The #1 Remote Nurse Job Board - Work from home nursing jobs posted daily in one place

AdventHealth

Clinical Documentation Integrity Specialist Remote

Posted on:

March 27, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

State License:

Florida

Hospitals, medical centers and facilities need more than physicians, nurses and specialists delivering care to our patients. A truly successful health care organization needs a thoughtful, dedicated, steady and experienced team working behind the scenes to make sure communities around the country receive the health care they need. If you’ve also been interested in working in the health care field but aren’t a health care provider, a corporate career at AdventHealth may just be the perfect fit. We’re a faith-based health care organization headquartered in Altamonte Springs, Florida. As a national leader in quality, safety and patient satisfaction, our 92,000 team members maintain a long tradition of whole-person health by caring for the physical, emotional and spiritual needs of every patient. Start your journey with a health care career at AdventHealth Corporate. Every day, our fellow team members show up to work, unified by one shared mission: Extending the Healing Ministry of Jesus Christ. As a faith-based health care organization, our story is one of hope as we strive to heal and restore the body, mind and spirit. Though our facilities are spread across the country, this unwavering belief binds us together. Across every office, exam and patient room, we’re committed to providing individualized, holistic care. This is our Christian mission, and it inspires us to help make communities healthier and happier.

Under general supervision of the Director of Clinical Documentation Integrity and in some situations the supervision of the Clinical Documentation Integrity Manager, and in collaboration with physicians, nursing and HIM coders, the Clinical Documentation Specialist (CDS) strategically facilitates and obtainsappropriate and quality physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient. The CDS educates members of the patient care team regarding documentation guidelines, including physicians, allied health practitioners, nursing, and care management. The CDS adheres to strict departmental and organizational goals, objectives, standards of performance and policies and procedures, continually ensuring quality documentation and regulatory compliance. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.

Associate and 5 years experience 5 years acute care 2 years CDI experience LICENSURE, CERTIFICATION OR REGISTRATION REQUIRED: Current active State license as a Registered Nurse, Nurse Practitioner, Physician's Assistant or an unlicensed physician who has graduated from a medical school that is listed in the World Directory of Medical Schools (World Directory) as meeting eligibility requirements for its graduates to apply to the Educational Commission for Foreign Medical Graduates (ECFMG) for ECFMG Certification and examination at the time of graduation and CCDS (Certified Clinical Documentation Specialist) certification, or/and CDIP (Certified Documentation Improvement Practitioner) certification Preferred Qualifications: BSN or higher degree and 3 years of CDI experience CCS (Certified Coding Specialist)

Demonstrates extending the healing ministry of Christ, through behavioral whole care standards of love me, make it easy, own it and keep me safe to every person they meet. Delivers exceptional care and strives for excellence. Committed to improving the health, prosperity and well-being of the communities we serve. Uphold the highest standards, with integrity driving every decision made and every action taken. Guided by relentless stewardship in the management of resources entrusted to them. Reviews concurrent medical record for documentation compliance including completeness and accuracy for severity of illness (SOI), risk of mortality (ROM) and quality. Completes accurate and timely record review to ensure the integrity of documentation compliance. Completes accurate and concise input of data into CDI Software resulting in accurate metrics obtained through the reconciliation process. Understands and supports CDI documentation strategies (upon completion of didactic training) and continues to educate self and team members, by attending monthly mandated education sessions and using educational tools, videos and provided Webinars Recognizes opportunities for documentation improvement using strong critical-thinking skills. Uses critical thinking and sound judgment in decision making keeping quality considerations in balance with regulatory compliance. Initiates/formulates CDI severity worksheets and clinically credible clarifications for inpatients, sending/presenting opportunities for improved documentation compliance to physicians, nurse practitioners and other clinical team members. Transcribes documentation clarifications as appropriate for SOI, ROM, PSI, HCCs and HACs to ensure documentation compliance is accomplished. Strategically educates members of the patient-care team regarding documentation regulations and guidelines, including physicians, allied health practitioners, nursing, and collaboration with the healthcare team. This includes quarterly and annual compliance updates from Medicare. Effectively and appropriately communicates with physicians and other healthcare providers as necessary to ensure appropriate, accurate and complete clinical documentation. Communicates with HIM staff and collaborates with them to resolves discrepancies with DRG assignments and other coding issues. Completes well-timed follow-up case reviews on all cases with priority given for resolution of those with clinical documentation clarifications. Participates in department meetings, including feedback on outstanding issues, presentations for educational opportunities and any other needs identified by the CDI leaders. Assumes personal responsibility for professional growth, development and continuing education to maintain a high level of proficiency. Proficient in formulating valid clarifications that are easily understood by physicians and other members of the medical team. Accurately reconciles all cases in CDI Software. Assists in new hire orientation through precepting and mentoring. Maintains CCDS credentialing

Save

Bookmark This Job

AdventHealth

ED Utilization Management RN Remote

Posted on:

March 27, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

State License:

Compact / Multi-State

The role of the Emergency Department Utilization Management (UM) Registered Nurse (RN) is to use clinical expertise by analyzing patient records to determine legitimacy of hospital admission, treatment, and appropriate level of care. This coverage will be required twenty-four hours per day, seven days a week including weekends, holidays and overnight. The Emergency Department UM RN leverages the algorithmic logic of the XSOLIS Cortex platform, utilizing key clinical data points to assist in status and level of care recommendations. The Emergency Department UM RN is responsible to document findings based on department and regulatory standards. When screening criteria does not align with the physician order or a status conflict is indicated, the UM nurse is responsible for escalation to the Physician Advisor or designated leader for additional review as determined by department standards. The Utilization Management Nurse is accountable for a designated patient caseload and responsible for specific functions within the role including: Reviewing available patient records pre-admission, providing timely status recommendations to optimize correct patient classification and corresponding payer notifications/authorizations Adhering to all rules and regulations of applicable local, state, and federal agencies and accrediting bodies Actively participating in team workflows and accepting responsibility in maintaining relationships

Associate in nursing Required or Bachelor's in nursing Required 3 acute care clinical nursing experience 2 Utilization Management experience, or equivalent professional experience RN - Registered Nurse - State Licensure and/or Compact State Licensure Must be able to demonstrate knowledge and skills necessary to provide appropriate status recommendations. Must demonstrate knowledge of the principles of growth, development, and disease states as it relates to the different life cycles. Familiarizes self with authorization requirements for assigned payers, based on payer matrix. Demonstrates working knowledge and understanding of state and federal guidelines pertinent to utilization management, as well as current procedural terminology (CPT) codes and inpatient-only procedures. Must be able to demonstrate knowledge and skills necessary to provide appropriate status recommendations based on medical necessity indicators, findings, and documentation. Excellent interpersonal communication and negotiation skill. Strong analytical, data management, and computer skills. Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components. Ability to navigate and utilize other related software and databases to perform required actions that encompass Utilization Management. Demonstrates strong analytical, problem solves skills and the ability to analyze complex data Promotes individual professional growth and development by meeting requirements for mandatory/continuing education, skills competency, supports department-based goals which contribute to the success of the organization; serves as a resource to less experienced staff. Preferred Qualifications: Accredited Case Manager (ACM) CCM - Certified Case Manager 5 Clinical experience in acute care facility 4 Utilization Management within acute care setting 2 Experience working in electronic health records

Performs pre-admission status recommendation in Emergency Department or elective procedure settings as assigned, to communicate with providers status guidance based on available information. Leverages clinical experience and critical thinking to provide status assignment recommendations to providers within an abbreviated timeframe. Maintaining thorough knowledge of payer guidelines, familiarity with payer processes for initiating authorizations, and following through accordingly to prevent loss of reimbursement, including the management of concurrent and pre-bill denials. Works collaboratively and maintains active communication with physicians, nursing and other members of the multi-disciplinary care team to effect timely, appropriate management of claims. Utilizes advanced conflict resolution skills as necessary to ensure timely resolution of issues. Collaborates with the physician and all members of the multidisciplinary team to facilitate care for designated case load; monitors the patient’s progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective; facilitates the following on a timely basis: *Assignment of appropriate patient status and level of care; Ability to work independently and exercise sound judgment in interactions with any physicians and/or other interdisciplinary team members; Completion of all required documentation in the Cortex platform and in the system’s electronic health record; *Escalating otherwise unresolved status conflicts appropriately and timely to the physician advisor as outlined in department workflow Communicates with all parties (i.e., staff, physicians, etc.) in a timely, helpful, and courteous manner while extending exemplary professionalism. Anticipates and responds to inquiries and needs in an assertive, yet courteous manner. Demonstrates positive interdepartmental communication and cooperation. Completes patient history indicators in Cortex platform, based on available information, to optimize accuracy of Care Level Scores Actively participates in clinical performance improvement activities. *Uses data to drive decisions and plan/implement performance improvement strategies for assigned patients, including fiscal, clinical, and patient satisfaction data. *Collects, analyzes, and addresses variances from the plan of care/care path with physician and/or other members of the healthcare team. Uses *concurrent variance data to drive practice changes and positively impact outcomes. *Documents key clinical path variances and outcomes which relate to areas of direct responsibility (e.g., discharge planning). Uses pathway data in *collaboration with other disciplines to ensure effective patient management concurrently. Performs additional tasks (e.g., continued stay reviews, discharge reconciliation) as assigned by leadership. Demonstrates the understanding of requirements for pre-certification process by payers; familiar with ICD-10 and DRG coding principles. Working knowledge of Inpatient/Outpatient Medicare procedures, commercial or managed care special contracted payer inpatient –vs-outpatient procedures. Maintains knowledge and or skill set related to patient’s presenting illness, or, severity of illness and intensity of services necessary for treatment and recovery.

Save

Bookmark This Job

Avosys Technology, Inc.

