ages of adolescence through adult. Emphasis is placed on the identification of signs and symptoms of disorders, selecting treatments and pharmacological interventions, inclusive of health promotion, health restoration and maintenance, and evidence-based practice in primary care settings.

Reporting Relationships: Adjunct Faculty will report to an Academic Dean Responsibilities: Competency-Based Education (CBE) allows students to master content and skills within a course or program at their own pace and prioritizes the demonstration of student learning over time. Students are able to show what they know when they know it. CBE courses are broken into multiple modules that are self-paced. Each module has an assessment at the end of it that allows students to demonstrate their mastery of the material. CBE Combined Instructional/Assessment Adjunct Faculty model consists of one faculty member facilitating and grading student assignment submissions. Faculty are responsible for running a number of live sessions during the week based on student need. These live sessions will cover a variety of topics including help with submissions, open office hours, content delivery, and general success strategies. Grading is facilitated through the use of detailed rubrics and feedback.

Experience and Qualifications: Teaching experience preferred. (Minimum of 3 years’ experience in the field of study) Self-motivated, flexible, and able to work in a team environment with minimal supervision Strong interpersonal skills to interact with students, leadership, and peers. Excellent written communication and strong verbal communication skills in the English language. Online adjuncts will need regular access to a computer with the following system requirements Windows XP or greater Microsoft Office 2010 An internet connection Education, certifications and Licensures: Doctorate in Nursing Must hold active Minnesota RN License and certified AGNP 2-3 years experience as an AGNP Rasmussen University follows the requirements set by the Department of Education, accrediting agencies, and the states in which the campuses operate. Must be able to provide professional licenses/certifications required for specialized schools (Health Sciences, Nursing) before teaching. License must be active and unencumbered Must be able to provide official transcripts for each degree earned from an accredited institution before teaching. Location: This position is remote but not available to CO residents

The essential function of the position include, but are not limited to the following tasks, duties, and responsibilities consistent with the function. The employee is expected to perform all other duties as requested, directed, and/or assigned. Adjunct faculty will be assigned up to 3 work units per academic quarter. Teaching Effectiveness: Professionalism, Use of Technology, and Content Expertise Dynamic, Active Classroom Use of effective teaching strategies and multiple teaching techniques; teaching and modeling appropriate level learning skills and creating an environment conducive to learning Creating high levels of student engagement through activities, community building, and student-centered learning including the use of live classroom tools to hold synchronous learning sessions with students Clarity, relevance, and connection of class session objectives to course performance objectives Organized classroom and efficient use of class time Subject Matter Expertise Demonstrate mastery and ability to articulate and relate to students Play an integral role in the development and implementation of curriculum and assessment for their area of expertise Student and University Support and Professionalism: Faculty are responsible for creating a classroom presence in support of students in collaboration with their Dean Student support and outreach that supports the success of students is accomplished through faculty availability to students in all courses through synchronous or asynchronous communication and meetings to help students achieve the learning objectives for their course(s) Faculty Meetings and other responsibilities: Faculty will attend events, programmatic meetings, and committee work as agreed upon and/or designated by the Dean Appropriate behavior, language, professional communication, demeanor and dress will be exhibited at all times Professional Development Faculty must complete a minimum of six (6) Rasmussen Educational Units (REUs) annually or two (2) REUs per quarter for each quarter you teach (whichever is less) between the combined areas of Teaching Development and Development in Discipline on an annual basis as described in the faculty handbook

American Senior Communities

Community Nurse Liaison LPN

Posted on:

April 26, 2026

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

LPN/LVN

State License:

Indiana

Compassion, Accountability, Relationships and Excellence are the core values for American Senior Communities. These words not only form an acronym for C.A.R.E., but they are also our guiding principles and create the framework for all our relationships with customers, team members and community at large. American Senior Communities has proudly served our customers since the year 2000, with a long history of excellent outcomes. Team members within each of our 100+ American Senior Communities take great pride in our Hoosier hospitality roots, and it is ingrained in everything we do. As leaders in senior care, we are not just doing a job, but following a calling.

American Senior Communities is now hiring a Community Nurse Liaison (LPN) Hours: Monday – Friday 4p – 8p and Weekends 9a – 6p Remote position but must live within reasonable driving distance to Indianapolis.