REMOTE Registered Nurse - Medical Review Specialist-Bexar County, Texas

Posted on:

March 27, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

State License:

Texas

Avosys is a growing integrator of professional, technological and management solutions services. Founded in 1998, Avosys provides services nationwide to Federal, Commercial, Local and State clients. We recognize the foundation of our firm is our people and we continue to rise above our competition by hiring the best.

Avosys is seeking a Bexar County Remote Registered Nurse - Medical Review Specialist to work remotely to review Medicare claims.. Maximize family time with no weekend, Holiday, or on-call requirements Maintain work-life balance with guaranteed 8-hour shifts Take advantage of our competitive, comprehensive benefits package including medical, dental, vision, life, short-term disability, long-term disability & 401(k)

Qualifications: Minimum of two (2) years’ clinical experience Excellent written and oral communication skills Demonstrated experience with evaluating medical and health care delivery issues Strong computer skills to include Microsoft Office proficiency License - Certifications Active and current Registered Nurse license Other Information Industry: Defense US Citizenship Required: Yes Background Check: Required Current Clearance Level Required: None Telework: Yes but Resides in Bexar County, Texas Travel: No

Perform clinical reviews of Medicare Part A and Part B claims for Medical Review, Redeterminations/Appeals (Appeals), and Prior Authorization requests (collectively, the “Services”) in accordance with CMS (Centers for Medicare & Medicaid Services) requirements Complete a projected number of clinical review hours while meeting timeliness and accuracy standards and completing documentation of clinical decisions for remittance. Clinical review of services Review medical record documentation within CMS timeliness parameters (i.e., 20 days from receipt of the medical record for pre-payment reviews and 50 days from receipt of the medical record for post payment reviews) Utilize the applicable Medicare policies (i.e., Local Coverage Determinations, National Coverage Determinations, Internet-Only Manual (IOM) citations, inpatient tools, etc.) to ensure the services comply with all Medicare regulations and documentation requirements Review documentation for medical necessity per guidelines outlined in the Social Security Act 1862(a)(1) Ensure that all documentation includes a valid signature consistent with the signature requirements Documentation of rationale for processing decisions Provide a claim sample of three (3) claims to Companies via established protocols and timeliness parameters (i.e., 18 days from receipt of the medical record for pre-payment reviews and 48 days from receipt of the medical record for post payment reviews) for quality review prior to finalization of documentation of reason for payment, reduction, or denial of service to ensure accuracy of claim decision making Companies will review the three-claim sample for accuracy of claim decision and will make and return decisions to the MRS within 24 hours or less Complete the documentation of the reason for payment, reduction, or denial of service for all claims on an electronic decision template to be provided by Companies. This rationale must be in sentence format so that it may be inserted directly into the response to the provider, must be clear and well-written, and contain sufficient information to educate the providers on how the review decision was made Return documented decision electronically to Companies via established protocols and timeliness parameters (i.e., 20 days from receipt of the medical record for pre-payment reviews and 50 days from receipt of the medical record for payment reviews) Complete the review results letter in the Companies’ letter writing system within 35 days from receipt of the medical record for pre-payment reviews and no later than 60 days from receipt of the medical record for post payment reviews Document all case activity in Companies’ provider tracking system on the day the activity occurs Complete one-on-one provider education (i.e., webinar, conference call, etc.) within 30 days of sending out review results letter Respond to provider inquiries related to case and/or claims throughout the course (i.e. in 24 hours or less) of review If additional clinical guidance is required, complete the Contractor Medical Director (“CMD”) assistance form, track response, and update review accordingly Conduct telephone development for missing or additional records for easily curable errors Notate date of receipt of additional documentation received in the Companies’ provider tracking system Upon request by Companies, initiate or participate in provider teaching activities, creating written teaching material, providing one-on-one education or education to a group as a result of an MR review If fraud activity is suspected, immediately complete initial referral packet for external entity referral and return the packet to the Companies Complete referrals to Companies’ provider outreach and education (“POE”) area in provider tracking system for cases that have a moderate or major error rate Lead and Alternate Lead will participate in all monthly departmental training and meetings, and all Staff will participate as requested Submit all cases for review and approval for quality and closure of cases

Save

Bookmark This Job

Western Growers Assurance Trust

Bilingual (Spanish) Care Management Review Nurse

Posted on:

March 27, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

State License:

California

Western Growers Assurance Trust (WGAT) was founded in 1957 to provide a solution to a need in the agricultural community — a need for employer-sponsored health benefit plans not previously available from commercial health insurance carriers. WGAT is now the largest provider of health benefits for the agriculture industry. The sponsoring organization of WGAT is Western Growers Association, created in 1926 to support the business interests of employers in the agriculture industry. WGAT’s headquarters is located in Irvine, California. WGAT’s mission is to deliver value to agriculture-based employer groups by offering robust health plans that meet the needs of a diverse workforce. By working at WGAT, you will join a dedicated team of employees who truly care about offering quality health benefits and excellent customer service to plan participants. If you want to start making a difference working in the health care industry, then apply to WGAT today!

This is a high-level clinical position responsible for administering and operating Western Growers Assurance Trust’s (WGAT) and Pinnacle Claims Management Inc.’s (PCMI) third-party and direct care management/utilization, health management and case management objectives and initiatives. This position reports to the Nurse Supervisor and requires a high level of clinical judgment and independent decision-making skills.

BA/BS degree and at least three years experience in working care management programs for companies offering employee health benefits, preferred. Current RN licensure to practice in the State of California, required. Currently licensed as Certified Case Manager (CCM) preferred. Comprehensive understanding of generally accepted medical practices, state and ERISA-mandated benefits, plan language, and contracts. Good understanding of health benefits claims processing, knowledge, and understanding of current procedural terminology (CPT), and international classification of diseases (ICD) 9/10 codes preferred. Ability to develop and present health educational sessions around health, nutrition, and other care management topics is required. Proficient in end-user software programs e.g. word-processing, calendaring, spreadsheet, and electronic health record software required. Knowledge of McKesson end-user software and integration of Interqual medical guidelines preferred. Excellent oral and written communication skills in English and Spanish, preferred. Internet access provided by a cable or fiber provider with 40 MB download and 10 MB upload speeds. Home router with wired Ethernet (wireless connections and hotspots are not permitted). A designated room for your office or steps taken to protect company information (e.g., facing computer towards wall, etc.) A functioning smoke detector, fire extinguisher, and first aid kit on site. Verifiable, clean DMV record and the ability to travel to various locations throughout the U.S. (mainly California and Arizona) up to 5% of the time. Physical Demands/Work Environment: The physical demands and work environment described here represent those that an employee must meet to successfully perform this job’s essential functions. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to communicate with others. The employee frequently is required to move around the office. The employee is often required to use tools, objects, and controls. This noise level in the work environment is usually moderate. #LI-Remote

Care Management: Provide education and coaching to members in the Health Management program. Review and approve referral requests for medical and other specialty services, diagnostic services, and other ancillary services using established medical criteria (per protocol). Develop and implement procedures for determining medical necessity, physician review, and a grievance procedure for both members and providers. Ensure regulatory compliance and maintain routine monitoring and oversight of the organization’s case management programs. Provide clinical guidance and oversight of the department’s care management activities. Serve as subject matter expert on all care management questions and assist underwriting and claims departments with clinical expertise. Act as a clinical subject matter expert and a point of contact on matters of clinical content. Provide clinical expertise to Product Development in the development of applications and tools. Act as a client-facing clinical subject matter expert and a clinical point of contact. Medical Review: Perform the pre-certification process by obtaining, organizing, and synthesizing clinical, benefit, and network information. Obtain and maintain clinical records from providers and facilities Perform claims medical necessity review. Maintain a positive working relationship with the Provider Maintenance (PM) Department and advise PM of issues with contracting, network, and rosters. Determine when physician advisor involvement is appropriate on a case-by-case basis. Follow-up with the results of reviews sent to physician advisors. Administration: Assist the claims examiners or customer service staff as needed when updating the system notes regarding managed cases. Interact (electronically & telephonically) with employees of other carriers such as Blue Cross and other networks to resolve pricing and contract issues. Provide prognosis reports for the Underwriting Department, as needed. Monitor large dollar case management clients to ensure effective cost savings while assuring the client receives quality health care. Other: Utilize all capabilities to satisfy one mission — to enhance the competitiveness and profitability of our members. Do everything possible to help members succeed by being curious and striving to understand what others are trying to achieve, planning and executing work in a helpful and collaborative manner, being willing to adjust efforts to ensure that work and attitude are helpful to others, being self-accountable, creating positive impact, and being diligent in delivering results. Maintain a valid California Registered Nurse’s License. Maintain internet speed of 40 MB download and 10 MB upload and router with wired Ethernet. Maintain a HIPAA-compliant workstation and utilize appropriate security techniques to ensure HIPAA-required protection of all confidential/protected client data. Maintain and service safety equipment (e.g., smoke detector, fire extinguisher, first aid kit). Attend client or off-site meetings as requested. Maintain a clean DMV record and the ability to travel to locations throughout the U.S. (mainly California and Arizona) up to 5% of the time. All other duties as assigned.

Save

Bookmark This Job

Morgan Stephens

Remote RN Discharge Planner (Full Remote)

Posted on:

March 27, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

State License:

California

Job Title: Remote RN Discharge Planner (Temp-to-Perm) Pay Rate: $40-$42/hr Schedule: Monday – Friday, 8:00 AM – 5:00 PM PST Location: Remote, but candidate must reside in California and hold a valid CA RN license Job Description A Managed Care Organization is seeking experienced Registered Nurses to assist with discharge planning for Health Plan members. The RNs will work closely with California hospitals, skilled nursing facilities (SNFs), and other lower levels of care to ensure members transition safely and appropriately. This role requires strong clinical expertise and an in-depth understanding of Medi-Cal post-acute care benefits, including criteria for coverage and contractual agreements related to post-acute services. The position is remote, with an exception allowing candidates to reside and be licensed in California. This is a temp-to-hire opportunity.

Required Skills & Qualifications: Active CA Registered Nurse (RN) license. Reside in California. Minimum of 5 years of clinical experience in acute care settings such as med-surg/telemetry, ICU, or ER. Minimum of 2 years of hospital-based discharge planning experience, with expertise in transitioning patients to home, SNF, custodial care, LTAC, and ARU. Strong understanding of Medi-Cal post-acute care benefits and covered services. Experience with MCG inpatient criteria. Familiarity with facility contract language for post-acute levels of care. Ability to manage multiple priorities and work effectively in a remote environment. Excellent communication and collaboration skills to engage with members, providers, and healthcare entities. Preferred Experience: Previous experience in managed care or health plan settings. Familiarity with case management and care coordination. Additional Information: This is a temp-to-perm position based on performance and business needs. Candidates must be available for full-time hours and demonstrate strong accountability in discharge planning.

Collaborate with hospitals, SNFs, and other lower-level care entities to coordinate member discharges. Utilize MCG criteria to assess and determine appropriate discharge plans. Review and interpret facility contracts related to post-acute levels of care. Ensure members transition efficiently and effectively while adhering to Medi-Cal post-acute care benefits. Communicate compassionately with members and providers to facilitate seamless care transitions. Demonstrate a high level of accountability in ensuring timely and appropriate discharge planning.

Save

Bookmark This Job

Morgan Stephens

Remote Case Manager (Remote) - $45/hr - Lee County

Posted on:

March 27, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

None Required

State License:

Florida

Job Title: Remote Case Manager Location: Ft. Myers, FL area (Remote with local travel) Pay: $45/hr + reimbursed expenses Time Zone: Eastern Standard Time Position Type: Full-time, Remote Summary: The Remote Case Manager is responsible for health care management and coordination of Managed Care members in the Ft. Myers area to achieve optimal clinical, financial, and quality of life outcomes. Working remotely, this position involves regular local travel to assisted living facilities, nursing homes, and members' homes for face-to-face visits. The Case Manager will collaborate with members to create and implement integrated care plans, monitor progress, and ensure consistent, cost-effective care in compliance with policy and regulations. Desired Work Hours: 8:30 AM – 5:00 PM

Must-Have Requirements: Bachelor's degree in related fields such as social work or health administration.

Conduct face-to-face visits with members in assisted living facilities, nursing homes, and homes to assess their healthcare needs. Set up appointments every 90 days or as needed to review and update care plans. Arrange transportation for members if needed. Identify gaps in care and healthcare needs, and access resources to address them. Assist caregivers with day-to-day stress and provide support. Coordinate transitions between healthcare settings, including hospital discharge planning. Assess eligibility for long-term care services and support. Connect members with community resources and social services programs. Arrange additional services as needed, such as physical therapy or meal delivery, in collaboration with primary care providers, family members, and other providers.

Save

Bookmark This Job

ARK Solutions, Inc.

EHR Epic Analyst

Posted on:

March 27, 2025

Job Type:

Contract

Role Type:

Clinical Operations

License:

None Required

State License:

North Carolina

Ark Solutions Inc is looking for EHR Epic Analyst! Position: EHR Epic Analyst Location: Raleigh, NC (REMOTE) Duration: 5+ Months and possibility of extension Seeking a Technical Specialist/ EHR Epic Analyst who is an Epic-certified will perform Epic Application Coordinator/Analyst functions to build the following modules for the new EHR: EpicCare Inpatient - Clinical Documentation including Secure Chat & Rover, Clinical Case Management, and Behavioral Health. The Technical Specialist will serve as the primary build and support contact for the assigned Epic modules. This position is responsible for coordinating all issues that arise during the project for their application and must become very knowledgeable about the organization's policies, procedures, and business operations.

Certified by Epic in EpicCare Inpatient – Clinical Documentation including Secure Chat & Rover, Clinical Case Management, and Behavioral Health app: Required 5 Years Epic implementation or operations support experience: Required 8 Years Health IT experience: Required 8 Years Familiarity with Epic tools: Clinical Case Management, Rover, MyChart Bedside, Behavioral Health, and Epic Monitor Required 5 Years Knowledge of clinical workflows: Required 8 Years Knowledge of the unique clinical & regulatory requirements for behavioral health settings and how these interact with other departments/service areas: Required 5 Years Knowledge of typical billing workflows: Required 5 Years Working knowledge in application development and system integration: Required 8 Years Thorough knowledge of assigned data and the use of its systems via developing through test plans/scenarios: Required 8 Years Skilled in enterprise systems and familiarity with best business practices related to systems: Required 8 Years Working knowledge of security protocols for systems utilized: Required 8 Years Working knowledge of the current architecture of systems and information to troubleshoot problems: Required 8 Years Working knowledge of the business functions and system needs of unit to develop working specifications for software application solutions: Required 8 Years Ability to manage timelines, financial resources, and the activities of others to achieve success and to monitor project progress and provide updates: Required 8 Years Experience in the entire development process including specification, workflow analysis, workflow diagrams, data modeling, documentation, and quality: Required 8 Years Coordinate and direct computer systems and application design and development: Required 5 Years Experience in assessing user needs through discussion with customer: Required 8 Years Able to convey technical information to client and promote understanding of relevant issues: Required 8 Years Software quality assurance/testing experience: Required 8 Years

Serve as the primary support contact for the application's end-users Work in developing, designing, configuring, scripting, testing, and/or supporting applications for the business, research, and/or instructional functions of clients. Develop solutions using programming expertise for day-to-day problems to include maintenance, modification, or development of complex inter-related applications/solutions. Evaluate hardware availability and software requirements Identify issues that arise in the application and working to resolve them Guide workflow design, build and test the system, and analyze other technical issues associated with Epic software Identify and implement requested changes to the system Serve as a liaison between end users' workflow needs and Epic implementation staff Maintain regular communication with Epic representatives, including participating in weekly project team meetings Develop an understanding of operational needs to set the direction for the organization's workflows by attending site visits and other integrated sessions Review the status of projects and issues on an ongoing basis with leadership Hold weekly communications with team members to discuss the status of deliverables, shared issues, end-user concerns, budget, and upcoming milestones

Save

Bookmark This Job

ARK Solutions, Inc.

Utilization Review Nurse

Posted on:

March 27, 2025

Job Type:

Contract

Role Type:

Utilization Review

License:

State License:

Washington

Ark Solutions Inc is looking for Registered Nurse - Utilization Reviews! Position: Registered Nurse - Utilization Reviews Location: REMOTE Duration: 6+ Months and possibility of extension

Required Skills: RN required Case management and nursing experience (5+ years) Preferred Skills: BSN preferred Understanding of both inpatient and outpatient, pre-authorizations Performed in hospital or commercial insurance (outpatient) environment Case Management or Health Care Quality Certification: Case Management/Utilization: CMGT-BC, CMM, or other equivalent Quality: CPHQ or other equivalent Education Required: Associates in Nursing Required: Registered Nurse (RN)

The scope of services includes clinical quality monitoring and applies to the entire Client (both direct and private sector care) and Conduct utilization reviews/Review of the cases on utilization.

Save

Bookmark This Job

K Health

Advanced Practice Provider (APP), NY-100% Remote

Posted on:

March 27, 2025

Job Type:

Full-Time

Role Type:

Primary Care

License:

NP/APP

State License:

New York

K Health is venture-backed, fast-growing startup with a mission to use the power of Artificial Intelligence (AI) to get everyone access to higher quality healthcare at more affordable costs. We’re looking for mission driven individuals to join our team and help us eliminate healthcare inequalities to build a better and healthier future. Featured most recently in Forbes and Business Insider as a leading AI startup, K Health is a telehealth company that harnesses the power of technology to help provide the smartest digital healthcare platform to patients, hospital systems, and providers across the United States. Our AI powered application helps bring together the knowledge of thousands of doctors and anonymous medical data to provide the highest quality care to our patients. We offer a free symptom checker, 24/7 access to board-certified doctors, ability to refill prescriptions from your phone, and more. All within one application - no insurance or preauthorization required. K Health was founded in 2016, and has partnered with visionary and leading hospital systems and providers such as Cedars-Sinai, Mayo Clinic, and Elevance Health. Join us on our mission to help provide better healthcare for less.

Join K Health as we partner with the nation's top-rated hospital systems to close care gaps by launching completely Virtual Comprehensive Care Clinics. We are seeking a full-time, board-certified Family Nurse Practitioner or Physician Assistant who will deliver fully remote text and video-based acute care, encompassing preventive care, sick visits, and chronic condition management. The ideal candidate must be licensed in NY. You will be responsible for maintaining a strong rapport with your patients, representing K Health and our clinical partners, while providing world-class remote care. You are comfortable practicing the full spectrum of comprehensive care, including pediatrics and mental health. Work from the comfort of your home and deliver care to those who need it the most, backed by K Health's cutting-edge clinical-grade AI Platform. Our virtual clinics are fully supported 24/7 by a dedicated team of Care Concierge, Clinical Operations, and technical support staff, which greatly reduces your administrative burden.