Minimum of three years of clinical experience in acute care or long-term care setting. Must be able to work weekends and evenings. Current LPN License

The Clinical Nurse Liaison provides patient evaluations, while collaborating with hospital personnel to determine patient’s clinical needs and appropriateness for admission to skilled nursing facility. This position works closely with our communities and healthcare partners. This position will also be checking benefits and payor sources.

Highmark

Complex Case Manager RN - (Remote)

Posted on:

April 26, 2026

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

An independent licensee of the Blue Cross Blue Shield Association, Highmark Inc., together with its Blue-branded affiliates, collectively comprise the fifth largest overall Blue Cross Blue Shield-affiliated organization in the country with approximately 7.1 million members in Pennsylvania, Delaware, West Virginia and western and northeastern New York. The following entities, which serve the noted regions, are independent licensees of the Blue Cross Blue Shield Association: Western and Northeastern PA: Highmark Inc. d/b/a Highmark Blue Cross Blue Shield; CPA/SEPA: Highmark Inc. d/b/a Highmark Blue Shield; Delaware: Highmark BCBSD Inc. d/b/a Highmark Blue Cross Blue Shield; West Virginia: Highmark West Virginia Inc. d/b/a Highmark Blue Cross Blue Shield; Western NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Cross Blue Shield; Northeastern NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Shield. All references to “Highmark” are to Highmark Inc. and/or to one or more of its affiliated Blue companies. We're proudly part of Highmark Health.

This job has primary ownership and oversight over a specified panel of members that range in health status/severity and clinical needs. The incumbent assesses health management needs of the assigned member panel and utilizing data/analytics in conjunction with professional clinical judgement to identify the right clinical intervention for each member. The incumbent will be supported by a multi-disciplinary team and will use clinical judgment to refer members to appropriate multi-disciplinary resources. In addition to identifying the appropriate clinical interventions and referrals, the incumbent will manage an active case load of members in his/her panel that are enrolled in case management. The incumbent conducts outreach to members enrolled in case management including but is not limited to developing a care plan, encouraging behavior changes, identifying and addressing barriers, helping members to coordinate care, and identifying various resources to assist members in achieving their personal health goals. The incumbent monitors, improves and maintains quality outcomes (clinical, financial and functional) for the specified panel of members.

Required: High School Diploma/GED Substitutions None Preferred Bachelor's Degree in Nursing EXPERIENCE Required 7 years of any combination of clinical, case management and/or disease/condition management experience, provider operations and / or health insurance experience Preferred Advanced training and experience in cognitive behavioral therapy (CBT), motivational interviewing or dialectical behavior therapy (DBT) Experience working with the healthcare needs of diverse populations Understanding of the importance of cultural competency in addressing targeted populations LICENSES AND CERTIFICATIONS Required Current State of PA RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC) or WV or DE or NY is required. Other RN license(s), if applicable, must be obtained within the first 6 months of employment. Preferred Certification in Case Management SKILLS Written and verbal presentation skills, negotiation skills, and skills in positively influencing others with respect and compassion Broad knowledge of disease processes Understanding of healthcare costs and the broader healthcare service delivery system Proficiency in MS Excel and strong analytic skills with ability to interpret, evaluate and act on clinical and financial data, including analysis of statistical data Excellent interpersonal/ consensus building skills as well as the ability to work with a variety of internal and external colleagues from all levels of an organization Ability to work in a high performing team environment that requires flexibility Demonstrated ability to handle multiple priorities in a fast paced environment. Excellent organizational, time management and project management skills Self-directed; self-starter, ability to work successfully with indirect supervision and moderate autonomy LANGUAGE REQUIREMENT (Other Than English) None TRAVEL REQUIREMENT 0% - 25% PHYSICAL, MENTAL DEMANDS AND WORKING CONDITIONS Position Type Office-Based Teaches/Trains others regularly Rarely Travels regularly from the office to various work sites or from site-to-site Rarely Works primarily out-of-the office selling products/services (Sales employees) Does Not Apply Physical Work Site Required No Lifting up to 10 pounds Rarely Lifting 10 to 25 pounds Rarely Lifting 25 to 50 pounds Rarely