2+ years of clinical practice experience as a Nurse Practitioner or Physician Assistant in a Family Practice setting Licensed in NY Board-Certified Family Nurse Practitioner or Physician Assistant Must-Have min 1 year of experience using Epic EMR Primary care experience and behavioral health experience, ability to treat both acute and chronic care conditions Should be tech-savvy, proactive, organized, detail-oriented, and have telemedicine experience Clean background and medical malpractice history Willing to commit 40 hours per week, 36 clinical hours Must be able to work one weekend day every other week

Provide text-based and video-based, comprehensive clinical care that encompasses Acute Care, including pediatrics and mental health Conduct video-based Acute Care, Primary Care, and Behavioral Health patient visits Support physicians with Epic inbox management (labs, imaging, patient questions, etc.) Educate patients on appropriate treatments and care plans for their health needs Prescribe medication and refills as appropriate Drive high-quality care with a focus on patient outcomes Elevate remote care; provide compassionate and meaningful care Think on your feet to devise creative solutions to problems that arise or escalate as appropriate Collaborate with Care Team Members Perform against challenging goals with a best-in-class team

Save

Bookmark This Job

K Health

Advanced Practice Provider (APP), CT-100% Remote

Posted on:

March 27, 2025

Job Type:

Full-Time

Role Type:

Primary Care

License:

NP/APP

State License:

Conneticut

Join K Health as we partner with the nation's top-rated hospital systems to close care gaps by launching completely Virtual Comprehensive Care Clinics. We are seeking a full-time, board-certified Family Nurse Practitioner or Physician Assistant who will deliver fully remote text and video-based acute care, encompassing preventive care, sick visits, and chronic condition management. The ideal candidate must be licensed in CT. You will be responsible for maintaining a strong rapport with your patients, representing K Health and our clinical partners, while providing world-class remote care. You are comfortable practicing the full spectrum of comprehensive care, including pediatrics and mental health. Work from the comfort of your home and deliver care to those who need it the most, backed by K Health's cutting-edge clinical-grade AI Platform. Our virtual clinics are fully supported 24/7 by a dedicated team of Care Concierge, Clinical Operations, and technical support staff, which greatly reduces your administrative burden.

2+ years of clinical practice experience as a Nurse Practitioner or Physician Assistant in a Family Practice setting Licensed in CT Board-Certified Family Nurse Practitioner or Physician Assistant Must-Have min 1 year of experience using Epic EMR Primary care experience and behavioral health experience, ability to treat both acute and chronic care conditions Should be tech-savvy, proactive, organized, detail-oriented, and have telemedicine experience Clean background and medical malpractice history Willing to commit 40 hours per week, 36 clinical hours Must be able to work one weekend day every other week

Save

Bookmark This Job

K Health

Clinical Operations Specialist, LPN

Posted on:

March 27, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

LPN/LVN

State License:

Conneticut

K Health has recently transitioned to a comprehensive care delivery model that will revolutionize patient care and we invite you to join in this expansion as a Clinical Operations Specialist (LPN)! You will play a pivotal role supporting virtual clinics by providing a best in class patient experience. This role will partner closely with our Medical Operations teams to support day to day operations across multiple clinics with clinical and non clinical support staff. You will report directly to our Practice Manager.

Current licensure as a Licensed Practical Nurse (LPN) in CT You have at least 5 years of experience in healthcare operations Must be comfortable with and willing to work a flexible schedule You have experience in telemedicine Experience with Epic EMR and Salesforce a plus You are extremely well organized, detail oriented, and adaptable. You naturally prioritize your work and feel comfortable maintaining varying deadlines. Comfortable working independently as well in a team environment. You are comfortable working within a highly ambiguous, fast paced environment, and can set priorities with minimal input from management.

Optimize and develop clinical workflows to support both clinician and patient experience You will develop mastery using EHR systems and our internal tools to help create best in class clinical workflow and processes Receive, monitor, and analyze incoming lab results daily, following appropriate escalation procedures when necessary Collaborate with key external vendors and suppliers to enable the delivery of lab and imaging services Monitor clinic phone - handling patient, clinician, lab, and pharmacy calls Work in collaboration with pharmacy, insurance, and enterprise partners on resolution of escalated patient or partner issues. Required-on call shifts monitoring Critical Lab Phone Line - (24/7) Prepare prior authorizations requests Efficiently process and send EMR Requests Additional clinical and administrative duties as required

Save

Bookmark This Job

Green Key Resources

Remote Nurse Case Manager

Posted on:

March 27, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

State License:

New York

Must have experience and ability in working with electronic health record management, electronic care coordination and electronic health record interface with external service providers. Active participant in the Interdisciplinary Team (IDT) NYS licensed RN

Provide direct nursing care as prescribed by the physician/Nurse Practitioner, in compliance with recognized nursing standards and State and Federal regulations. Uses nursing process to make continuing assessments of the individuals with developmental disabilities total health needs. Maintain direct interaction with consumers on a regular basis, but in no case, at a frequency of less than once per week. Perform nursing assessments, by direct physical examination, of each consumer upon entry into the program quarterly (at a minimum) thereafter. Develop and implement an individualized plan for nursing service. The nursing care plan must be updated at least annually or whenever there is significant change in the consumer’s condition. Coordinate all acute and ongoing health services, as indicated by need and regulatory mandate. Monitor health and behavioral status, labs and efficacy of prescribed treatments. Ensure timely communication of findings to appropriate clinical personnel. Ensure that all medical record documentation is accurate, timely and outcome based and reflected in the nursing notes. Provide initial and ongoing, but at a minimum frequency of annually, training to staff in all nursing tasks, functions, protective and preventive health measures that include but are not limited to: Appropriate health and hygiene methodologies Control of communicable diseases and infections Detection of signs and symptoms of illness, first aid for accidents or illness and basic skills required to meet the health needs of the consumers Client specific medical/health related issues Seizure management Ensure that training in the above noted areas is given to all new hires and per diems prior to their assuming client specific work assignments. Provide training and ongoing support to direct care staff regarding medication administration, tube feeding and diabetic care utilizing the standard curriculum approved by OPWDD. In conjunction with the Director of Nursing, interview and determine candidacy of L.P.N, applicants. Responsible for supervision, discipline and scheduling of L.P.N’s staff hours. Conduct annual clinical performance evaluations for unlicensed direct support staff for procedures that include but are not limited to: medication administration, tube feeding and insulin administration. Evaluations must become part of the employee’s annual performance evaluation. Maintain documentation of all training curriculums, attendance and post training testing.

Save

Bookmark This Job

CallTek

Telehealth Nurse

Posted on:

March 27, 2025

Job Type:

Part-Time

Role Type:

Telehealth

License:

State License:

California

The Telehealth Nurse provides medical advice and support to patients over the phone or via video conferencing. The Telehealth Nurse assesses patients, forms diagnoses, develops care plans, and provides direct patient care, including medication management. The Telehealth Nurse also provides patient education, referral services, and follow-up care. The Telehealth Nurse must be knowledgeable in the use of telemedicine technologies and understand the complexities of providing healthcare in remote settings. The Telehealth Nurse must have excellent communication and interpersonal skills, as well as strong critical thinking and problem-solving abilities. Part-Time (4 hours minimum per day) Pay Rate{{:}} $35.00 US DNOTE{{:}} This position is OPEN only for applicants within the United States.

Telehealth Nurse Skills: Ability to assess patient needs remotely Excellent communication, problem-solving and interpersonal skills Knowledge of medical terminology and approved protocols Proficient with electronic medical records and home monitoring systems Ability to provide patient and family education Telehealth Nurse Requirements: Registered Nurse license Experience with telehealth systems Understanding of clinical protocols Ability to work with a diverse range of patients Strong communication and problem solving skills Must have an active Nursing Compact License or for specific states such as New York, Illinois, etc Personal Traits: Excellent communication skills Ability to think critically and problem-solve Team-player attitude A passion for helping others Knowledge of healthcare regulations Ability to manage time efficiently

Provide telehealth nursing services to patients via phone, video, and other digital media Answer patient inquiries, provide health education and advice, and assess patient needs Refer patients to appropriate health professionals and follow up on health care services Develop and implement patient care plans Document patient care services in medical records and reports Stay up-to-date on changes in the health care industry and relevant regulations and protocols

Save

Bookmark This Job

Intellatriage

Remote Hospice Triage RN- PT 2 shift 6p-12a + rotating Sat & Sun 3:30-12 CST

Posted on:

March 26, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

State License:

Compact / Multi-State

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

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

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

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

Save

Bookmark This Job

Intellatriage

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

Posted on:

March 26, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

State License:

Compact / Multi-State

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

Save

Bookmark This Job

St. Luke's University Health Network

Patient Engagement Partner - Access Center, Part Time Nightshift, Remote position (PA/NJ residency)

Posted on:

March 26, 2025

Job Type:

Part-Time

Role Type:

Clinical Operations

License:

None Required

State License:

Pennsylvania

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

Hours are 24/week. Every Thursday, Friday and Saturday, 11pm-7:30am. Plus every other holiday rotation. Training is in person in Allentown, PA. Preference is given to candidates who live in close proximity to St. Luke's University Health Network locations. The Patient Engagement Partner – Access Center role is critical to an exceptional patient experience. This role provides a positive patient experience during all encounters and is responsible for answering patient calls, scheduling appointments, working referral work queues, and assisting the patient with their current needs. The Patient Engagement Partner establishes and maintains ongoing partnerships with designated practice and clinical partners to ensure achievement of aligned goals.

PHYSICAL AND SENSORY REQUIREMENTS: Requires sitting for extended periods of time (up to 8 hours at time). Requires continual use of fingers, writing and computer entry. Requires ability to hear normal conversation and good general near and peripheral vision. EDUCATION: High School diploma or equivalent required TRAINING AND EXPERIENCE: Previous general computer experience with data entry required Minimum 1-2 years of demonstrated customer service excellence in a contact center preferred Previous healthcare experience with medical terminology preferred Previous experience with electronic medical record (EMR) preferred Competencies required: Excellent communication, facilitation, and presentation skills. Focused on compliance Demonstrates continuous growth Quality-driven Service-oriented Excels at time management Ability to work from home in accordance with the Network Work from Home Policy if needed.

Answers incoming calls and performs a variety of actions including scheduling, rescheduling, or canceling appointments within established time frames and protocols in a fast paced, high volume Access Center environment. Determines how requests should be handled using expert questioning techniques to determine how a request should be scheduled, when to refer a call to a specific clinic or escalate the call to a nurse for immediate attention; coordinates services, as needed. Verifies and updates patient demographic and insurance information. Creates a positive patient experience at every encounter, attempting to resolve any issues or concerns of the patient at the time of the phone call, within the scope of the role. Manages and works referral work queues when assigned and provides supplemental inbound patient call support during high volume times using (and vice versa), and uses judgment to prioritize and accommodate patients, based on patient needs. Actively participates as a team member in resolution of problems as they are identified. Escalates any scheduling or insurance issue to the Patient Engagement Supervisor or Patient Engagement Manager to resolve. Consistently meets productivity, schedule adherence, and quality standards as set by the Access Center. Works with designated clinical partners to establish and maintain appropriate appointment scheduling protocols. Consistently acts to build positive relationships with our clinical partners. Other duties as assigned.