Maintain oversight over specified panel of members by performing ongoing assessment of members’ health management needs, identifying the right clinical interventions to address member needs and/or triaging members to appropriate resources for additional support. For assigned case load, create care plans to address members’ identified needs, remove barriers to care, identify resources, and conduct a number of other activities to help improve the health outcomes of members; care plans include both long and short term goals and plan of regular contacts for re-assessment. Ensure targeted percentage of patient goal achievement (i.e., realization of member care plan), and other patient outcomes, as applicable, are achieved. Ensure all activities are documented and conducted in compliance with applicable business process requirements, regulatory requirements and accreditation standards. Maintain current knowledge and adheres to applicable CMS, state, local, and regulatory agency requirements and applicable standards of practice for case management including those published by CMSA and/or ACMA, as required by the organization. Other duties as assigned or requested.

Guidehealth

RN Case Manager - Remote

Posted on:

April 26, 2026

Job Type:

Full-Time

Role Type:

Telehealth

License:

RN

State License:

Compact / Multi-State

Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. Our goal is to make great healthcare affordable, improve the health of patients, and restore the fulfillment of practicing medicine for providers. Driven by empathy and powered by AI and predictive analytics, Guidehealth leverages remotely-embedded Healthguides™ and a centralized Managed Service Organization to build stronger connections with patients and providers. Physician-led, Guidehealth empowers our partners to deliver high-quality healthcare focused on outcomes and value inside and outside the exam room for all patients. As a growing and innovative organization, we operate with a high degree of agility. Employees are expected to adapt to evolving business needs, step in to support cross-functional initiatives, and contribute beyond traditional role boundaries when needed. This collaborative and flexible mindset is essential to our success. We encourage cross-training, ongoing development, and a commitment to learning across all areas of the business—ensuring we continue to grow and you continue to thrive as a high-performing, mission-driven team.

As an RN Case Manager, you will partner with clinical teams to provide complex case management and strengthen the connection between the patient, the primary care physician/medical practice staff, and the patient’s care team. The Registered Nurse (RN) Case Manager is responsible for a specific patient population experiencing complex medical conditions, socio-economic, and/or mental health co-morbidities. The RN Case Manager will optimize the patient’s health status through assessment, planning, implementation, coordination, monitoring, and evaluation of the options and services available to the patient. The RN Case Manager collaborates with their assigned Healthguides to achieve optimal quality, clinical, and financial outcomes. This is primarily a remote position that will require travel as needed (10%-15%) to clinical sites in the Atlanta, GA area.

Licensed Registered Nurse in good standing in the State of Georgia with a compact license. 3+ years of RN Case Management experience in an outpatient setting. Bachelor of Science in Nursing, preferred. Certification in Case Management, preferred. Strong problem-solving skills to diagnose, troubleshoot, and resolve barriers to patient care, workflows, and care plan progression. Ability to analyze complex healthcare challenges and implement effective solutions while maintaining compliance within a high-regulation healthcare environment. Ability to manage multiple priorities, meet deadlines, and work independently in a fast-paced environment, ensuring timely and efficient case management. Exceptional written, visual, and verbal communication skills. Ability to participate in virtual meetings with clear verbal communication, engaging effectively with healthcare teams, patients, and stakeholders. Exceptional conversational skills and the ability to precisely document patient interviews, leveraging software in real time. Strong interpersonal skills with a focus on empathy, patience, professionalism, and respect in all patient, team, and client interactions. Demonstrated competency and ability to independently navigate technology using multiple platforms, computer screens, and other technical components (i.e., Electronic Medical Records, care management analytics databases, phone dialing system, Microsoft Office). Ability to meet accreditation and quality standards, including but not limited to NCQA and HEDIS. Observance of patient confidentiality through the use of the provided headset during all conversations in a private home office without distraction. Compliance with all Guidehealth policies and procedures. What we'd love for you to have: BSN and Case Management certification preferred.

Conducting in-depth telephonic assessments to understand each patient’s medical, psychosocial, and social needs. Reviewing and updating medical histories—including medications, chronic conditions, and preventive care. Developing individualized care plans and guiding patients through their treatment goals and care options. Providing empathetic, evidence-based education on chronic disease management and preventive health. Monitoring progress by phone, adjusting care plans, and ensuring patients stay connected to their providers. Completing Medicare Annual Wellness Visits (AWVs) via telehealth under physician supervision. Partnering with Healthguides who support non-clinical needs such as scheduling, transportation, food assistance, and SDOH resources. Performing proactive outreach and timely follow-ups to maintain continuity of care and patient engagement. Advocating for patients, helping them access the right resources at the right time. Documenting clearly and accurately in the EHR and care-management systems during and after calls. Supporting quality outcomes (HEDIS, NCQA) by coordinating preventive services and managing chronic conditions. Participating in virtual meetings, ongoing education, and clinical training to stay current with care standards. Using multiple communication methods (phone, text, patient portals, email, AI-supported tools) to reach high-risk patients. Collaborating in AI-driven outreach programs that help connect with vulnerable populations. Protecting patient privacy in a secure, private home workspace. Performing additional responsibilities as needed to support patients and the care team.

Henry Ford Health

Registered Nurse-Access Care-UMC-Remote work-36 Hours-Afternoons - Detroit

Posted on:

April 26, 2026

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Michigan

Serving communities across Michigan and beyond, Henry Ford Health is committed to partnering with patients & members along their entire health journey. Henry Ford Health provides a full continuum of services – from primary and preventative care, to complex and specialty care, health insurance, a full suite of home health offerings, virtual care, pharmacy, eye care & other healthcare retail. It is one of the nation’s leading academic medical centers, recognized for clinical excellence in cancer care, cardiology and cardiovascular surgery, neurology and neurosurgery, orthopedics and sports medicine, and multi-organ transplants. Consistently ranked among the top five NIH-funded institutions in Michigan, Henry Ford Health engages in thousands of research projects annually. Equally committed to educating the next generation of health professionals, Henry Ford Health trains more than 4,000 medical students, residents and fellows every year across 50+ accredited programs. With more than 50,000 valued team members, Henry Ford Health is also among Michigan’s largest and most diverse employers. President and CEO Bob Riney leads the health system and serves a growing number of customers across more than 550 sites across Michigan. That includes: 13 acute care hospitals; 3 behavioral health facilities including two world-class addiction treatment centers; a state-of-the-art orthopedics and sports medicine facility; multiple cancer care destinations including the Brigitte Harris Cancer Pavilion, Henry Ford Health’s premier location in Detroit; & more options than ever for primary care for patients and families across the region.

Position: 36 hours per week Shift: Afternoons 12 Hour Shifts Every other weekend and Holiday Rotations Benefits: Full time benefit package MUST be within driving distance of Elijah McCoy building in downtown Detroit for purposes of ongoing training and if internet is down at remote location

Education/Experience Required: Bachelor's degree in nursing. Three (3) years of clinical experience. Experience facilitating InterQual reviews, admission process preferred. Experience with systems that support patient flow, admission, and transfer preferred. Ability to prioritize, meet deadlines and produce detailed and accurate work. Excellent clinical knowledge and assessment skills to evaluate and prioritize care issues. Ability to assess and handle highly sensitive and confidential matters with considerable discretion and independent judgment. Demonstrated positive work ethic and strong sense of teamwork/problem solving with co-workers. Understanding of Henry Ford Health policies and procedures preferred. Certifications/Licensures Required: Licensed as a Registered Nurse in the State of Michigan

Within the System Capacity Command Center (SC3) at Henry Ford Health, the Access Management Nurse operates under minimal supervision, to review and screen recommended admission cases at Henry Ford Health System Emergency Departments (ED). Utilizes clinical and regulatory knowledge and skills to reduce financial risk and exposure due to inappropriate admissions. Collaborates with ED physicians, attending physicians, and third-party payers regarding initial screening reviews. Facilitates throughput in the most cost-effective manner, through continuous assessments, problem identification, and education.

Tuesday Health

Licensed Practical Nurse (Boston)

Posted on:

April 25, 2026

Job Type:

Full-Time

Role Type:

Care Management

License:

LPN/LVN

State License:

Massachusetts

Tuesday Health is a value-based palliative care provider group dedicated to transforming serious illness and end-of-life care. We deliver goal-centered care focused on alleviating physical symptoms and emotional stress for individuals and their caregivers. Our interdisciplinary care teams reduce avoidable hospitalizations and improve quality of life wherever individuals call home. Through our leading-edge care model, Tuesday Health is shaping the future of community-based palliative care nationwide.