Save

Bookmark This Job

St. Luke's University Health Network

Weekend Clinical Triage Specialist, Registered Nurse, Connect to Care, Part Time, Remote Position (PA/NJ residency)

Posted on:

March 26, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

State License:

Compact / Multi-State

Hours are 24/week. Every Saturday and Sunday 12 hour shifts plus every other holiday rotation. A Clinical Triage Specialist (CTS) (RN) - Connect to Care - Access Center will compassionately deliver an exceptional patient experience and provide clinical support to CTS-MA team members by serving as a clinical resource. The CTS-RN is responsible for using nursing judgment in answering/returning patient calls related to direct care provided by the practices. When appropriate, the caller’s symptoms will be assessed and triaged using approved nursing protocols and guidelines in order to assist in obtaining the appropriate level of care and/or self-care advice.

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

Save

Bookmark This Job

Alternate Solutions Health Network

Utilization Review Specialist I

Posted on:

March 26, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

State License:

Ohio

Our culture and people are what set us apart from other post-acute care providers. We’re dedicated to the growth and development of our team to set them up for success. We CARE for our patients like they are our own FAMILY. Note: The Centers for Medicare & Medicaid Services (CMS), in collaboration with the Centers for Disease Control and Prevention (CDC), require COVID-19 vaccinations for all Medicare and Medicaid certified providers. Based on this regulation, all of our employees must be fully vaccinated or have a valid exemption.

The Utilization Review Specialist reviews patient charts and collects data to identify areas in need of improvement both clinically and administratively that directly affect patient care and quality outcomes. The Utilization Review Specialist is responsible for development and implementation of process improvement, Oasis Review, Orders Processing, or BOT support as identified by primary role Responsibility and business need. The Utilization Review Specialist complies with all legal, Medicare & private insurance and company rules and regulations.

Registered Nurse (RN) with Current State Licensure to meet business needs of the department, including but not limited to: OH, FL, MI, and Virgina Minimum of 3 years in Home Care or in quality Improvement Knowledge of CMS guidelines, Quality Metrics, Star Measures, Outcome Measures, HHCAHPS, HHVBP, Oasis Rules and Guidelines, Clinical Best Practices Attend in-service trainings and mandatory meetings. Comfortable learning new software and database systems Ability to use Microsoft Office with extensive experience with Word and Excel programs Observant and detail oriented Ability to multi-task and prioritize Ability to track and analyze data Ability to follow directions and work as a team member and maintain effective communication. Adhere to ASHN Vision, Mission, and Beliefs SCHEDULE: Primary Role: Orders: 4/10 hour shifts, including every other weekend BOTs and Oasis Review: Weekday; Schedule per offer based on business need. Health Requirements: Employee must be free of physical/medical conditions that would limit or restrict their ability to perform the job functions listed below. Bloodborne Exposure risk is none. 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 accommodations may be made to enable individuals with disabilities to perform the essential functions. Below are minimal knowledge/physical requirements of this position. Constantly (66%-100%): Reading, Speaking, Writing English Communications Skills Computer/PDA Usage Hand/finger dexterity Hearing/Seeing Vision for close work Talking on the phone Hearing on the phone Talking in person Hearing in person Frequently (34%-66%) Walking Bending Standing Sitting Stretching/Reaching Driving Stooping (bend at waist) Occasionally (2%-33%) Lifting up to 50 lbs. with or without assistance Distinguish smell/taste Climbing Rarely (1% or less) N/A

Understanding of Regulatory Standards and Agency Policies and Procedures: Quality assurance professionals must be knowledgeable about CMS guidelines and submission times, Quality Metrics, Star Measures, Outcome Measures, HHCAHPS, HHVBP, Oasis Rules and Guidelines, Clinical Best Practices. To include but not limited to: VPE, LUPA, readmission rates, Quality Visit guidance, PDGM/Insurance Guidelines Analytical Skills: Quality assurance professionals need strong analytical skills to review and assess data, identify trends, and detect areas for improvement. Patient-Centered Approach: A focus on patient outcomes and safety is integral to quality assurance, as patient satisfaction and safety are central to healthcare quality. Reviews orders, utilization management, assessment, plans of care, and oasis for accuracy and patient safety with adherence to all regulations, guidance, and legal and government regulations. Documentation: Quality assurance roles often involve record-keeping and documentation of quality-related data and processes Critical Thinking: The ability to evaluate complex situations, identify problems, and propose effective solutions is essential for quality assurance work. Computer Skills: Proficiency in using quality management software, data analysis tools, and BOT support as appropriate. Interpersonal Skills: Quality assurance professionals often work with diverse teams, so strong interpersonal skills are essential. Problem-Solving: The ability to identify issues, root causes, and develop strategies to address them is fundamental in quality assurance. Interdepartmental Collaboration with field clinician as needed. Attention to Best Practices: Keeping informed about evidence-based practices and incorporating them into quality improvement efforts is important. Continuous Learning: Staying up-to-date with evolving healthcare practices, regulations, and quality improvement methodologies is critical. Ethical and Legal Awareness: Understanding ethical and legal issues in healthcare is crucial when reviewing and improving care quality. Read and Adhere to all Agency Policies and Procedures and follow employee Handbook Guidelines Maintain or Exceed Productivity expectations. Other duties as assigned.

Save

Bookmark This Job

Alternate Solutions Health Network

Clinical Training Specialist, Registered Nurse

Posted on:

March 26, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

State License:

Compact / Multi-State

Mon-Fri 8am-5pm, Travel required SUMMARY Clinical Training Specialist, Registered Nurse will be responsible for training new hire field employees and internal staff during the on-boarding process as needed based on onboarding schedule and need. The Clinical Training Specialist, Registered Nurse will deliver structured training of operational procedures, homecare guidelines and workflow training to clinical field employees and internal support employees. This role will ensure competency evaluations of skills required for home health care. The Clinical Training Specialist, Registered Nurse will provide training for joint venture (JV) implementations to ensure quality training and patient outcomes; this role requires up to 60% of travel. This position serves as a resource and provides corporate support through extensive knowledge of the regulatory guidelines governing home health agencies. Complies with all agency policies and legal rules and regulations. The Clinical Training Specialist, Registered Nurse ensures compliance with all federal, state, and agency rules and regulations.

Current Registered Nurse compact licensure. 1-2 years of clinical experience required; homecare experience preferred. 2-4 years of experience in training/education of adult learners preferred. Ability to be onsite during JV implementation training. Ability to travel as needed for NHO at current agencies. Ability to identify adult learning and communication needs to enhance the quality of training provided to individual team members. Proficient in multiple systems; including but not limited to Microsoft Office, HCHB, SmartSheet, HealthStreams and Learning Management Systems (LMS). Experience in presenting training materials, programs, and ongoing education. Skilled in providing constructive feedback to new hire staff members and to improve the educational experience. Excellent written and verbal communication skills with leadership and field employees. Proficient in utilizing change management skills to coordinate, collaborate, and communicate effectively with team members. Ability to prioritize tasks, work efficiently and oversee multiple responsibilities. MANAGEMENT RESPONSIBILITY: N/A HEALTH QUALIFICATIONS: 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 with or without accommodation. Constantly (66%-100%): Reading, Speaking, Writing English Communications Skills Computer/PDA Usage Sitting Hand/finger dexterity Hearing/Seeing Hearing in person Talking in person Vision for close work Frequently (34%-66%) Walking Bending Standing Driving Lifting up to 50 lbs. with or without assistance Stretching/Reaching Occasionally (2%-33%) Climbing Stooping (bend at waist) Hearing on the phone Talking on the phone Rarely (1% or less) Distinguish smell/taste

Effectively educate newly hired employees during orientation, for both field and internal support staff roles. Successfully train new hire and JV employees on the clinical processes and procedures of the agency. Provide training either in-person or remotely for clinical field and internal support staff. Expertise in CMS guidelines to ensure proper training and documentation techniques are taught to staff. Communicate with agencies on updates, outcomes, and competencies during the new hire process. Facilitate New Hire and Annual competencies within scope of practice of RN licensure. On occasion, be willing to alter work schedule to accommodate new hires that may need additional assistance. Attend in-service trainings and mandatory agency meetings. Collaborate with department leaders and team for process improvement (PI) initiatives. Maintain a professional appearance as a representative of the company. Educate on, understands, and practices agency policies and procedures. Actively promote the values, mission, and culture of the Company. Travel during Joint Venture training (onsite) and at agencies when in person training is needed.

Save

Bookmark This Job

Alternate Solutions Health Network

RN Care Manager

Posted on:

March 26, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

State License:

Ohio

The RN Care Manager is responsible for the development, oversight and continuity of the patient plan of care, serving as the liaison for collaboration and communication with the field staff. The RN Care Manager will participate in the interdisciplinary team meetings to ensure tight collaboration and appropriate care planning and delivery. This role will manage health care costs by influencing patient care decisions for value-based care delivery, visit type, frequency and calendar plotting cadence based on medical necessity review and utilization management guidelines. The RN Care Manager will assess for real time patient clinical, functional and behavioral health status to ensure rapid follow up, and allocation of services. The RN Care Manager will work alongside branch operations to ensure a holistic approach to patient care. The RN Care Manager will be integral in contributing to the development of new and / or revised work processes, policies and procedures relating to the ASHN Care Management Program.