The Complex Care Navigator LPN plays a key role in delivering coordinated, compassionate care for members with serious illnesses. Working closely with nurse practitioners and registered nurses, the LPN administers clinical assessments and screenings throughout the care journey. They prioritize member needs based on assessment results and collaborate with the interdisciplinary team to develop and execute individualized care plans. The LPN ensures seamless communication, participates in care rounds, and leverages Tuesday Health’s electronic tools to optimize the member experience. Trust-building, empathy, and consistent member engagement are essential to the role, enabling a truly person-centered approach to care.

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

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

Molina Healthcare

(RN) Care Review Clinician- Utilization Review

Posted on:

April 25, 2026

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

California

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

This role provides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care. EMERGENCY DEPARTMENT SUPPORT UNIT This is a remote role supporting our California Health Plan. The role is remote, but candidates must have an active and valid CALIFORNIA RN license and must be willing to work the Pacific Time Zone shift hours as posted. 3-12 SHIFT 7:00 AM - 08:30PM PACIFIC HOURS, schedule will rotate Must commit to working every other weekend and 4 Molina recognized holidays per year. This role will be on a provider-facing phone queue for the entirety of the shift, excluding breaks and lunches.

At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience. Registered Nurse (RN). License must be active and unrestricted in state of practice. Ability to prioritize and manage multiple deadlines. Excellent organizational, problem-solving and critical-thinking skills. Strong written and verbal communication skills. Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications: Certified Professional in Healthcare Management (CPHM). Recent hospital experience in an intensive care unit (ICU) or emergency room.

Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines. Analyzes clinical service requests from members or providers against evidence based clinical guidelines. Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. Conducts reviews to determine prior authorization/financial responsibility for Molina and its members. Processes requests within required timelines. Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner. Requests additional information from members or providers as needed. Makes appropriate referrals to other clinical programs. Collaborates with multidisciplinary teams to promote the Molina care model. Adheres to utilization management (UM) policies and procedures.

Molina Healthcare

Remote Medical Review Nurse (RN) - Must Work CST time zone

Posted on:

April 25, 2026

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

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

Provides support for medical claim and internal appeals review activities - ensuring alignment with applicable state and federal regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Contributes to overarching strategy to provide quality and cost-effective member care.

Highlights of the skills and qualifications needed for the Medical Review Nurse: Registered Nurse with a compact/multi-state license Must be willing to work a schedule within the Central Time Zone, Monday - Friday Have at least 2 years of clinical experience as a nurse Have at least 1 year of experience in the following areas: utilization review, medical claims review, claims auditing, medical necessity review and/or coding experience Excellent skills working with Microsoft Office Suite Confidence in having multiple screens open and toggling between them to complete necessary forms and documentation REQUIRED QUALIFICATIONS: At least 2 years clinical nursing experience, including at least 1 year of utilization review, medical claims review, long-term services and supports (LTSS), claims auditing, medical necessity review and/or coding experience, or equivalent combination of relevant education and experience. Registered Nurse (RN). License must be active and unrestricted in state of practice. Experience demonstrating knowledge of ICD-10, Current Procedural Technology (CPT) coding and Healthcare Common Procedure Coding (HCPC). Experience working within applicable state, federal, and third-party regulations. Analytic, problem-solving, and decision-making skills. Organizational and time-management skills. Attention to detail. Critical-thinking and active listening skills. Common look proficiency. Effective verbal and written communication skills. Microsoft Office suite and applicable software program(s) proficiency. Preferred Qualifications: Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ), or other health care certifications. Nursing experience in critical care, emergency medicine, medical/surgical or pediatrics. Billing and coding experience.

Facilitates clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases in which an appeal has been made, or is likely to be made, to ensure medical necessity and appropriate/accurate billing and claims processing. Reevaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of relevant and applicable state and federal regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of services provided, length of stay, level of care, and inpatient readmissions. Validates member medical records and claims submitted/correct coding, to ensure appropriate reimbursement to providers. Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) issues. Identifies and reports quality of care issues. Assists with complex claim review including diagnosis-related group (DRG) validation, itemized bill review, appropriate level of care, inpatient readmission, and any opportunities identified by the payment integrity analytical team; makes decisions and recommendations pertinent to clinical experience. Prepares and presents cases representing Molina, along with the chief medical officer (CMO), for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings. Reviews medically appropriate clinical guidelines and other appropriate criteria with medical directors on denial decisions. Supplies criteria supporting all recommendations for denial or modification of payment decisions. Serves as a clinical resource for utilization management, CMOs, physicians and member/provider inquiries/appeals. Provides training and support to clinical peers. Identifies and refers members with special needs to the appropriate Molina program per applicable policies/protocols.

CareOregon

Registered Nurse - Utilization Management I

Posted on:

April 25, 2026

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Oregon

CareOregon is a nonprofit, mission-driven health plan, focused on providing care to low-income Oregonians. The CareOregon family includes Columbia Pacific CCO, Jackson Care Connect, Housecall Providers and our work as part of Health Share of Oregon. We also support recruitment for the Oregon Health and Education Collaborative.

The Registered Nurse – Utilization Management I is responsible for supporting specific utilization management (UM) program functions within the Clinical Operations department. UM program functions include Benefit Management, Benefit Review, Appeals and Grievances and Health Related Services (HRS). Together they support the healthcare needs of members, determine the best medically appropriate services, and apply clinical-based criteria for decision-making while managing medical expenses. Estimated Hiring Range $100,350.00 - $122,650.00 Bonus Target Bonus - SIP Target, 5% Annual Current CareOregon Employees: Please use the internal Workday site to submit an application for this job.

Experience and/or Education: Current unrestricted Oregon RN license Minimum 2 years RN experience [OR 1 year RN experience AND 3 years’ experience in healthcare setting role(s) such as billing, coding, medical assistant, etc.] Preferred: More than 1 year RN experience Healthcare utilization management experience in the functional focus area (Appeals and Grievance, Benefits Review or Benefit Management) Experience with Medicaid and/or Medicare utilization management Knowledge, Skills And Abilities Required Knowledge Knowledge of Medicaid health plan and Medicare benefits Knowledge of applicable DMAP rules and regulations Knowledge of ICD-10, CPT, and HCPCS codes Familiarity with the principles of utilization management Familiarity with healthcare documentation systems Skills And Abilities: General computer skills including use of Microsoft Office applications and internet search functions Ability to use review criteria in accordance with departmental policies Ability to adhere to HIPAA regulations e.g., maintaining confidentiality of protected health information Ability to interpret and apply complex policies and procedures Ability to review work for accuracy Ability to independently prioritize work Ability to use critical thinking and problem-solving skills Strong spoken and written communication skills Strong interpersonal and customer service skills Ability to work effectively with diverse individuals and groups Ability to learn, focus, understand, and evaluate information and determine appropriate actions Ability to accept direction and feedback, as well as tolerate and manage stress Ability to see, read, and perform repetitive finger and wrist movement for at least 6 hours/day Ability to hear and speak clearly for at least 3-6 hours/day Working Conditions: Work Environment(s): ☒ Indoor/Office ☐ Community ☐ Facilities/Security ☐ Outdoor Exposure Member/Patient Facing: ☒ No ☐ Telephonic ☐ In Person Hazards: May include, but not limited to, physical and ergonomic hazards. Equipment: General office equipment Travel: May include occasional required or optional travel outside of the workplace; the employee’s personal vehicle, local transit or other means of transportation may be used. Work Location: Work from home