Registered Nurse licensure required Two years home care field experience preferred One-year clinical review preferred Two years case management and/or utilization management experience preferred Demonstrates exceptional collaboration skills Self-starter and innovative problem solver Proficiency in HCHB preferred Knowledge of Medicare, Medicaid and all State/Federal guidelines for compliance of patient clinical care Strong clinical acumen to thoroughly understand the patient’s health and functional status and foster effective communication Able to create positive impressions and communicate effectively with a variety of people and personalities Is an active listener and demonstrates ability to engage care team in the patient plan of care Must project a professional image during virtual communication Ability to set up work systems and engage in flexible problem-solving behavior Observant and detail oriented Proficient in Microsoft Office including Excel, Outlook, Power Point and Word

Plan of Care (POC) review and revision to reflect accuracy and regulatory standards Recertification/Discharge review and recommendation Utilization/Calendar Management Adhere to Utilization Management Guidelines Participate in Interdisciplinary Team Meetings and Agency Townhall Meetings Seek opportunities to contain cost Review Charts to monitor compliance with regulatory and governmental regulations Meets productivity standards and workflow expectations Functions as a resource for clinicians, agency staff, and internal staff Collaborates with clinicians as necessary for documentation clarification or educational opportunities Attends in-service trainings and mandatory agency meetings Stays current with CMS guidelines and Oasis Guidelines Read and adhere to all Agency Policies and Procedures and follow Employee Handbook Guidelines Completes and submits all required documentation within specified company requirements Other duties as assigned

Save

Bookmark This Job

Alternate Solutions Health Network

Remote Registered Nurse (RN) Clinical Liaison

Posted on:

March 26, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

State License:

Compact / Multi-State

Remote Schedule: Every Saturday and Sunday 8:00 am to 5:00 pm Agency: Baptist Health Home Care SUMMARY: The RN Clinical Field Staff Liaison (CFSL) provides support and acts as a resource to clinicians in the field. The CFSL assists in monitoring compliance quality and safe delivery of services by following a clinical process set by clinical management. The CFSL is responsible for all practices and duties within the scope of practice as outlined by the state.

Registered Nurse with current license in the state of employment. Compact licensure, for states that participate, is required to be obtained within first 30 days of employment for additional support in all ASHN affiliated agencies. Three years of experience as an RN in an acute care setting Minimum one-year home health experience is preferred Ability to effectively communicate and create positive impressions with patients, families, physicians and co-workers Ability to remain calm, have patience and be accommodating. Compassionate and caring while working with patients Knowledgeable on nursing best practices Ability to make appropriate nursing judgments Ability to identify a situation and handle it with the best possible solution Detail-oriented and observant Disciplined style of work ethic with the ability to prioritize and be timely Ability to follow directions and work as a team member Knowledge of MS Office applications including Word, Excel, PowerPoint and Outlook Valid driver’s license and auto insurance with your name as a listed driver 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 with or without reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Below are minimal knowledge/physical requirements of this position. Travel is required for this position. Constantly (66%-100%): Reading, Speaking, Writing English Communications Skills Computer/PDA Usage Hand/finger dexterity Hearing/Seeing Hearing in person Hearing on the phone Talking in person Talking on the phone Vision for close work Frequently (34%-66%) Sitting Occasionally (2%-33%) Walking Bending Standing Stretching/Reaching Driving Lifting up to 50 lbs. with or without assistance Climbing Stooping (bend at waist) Distinguish smell/taste

Serve as a resource for field staff, referral sources, physicians, patients and their families pertaining to clinical issues and/or concerns Facilitate calls to and from Field staff; uses resources to resolve issues and reports anything of concern to manager Work in the field with staff and patients as needed Maintains positive working relationships with referral sources including physicians, hospitals, skilled facilities, assisted livings and families Assist with monthly Case Manager, Nurse and Therapy meetings Ensure Start of Care compliance Ensure quality and safe delivery of home health services Monitor Home Health Aide supervisory visits Focus on Outcome Monitors as assigned Implement quality improvement programs in the field Completes field visits as needed Participates in managing cost of good working with monitoring supply costs and visits per episode Knowledgeable of CFSS workflow Review relevant reports Reviews clinical documentation in accordance with agency protocol and Medicare/Federal guidelines Maintains active RN license in state of employment Participates in on-call, evening/weekend shifts and provides patient care, per agency needs Participates in in-service program development Maintains a professional appearance as a representative of the company Understands, implements and practices policies and procedures for agency operation Other duties as assigned

Save

Bookmark This Job

CVS Health

Case Manager, Registered Nurse - Work from Home

Posted on:

March 26, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

State License:

Compact / Multi-State

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

This is a remote work from home role anywhere in the US with virtual training. Shift schedule is 8:30am - 5pm within time zone of residence. American Health Holding, Inc (AHH) is a medical management company that is a division within Aetna/CVS Health. Founded in 1993, AHH is URAC accredited in Case Management, Disease Management and Utilization Management. AHH delivers flexible medical management services that support cost-effective quality care for members.

Required Qualifications: 5+ years’ experience as a Registered Nurse with at least 1 year of experience in a hospital setting A Registered Nurse that holds an active, unrestricted license in their state of residence, and willingness to receive a multi-state/compact privileges and can be licensed in all non-compact states 1+ years’ current or previous experience in Oncology, Transplant, Pediatrics, and Medical/Surgical 1+ years’ experience documenting electronically using a keyboard Preferred Qualifications: 1+ years’ Case Management experience or discharge planning, nurse navigator or nurse care coordinator experience as well as experience with transferring patients to lower levels of care 1+ years' experience in Utilization Review CCM and/or other URAC recognized accreditation preferred 1+ years’ experience with MCG, NCCN and/or Lexicomp Bilingual in Spanish preferred Education: Diploma or Associates Degree in Nursing required BSN preferred

This position consists of working intensely as a telephonic case manager with patients and their care team for fully and/or self-insured clients Application and/or interpretation of applicable criteria and clinical guidelines, standardized care management plans, polices, procedures and regulatory standards while assessing benefits and/or member’s needs to ensure appropriate administration of benefits Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and barriers and address complex health and social indicators which impact care planning and resolution of member issues Assessments utilize information from various sources to address all conditions including co-morbid and multiple diagnoses that impact functionality Consults with supervisor and others in overcoming barriers in meeting goals and objectives, presents cases at case conferences for multidisciplinary focus to benefit overall claim management Using a holistic approach, consults with clinical colleagues, supervisors, Medical Directors and/or other programs to overcome barriers to meeting goals and objectives Utilizes case management processes in compliance with regulatory and company policies and procedures Utilizes motivational interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversations Identifies and escalates member’s needs appropriately following set guidelines and protocols Need to actively reach out to members to collaborate/guide their care Perform medical necessity reviews

Save

Bookmark This Job

UVA Health

REMOTE Certified Tumor Registrar

Posted on:

March 26, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

None Required

State License:

Virginia

Education: High School Graduate or Equivalent required. Associate’s Degree in Allied Health Preferred. Experience: 2 years’ relevant experience preferred. Licensure: Certified Tumor Registrar or Oncology Data Specialist through the National Cancer Registrar Association (NCRA) required. PHYSICAL DEMANDS: This is primarily a sedentary job involving extensive use of desktop computers. The job does occasionally require traveling some distance to attend meetings, and programs.

Provides basic cancer statistics and graphs and supports the research prevention and control initiatives according to the Virginia Department of Health the American College of Surgeons Commission on Cancer standards and the organizational priorities of the University of Virginia Health System. Abstracts clinical documentation on newly diagnosed/treated cancer patients. Assists with Cancer Committee Planning and Follow Up. Completes studies as requested by physicians and researchers Performs additional duties within the Cancer Registry area as assigned by management. In addition to the above job responsibilities, other duties may be assigned.

Save

Bookmark This Job

UVA Health

Registered Nurse (RN) - Neurology Clinic Phone Triage (Remote)

Posted on:

March 26, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

State License:

Virginia

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

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

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

Save

Bookmark This Job

Conduit Health Partners

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

Posted on:

March 26, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

State License:

Compact / Multi-State

At Bon Secours Mercy Health, we are dedicated to continually improving health care quality, safety and cost effectiveness. Our hospitals, care sites and clinicians are recognized for clinical and operational excellence. Part Time Evenings 4pm-9:30pm working 4 shifts per week, rotating every other weekend and holiday or Part Time Evening 3pm-11:30pm working 3 shifts per week, rotating every other weekend and holiday Primary Function/General Purpose of Position 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.

Licensing/Certification: RN license required in applicable state(s). Multistate/Compact RN Licensure  preferred 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) 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. Other:  Remote/ At Home work Environment Opportunity may be provided. This is dependent upon business needs and capability. Will require a signed agreement. Minimum internet speed of primary and secondary work locations is: download speed of 100Mpbs; upload speed of 20Mbps. Reference policy: Conduit Health Partners Work from Home. 

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

Save

Bookmark This Job

Sunshine State Health Plan

Pediatric Care Manager (RN)

Posted on:

March 25, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

State License:

Compact / Multi-State

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

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

Save

Bookmark This Job

IntellaTriage

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

Posted on:

March 25, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

State License:

Compact / Multi-State

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

Save

Bookmark This Job

Millennium Physician Group

ACO Triage Nurse ( Remote Position )

Posted on:

March 25, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

State License:

Florida

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

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

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

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

Save

Bookmark This Job

Actalent

Remote Post Acute Clinical Review Nurse

Posted on:

March 25, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

State License:

Maryland

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

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

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

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

Save

Bookmark This Job

Revecore

Denial Prevention Nurse Consultant

Posted on:

March 25, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

State License:

Tennessee

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

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

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

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

Save

Bookmark This Job

Convergence

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

Posted on:

March 25, 2025

Job Type:

Part-Time

Role Type:

Care Management

License:

LPN/LVN

State License:

Compact / Multi-State

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

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

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

Save

Bookmark This Job

Wellbox Health

LPN Care Coordinator

Posted on:

March 25, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

LPN/LVN

State License:

Compact / Multi-State

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

We are seeking full-time LPN team members who can work 40 hours per week, between the hours of 8 am – 6 pm MST, Monday – Friday. Pay Structure Orientation + Training (First two months): $20 hourly Post-Orientation: $22 hourly, plus bonus incentive Monthly Bonuses up to $525 Referral Bonuses up to $1000

Active Compact LPN License. Minimum two years of clinical experience; care coordination experience preferred. Proficient with Electronic Medical Records and Microsoft Office. Excellent communication and problem-solving skills. Candidates who reside in Mountain Standard Time (MST) are preferred; candidates in Pacific or Central time zones will also be considered.