Communicate with members and/or providers in a professional manner and in accordance with State and Federal requirements as needed to complete requests. Maintain confidentiality of all discussions, records, and other data in connection with quality management activities according to professional standards. Refer members to care coordination per policies and procedures. Maintain accurate and complete documentation. Collaborate with Medical Directors to determine medical necessity and appropriateness of care for benefits requested and/or rendered. Work with clinical support staff to ensure service requests, authorizations and/or grievances are managed in accordance with state and federal guidelines. Identify and refer potential quality of care issues for peer review. Ensure that authorization decisions are based on organizational policy and state and federal coverage rules. Gather and submit documents for third party case review; this includes all documentation and follow-up activities. Issue denial notices based on established unit protocols and state and/or federal requirements. Assist with periodic audits, general quality management and improvement activities, and other regulatory activities as needed. Foster collaboration with teams across the Clinical Operations department to ensure work and goals are met. Meet or exceed department production, timelines, and quality standards established for level I. May participate in departmental workgroups or projects as assigned. Support testing for system updates and implementations as assigned. May help train new staff and teammates as assigned. Cross train in additional functional focus areas as assigned. Duties Specific To Functional Focus Area Benefit Management Review provider pre-service requests and determine benefit coverage according to Medicare, Medicaid and/or organizational guidelines Benefit Review Determine appropriate level of care and length of stay for inpatient members to include hospitals, skilled nursing facilities, long term acute care hospitals, inpatient rehabilitation hospitals, and respite care programs. Review inpatient admission for re-insurance clinical reporting. Appeals and Grievance Assemble evidence and build clinical cases for administrative hearings or Independent Review Entity (IRE) reviews. Function as a CareOregon representative in administrative hearings. Assist with the analysis and summary of data for written reports and public presentations as needed. Communicate with members, providers, health plan administrators to manage grievances and appeals and provide case status updates as needed. Investigate and use clinical judgement to identify quality of care or safety issues and present findings to an oversight committee. Health Related Services Review provider and member submitted HRSN and Flexible Services requests and determine benefit eligibility according to Medicaid and/or organizational guidelines. Organizational Responsibilities Perform work in alignment with the organization’s mission, vision and values. Support the organization’s commitment to equity, diversity and inclusion by fostering a culture of open mindedness, cultural awareness, compassion and respect for all individuals. Strive to meet annual business goals in support of the organization’s strategic goals. Adhere to the organization’s policies, procedures and other relevant compliance needs. Perform other duties as needed.

Optum

Behavioral Health RN Case Manager - Remote

Posted on:

April 25, 2026

Job Type:

Full-Time

Role Type:

Behavioral Health

License:

RN

State License:

Compact / Multi-State

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.

We're making a solid connection between exceptional patient care and outstanding career opportunities. The result is a culture of performance that's driving the health care industry forward. As a Telephone Case Manager RN with UnitedHealth Group, you'll support a diverse member population with education, advocacy and connections to the resources they need to feel better and get well. Instead of seeing a handful of patients each day, your work may affect millions for years to come. Ready for a new path? Apply today! The Telephonic Case Manager RN Behavioral Health will identify, coordinate, and provide appropriate levels of care. The Telephonic Case Manager RN Behavioral Health is responsible for clinical operations and medical management activities across the continuum of care (assessing, planning, implementing, coordinating, monitoring and evaluating). This includes case management, coordination of care, and medical management consulting. This is high volume, customer service environment. You'll need to be efficient, productive and thorough dealing with our members over the phone. Solid computer and software navigation skills are critical. You should also be solidly patient-focused and adaptable to changes. This is a full-time, Monday - Friday, 8am-5pm position in your time zone. You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.

Required Qualifications: Current, unrestricted Compact RN license in the state of residence 1+ years of experience with mental health/behavioral health/substance use focus Proficiency in Microsoft Office Tools and Systems (Outlook, Word, Excel, Teams) Access to high-speed internet (DSL or Cable) Dedicated work area established that is separated from other living areas and provides information privacy Preferred Qualifications: BSN Certified Case Manager (CCM) 3+ years of experience with a mental health/behavioral health/substance use focus Case management experience Experience or exposure to discharge planning Experience in a telephonic role Background in managed care Bilingual in English and Spanish All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy.

Make outbound calls and receive inbound calls to assess members current health status Identify gaps or barriers in treatment plans Provide patient education to assist with self-management Make referrals to outside sources Provide a complete continuum of quality care through close communication with members via in-person or on-phone interaction Support members with condition education, medication reviews and connections to resources such as Home Health Aides or Meals on Wheels You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

CVS Health

Case Manager RN

Posted on:

April 25, 2026

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Arizona

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

This Case Manager RN position is 100% remote, no travel is expected with this position. Normal Working Hours: Monday through Friday, 8 hour shift between 7am to 5pm Arizona time The Nurse Case Manager is responsible for telephonically assessing, planning, implementing and coordinating all case management activities with members from our Federal Plans. The Case Manager is responsible to evaluate the medical needs of the member in order to facilitate and promote the member’s overall wellness. The Case Manager develops a proactive course of action to address issues presented to enhance the member's short and long term outcomes.

Required Qualifications: Must have active, current and unrestricted RN licensure in state of residence and have the ability to be licensed in all non-compact states. Must be willing and able to work Monday through Friday, 8 hour shift between 7am to 5pm Arizona time Must live in either PST, MST, or Arizona Time zones 3+ years of clinical practice experience required 1+ years of experience utilizing MS Office suites Preferred Qualifications: Case management experience preferred Case Manager Certification Education: Associate's degree required BSN preferred

Apply data driven methods of identification of members to fashion individualized case management programs and/or referrals to alternative healthcare programs. Conduct comprehensive clinical assessments. Evaluate needs and develop flexible approaches based on member needs, benefit plans or external programs/services. Advocate for patients to the full extent of existing health care coverage. Promote quality, cost effective outcomes, and make suggestions to improve program/operational efficiency. Identify and escalate quality of care issues through established channels. Provide an expected very high level of customer service. Utilize assessment techniques to determine member’s level of health literacy, technology capabilities, and/or readiness to change. Utilize influencing/motivational interviewing skills to ensure maximum member engagement and promote lifestyle/behavior changes to achieve optimum level of health.

Private Health Management

Associate Clinical Director - Oncology

Posted on:

April 25, 2026

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

NP/APP

State License:

California

Private Health Management (PHM) supports people with serious and complex medical conditions, helping them obtain the best possible medical care. We guide individuals and families to top specialists, advanced diagnostics, and personalized care. Trusted by healthcare providers and businesses, PHM offers independent, science-backed insights to help clients make informed decisions and access the best care.

As an Associate Clinical Director at PHM, you’ll help patients in their deepest moment of need to challenge the status quo and go beyond the standard of care to achieve the best possible health outcomes. Working from your home office, you’ll serve as the lead clinician and engagement manager collaborating with team members through our process to uncover opportunities to improve your client’s care. Team members may include additional clinicians, PhD scientists who mine the medical literature to identify data-supported care options, and care coordinators who manage care-related logistics. You will utilize your clinical expertise and curiosity along with your tenacious problem-solving skills to ascertain the key issues that must be addressed, identify and engage with top experts, and guide patients to optimized care plans. In collaboration with your personal care team colleagues, you will explore specialized diagnostics to better define the underlying mechanisms and array of treatment options beyond the current standard of care. Cutting through the barriers inherent to our chaotic healthcare system, you enable patients to access an unrivaled level of personalized care and attention while guiding them to the best possible treatment plan available.

Active NP or PA license in your home state A “Do what it takes to get the job done” attitude Five years of clinical experience managing complex medical issues in an oncology and/or hematology environment where careful assessment and critical thinking are required Exceptional client-facing skills including: Executive written & verbal communication, impeccable attention to detail and organization, and a highly professional demeanor under pressure. An insatiable clinical curiosity. You’re never satisfied by “the obvious answer” you think creatively, solve complex problems, and work successfully with others. Technically savvy and feel comfortable navigating various tech platforms to efficiently document your work and communicate with your colleagues Significant bonus points for oncology experienced mixed with another complex discipline.

What You’ll Accomplish: Building Strong Client Relationships. You’ll become the trusted guiding hand through a client's healthcare journey by managing complex medical issues, coordinating their care, facilitating best diagnostic and therapeutic treatment options available world-wide, and navigating being their guide to the healthcare system Demonstrating Strong Clinical Acumen. You’ll offer high level clinical management and education to clients and families in a caring, compassionate manner. Bring Together the Best Minds: Work closely with clinical and research team members at PHM to identify latest therapies and deliver comprehensive information on medical conditions, medications, treatments, and clinical trials Articulating needs for collaboration with external care providers, interdisciplinary team resources, and internal team rounding Networking with key opinion leaders to invite collaboration and build relationships that facilitate our ability to help our clients achieve best care Managing other clinical staff as it relates to a particular case or service line