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

Save

Bookmark This Job

UnitedHealthcare

Behavioral Telephonic Case Management Nurse - Remote in New York

Posted on:

March 25, 2025

Job Type:

Full-Time

Role Type:

Behavioral Health

License:

State License:

New York

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

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

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

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

Save

Bookmark This Job

CenterWell Home Health

Care Manager- Telephonic Nurse PT - After Hours & Weekends

Posted on:

March 25, 2025

Job Type:

Part-Time

Role Type:

Care Management

License:

State License:

Compact / Multi-State

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

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

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

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

Save

Bookmark This Job

ChenMed

Registered Nurse, Telehealth, Part Time (Spanish Bilingual)

Posted on:

March 25, 2025

Job Type:

Part-Time

Role Type:

Telehealth

License:

State License:

Compact / Multi-State

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

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

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

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

Save

Bookmark This Job

ChenMed

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

Posted on:

March 25, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

State License:

Compact / Multi-State

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

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

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

Save

Bookmark This Job

Summit Health

Transitional Care Coordinator - CMA or LVN

Posted on:

March 25, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

LPN/LVN

State License:

Arizona

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

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

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

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

Save

Bookmark This Job

Summit Health

Virtual Triage RN

Posted on:

March 25, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

State License:

New York

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

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

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

Save

Bookmark This Job

Highmark Inc.

Intake Coordinator

Posted on:

March 24, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

None Required

State License:

Pennsylvania

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

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

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

Save

Bookmark This Job

Highmark Inc.

Payment Integrity Clinician - (Remote)

Posted on:

March 24, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

State License:

Pennsylvania

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

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

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

Save

Bookmark This Job

EXL Services

Case Management Clinical Quality Analyst, Registered Nurse

Posted on:

March 24, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

State License:

Compact / Multi-State

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

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

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

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

Save

Bookmark This Job

Valor Healthcare, Inc.

Remote Senior Program Manager - Nurse Call Center

Posted on:

March 24, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

None Required

State License:

Virginia

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

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

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

Save

Bookmark This Job

Valor Healthcare, Inc.

Remote Quality Assurance Program Manager - Nurse Call Center

Posted on:

March 24, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

None Required

State License:

Virginia

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

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

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

Save

Bookmark This Job

Optum

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

Posted on:

March 24, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

State License:

Compact / Multi-State

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

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

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

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

Save

Bookmark This Job

Sedgwick Government Solutions

Clinical Quality Management Specialist II (Remote) 2025-1419

Posted on:

March 24, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

State License:

Georgia

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

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

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

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

Save

Bookmark This Job

Sedgwick Government Solutions

Quality Management Specialist (Remote) 2025-1418

Posted on:

March 24, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

State License:

Georgia

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

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

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

Save

Bookmark This Job

Sedgwick Government Solutions

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

Posted on:

March 24, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

State License:

Compact / Multi-State

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

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

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

Save

Bookmark This Job

Managed Resources, Inc (MRI)

Clinical Appeals Nurse (medical necessity)

Posted on:

March 24, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

State License:

California

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

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

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

Save

Bookmark This Job

Vega Consulting Solutions, Inc

Utilization Management RN /LPN

Posted on:

March 24, 2025

Job Type:

Contract

Role Type:

Utilization Review

License:

State License:

Maryland

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

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Education Level: Bachelor's Degree Education Details: Nursing Experience: 5 years Clinical nursing experience 2 years Care Management Preferred Qualifications: Working knowledge of managed care and health delivery systems. Working knowledge of nd Medical Management systems, familiarity with web-based software application environment and the ability to confidently use the internet as a resource. Proficient in the use of web-based technology and Microsoft Office applications such as Word, Excel and PowerPoint, Proficient Excellent analytical and problem-solving skills to judge appropriateness of member services and treatments on a case by case basis, Proficient Licenses/Certifications: RN - Registered Nurse - State Licensure And/or Compact State Licensure Upon Hire Req or CNS-Clinical Nurse Specialist Pref

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

Save

Bookmark This Job

TriWest Healthcare Alliance

Applied Behavior Analysis - Quality Monitor Clinician

Posted on:

March 24, 2025

Job Type:

Full-Time

Role Type:

Behavioral Health

License:

State License:

Arizona

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

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

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

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

Save

Bookmark This Job

TRILLIUM HEALTH RESOURCES

Population Health Program Nurse

Posted on:

March 23, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

State License:

North Carolina

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

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

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

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

Save

Bookmark This Job

Apria Healthcare LLC

Chronic Account Manager - Remote

Posted on:

March 23, 2025

Job Type:

Full-Time

Role Type:

License:

State License:

North Carolina

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

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

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

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

Save

Bookmark This Job

Point32Health

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

Posted on:

March 23, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

State License:

Massachusetts

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

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

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

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

Save

Bookmark This Job

Ingenovis Health

Clinical Services Leader

Posted on:

March 23, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

State License:

Ohio

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

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

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

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

Save

Bookmark This Job

Molina Healthcare

Telephonic Case Manager (RN) - Illinois ONLY

Posted on:

March 23, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

State License:

Illinois

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

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

Required Education: Graduate from an Accredited School of Nursing. Bachelor's Degree in Nursing preferred. Required Experience: 1-3 years in case management, disease management, managed care or medical or behavioral health settings. Required License, Certification, Association: Active, unrestricted State Registered Nursing (RN) license in good standing. Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation. Preferred Education: Bachelor's Degree in Nursing Preferred Experience: 3-5 years in case management, disease management, managed care or medical or behavioral health settings. Preferred License, Certification, Association: Active, unrestricted Certified Case Manager (CCM)

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

Save

Bookmark This Job

Medavie

Bilingual Nurse

Posted on:

March 23, 2025

Job Type:

Part-Time

Role Type:

Telehealth

License:

State License:

Nebraska

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

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

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

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

Save

Bookmark This Job

Lucet

Manager, Care Management

Posted on:

March 23, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

State License:

Akansas

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

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

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

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

Save

Bookmark This Job

Lucet

Bilingual Care Manager (Spanish)

Posted on:

March 23, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

State License:

Florida

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

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

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

Save

Bookmark This Job

Lucet

Clinician, C365

Posted on:

March 23, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

State License:

Kansas

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

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

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

Save

Bookmark This Job

Health Care Service Corporation

Utilization Management Coordinator - OK

Posted on:

March 23, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

State License:

Oklahoma

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

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

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

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

Save

Bookmark This Job

Molina Healthcare

Remote Supv, Care Management BH team - TX ONLY

Posted on:

March 23, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

State License:

Texas

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

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

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

Save

Bookmark This Job

Personify Health

Utilization Review Nurse, RN

Posted on:

March 23, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

State License:

Rhode Island

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

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

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

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

Save

Bookmark This Job

Texas Health Resources

Clinical Documentation Integrity Specialist

Posted on:

March 22, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

State License:

Texas

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

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

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

Save

Bookmark This Job

Thrive Health Care Services

Trauma Performance Improvement Coordinator

Posted on:

March 22, 2025

Job Type:

Contract

Role Type:

License:

State License:

Missouri

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

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

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

Save

Bookmark This Job

Thrive Health Care Services

Trauma Abstractor

Posted on:

March 22, 2025

Job Type:

Contract

Role Type:

License:

State License:

Virginia

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

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

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

Save

Bookmark This Job

Atrium Health

Registered Nurse - Atrium Health Virtual Care Remote FT Days

Posted on:

March 22, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

State License:

North Carolina

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

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

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

Save

Bookmark This Job

Molina Healthcare

LPN Care Review Clinician, Prior Authorization Remote in WA state

Posted on:

March 22, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

LPN/LVN

State License:

Washington

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

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

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

Save

Bookmark This Job

Pacific Cancer Care

Triage RN (Remote)

Posted on:

March 22, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

State License:

California

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

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

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

Save

Bookmark This Job

IntellaTriage

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

Posted on:

March 22, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

State License:

Compact / Multi-State

We invite you to join our growing team! IntellaTriage Nurses enjoy the benefits of working from home, providing care, without the stress and expense of commuting each day! **MUST have or be willing to obtain a Compact RN license **MUST live in/work from a Compact US state **Experience with end-of-life care is required **Must have high speed internet **Must be tech savvy, enjoy a fast-paced environment, and have keyboard competence **Part-time nurses only work 4 days out of a 14-day pay period Part- time schedule: Work a minimum 1 evening shift weekly 6p-12a CST (shift times are set/ week day flexes) Work every other weekend, both Saturday and Sunday 3:30p-12a CST

Save

Bookmark This Job

IntellaTriage

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

Posted on:

March 22, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

State License:

Compact / Multi-State

We invite you to join our growing team! IntellaTriage Nurses enjoy the benefits of working from home, providing care, without the stress and expense of commuting each day! **MUST have or be willing to obtain a Compact RN license **MUST live in/work from a Compact US state **Experience with end-of-life care is required **Must have high speed internet **Must be tech savvy, enjoy a fast-paced environment, and have keyboard competence **Part-time nurses only work 4-6 days out of a 14-day pay period Part- time schedule: Work a minimum 1-2 evening shift weekly 3:30p-12a CST (shift times are set/ week day flexes) Work every other weekend, both Saturday and Sunday 7:30a-4p CST

Save

Bookmark This Job

Personalized Health Partners

RN Overnight Telehealth Administrator on Call, Remote

Posted on:

March 22, 2025

Job Type:

Part-Time

Role Type:

Telehealth

License:

State License:

Compact / Multi-State

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

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

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

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

Save

Bookmark This Job

Staft

Registered Nurse

Posted on:

March 22, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

State License:

California

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

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

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

Save

Bookmark This Job

HCR Home Care

Health Home Care Manager (Remote) - Full Time

Posted on:

March 22, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

State License:

New York

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

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

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

Save

Bookmark This Job

83BAR

Bilingual RN - Healthcare Sales

Posted on:

March 22, 2025

Job Type:

Part-Time

Role Type:

License:

State License:

Texas

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

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

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

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

Save

Bookmark This Job

Point32Health

Senior Care Options Transition RN

Posted on:

March 22, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

State License:

Massachusetts

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

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

Save

Bookmark This Job

City of Hope

Manager, Patient Generated Health Data Program - Remote

Posted on:

March 22, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

State License:

California

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

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

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

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

Save

Bookmark This Job

Travel Nurse Across America, LLC

Clinical Interview Specialist

Posted on:

March 21, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

State License:

Akansas

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

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

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

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

Save

Bookmark This Job

Dane Street, LLC

Group Health Operations Manager (RN/LPN)

Posted on:

March 21, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

State License:

Florida

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

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

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

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

Save

Bookmark This Job

Centene

Quality Improvement Specialist

Posted on:

March 21, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

State License:

Illinois

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

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

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

Save

Bookmark This Job

Infiniti home health care Agency

Quality Improvement Nurse (Registered Nurse)

Posted on:

March 21, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

State License:

Compact / Multi-State

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

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

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

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

Save

Bookmark This Job

Humana

Mom's Maternity Telephonic Nurse

Posted on:

March 21, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

State License:

Compact / Multi-State

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

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

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

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

Save

Bookmark This Job

Community Health Network

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

Posted on:

March 21, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

State License:

Indiana

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

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

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

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

Save

Bookmark This Job

Dignity Health

Care Coordination Clinical Educator

Posted on:

March 21, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

State License:

Arizona

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

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

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

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

Save

Bookmark This Job

Accord Technologies Inc

RN Medical Case Manager

Posted on:

March 21, 2025

Job Type:

Contract

Role Type:

Case Management

License:

State License:

Wyoming

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

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

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

Save

Bookmark This Job

Humana

Utilization Management LTSS Registered Nurse

Posted on:

March 21, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

State License:

Compact / Multi-State

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

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

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

Uses clinical knowledge, communication skills, and independent critical thinking skills towards. Interpreting criteria, policies, and procedures related to Long Term Services and Support authorizations to provide the best and most appropriate treatment, care, or services for members. Coordinates and communicates with providers, members, or other parties to facilitate optimal care and treatment. Understands department and organizational strategy and operating objectives, including their linkages to related areas. Follows established guidelines/procedures. Makes decisions regarding own work methods, occasionally in ambiguous situations, requires minimal direction and receives guidance where needed.

Save

Bookmark This Job

Humana

CarePlus - Utilization Management Nurse

Posted on:

March 21, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

State License:

Florida

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

The Utilization Management Nurse 2 utilizes clinical nursing skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations. The Utilization Management Nurse 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

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

The Utilization Management Nurse 2 uses clinical knowledge, communication skills, and independent critical thinking skills towards interpreting criteria, policies, and procedures to provide the best and most appropriate treatment, care or services for members. Coordinates and communicates with providers, members, or other parties to facilitate optimal care and treatment. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.

Save

Bookmark This Job

Diana Health

Remote Triage Nurse (Full-Time)

Posted on:

March 21, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

LPN/LVN

State License:

Tennessee

Diana Health is a network of modern women’s health practices working in partnership with hospitals to reimagine the maternity and women’s healthcare experience. We are restructuring the traditional approach to care to create an experience that is good for patients and good for providers. We do that by combining a tech-enabled, wellness-focused care program that women love with a clinical system that helps us drive continuous quality improvement and ensure work-life balance for our care team. We work with clients across all life stages to empower and support them to live happier, healthier, more fulfilling lives. With strong collaborative care teams; passionate administrators and a significant investment in operational support, Diana Health providers are well-supported to bring their very best to the work they love. We are an interdisciplinary team joined together by our shared commitment to transform women’s health. Come join us!

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

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

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

Save

Bookmark This Job

Info Origin, Inc.

Registered Nurse (RN)

Posted on:

March 21, 2025

Job Type:

Contract

Role Type:

Primary Care

License:

State License:

Kansas

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

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

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

Save

Bookmark This Job

Aflac

Clinician Reviewer

Posted on:

March 21, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

State License:

Georgia

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

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

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

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

Save

Bookmark This Job

Dignity Health Medical Foundation

Inpatient Concurrent Review RN

Posted on:

March 21, 2025

Job Type:

Role Type:

Utilization Review

License:

State License:

California

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

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

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

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

Save

Bookmark This Job

CVS Health

Case Manager RN-Work From Home

Posted on:

March 21, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

State License:

Illinois

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

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

Develops a proactive course of action to address issues presented to enhance the short and long-term outcomes as well as opportunities to enhance a member’s overall wellness through integration. Through the use of clinical tools and information/data review, conducts an evaluation of member’s needs and benefit plan eligibility and facilitates integrative functions as well as smooth transition to Aetna programs and plans. Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and barriers and address complex health and social indicators which impact care planning and resolution of member issues. Assessments take into account information from various sources to address all conditions including co-morbid and multiple diagnoses that impact functionality. Reviews prior claims to address potential impact on current case management and eligibility. Assessments include the member’s level of work capacity and related restrictions/limitations. Using a holistic approach assess the need for a referral to clinical resources for assistance in determining functionality. Consults with supervisor and others in overcoming barriers in meeting goals and objectives, presents cases at case conferences for multidisciplinary focus to benefit overall claim management. Utilizes case management processes in compliance with regulatory and company policies and procedures. Utilizes interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversation.

Save

Bookmark This Job

Access Healthcare Associates

Clinical Supervisor

Posted on:

March 20, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

State License:

California

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

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

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

Save

Bookmark This Job

Community Health Systems

Clinical Review Auditor

Posted on:

March 20, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

State License:

Florida

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

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

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

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

Save

Bookmark This Job

Cambia Health Solutions

Appeals Clinician I

Posted on:

March 20, 2025

Job Type:

Full-Time

Role Type:

Behavioral Health

License:

State License:

Oregon

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

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

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

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

Save

Bookmark This Job

Cambia Health Solutions

Payment Integrity RN

Posted on:

March 20, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

State License:

Washington

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

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

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

Save

Bookmark This Job

J&B Family of Companies

Registered Nurse - Telehealth Pt Assessment - REMOTE in MI

Posted on:

March 20, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

State License:

Michigan

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

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

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

Save

Bookmark This Job

Omega-Himagine Solutions

Case Management Utilization Review RN

Posted on:

March 20, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

State License:

Oregon

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

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

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

Save

Bookmark This Job

ProgenyHealth LLC

Maternity Case Management Supervisor

Posted on:

March 20, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

State License:

Pennsylvania

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

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

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

Save

Bookmark This Job

ProgenyHealth LLC

Utilization Management Supervisor

Posted on:

March 20, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

State License:

Pennsylvania

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

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

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

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

Save

Bookmark This Job

ProgenyHealth LLC

Utilization Management Nurse

Posted on:

March 20, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

None Required

State License:

Pennsylvania

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

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

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

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

Save

Bookmark This Job

	Telehealth Starter Pack	Telehealth Pro Toolkit	Telehealth Mastery Suite
Price	$34	$79	$149
Resume Template Package ATS optimized design for nurses
Matching Cover Letter
Matching Reference Page
Resume Tips and Tricks
Resume Optimization Guide
7 Nurse Resume Examples
20+ Professional Summary Examples
How to Structure Unique Career Experiences
Career Accelerator Success Guide Proven method for landing your dream role
Lifetime Premium Job Board Access
Job Application Tracker
1:1 Expert Support & Mentorship
	Buy Now Learn More	Buy Now Learn More	Buy Now Learn More

Discover Your Next Career Opportunity

Empowering nurses with professional remote opportunities, you deserve to work smarter.

Filter Job Posts:

Wanting to use all of our filtering and favoriting features?

LPN Travel Nurse - Skilled Nursing Facilityng

Chronic Care Primary Nurse Georgia

Unlock X new remote job opportunities!

Clinical Documentation Integrity Specialist Remote

ED Utilization Management RN Remote

REMOTE Registered Nurse - Medical Review Specialist-Bexar County, Texas

Bilingual (Spanish) Care Management Review Nurse

Remote RN Discharge Planner (Full Remote)

Remote Case Manager (Remote) - $45/hr - Lee County

EHR Epic Analyst

Utilization Review Nurse

Advanced Practice Provider (APP), NY-100% Remote

Advanced Practice Provider (APP), CT-100% Remote

Clinical Operations Specialist, LPN

Remote Nurse Case Manager

Telehealth Nurse

Remote Hospice Triage RN- PT 2 shift 6p-12a + rotating Sat & Sun 3:30-12 CST

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

Patient Engagement Partner - Access Center, Part Time Nightshift, Remote position (PA/NJ residency)

Weekend Clinical Triage Specialist, Registered Nurse, Connect to Care, Part Time, Remote Position (PA/NJ residency)

Utilization Review Specialist I

Clinical Training Specialist, Registered Nurse

RN Care Manager

Remote Registered Nurse (RN) Clinical Liaison

Case Manager, Registered Nurse - Work from Home

**REMOTE** Certified Tumor Registrar

Registered Nurse (RN) - Neurology Clinic Phone Triage (Remote)

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

Pediatric Care Manager (RN)

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

ACO Triage Nurse ( Remote Position )

Remote Post Acute Clinical Review Nurse

Denial Prevention Nurse Consultant

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

LPN Care Coordinator

Behavioral Telephonic Case Management Nurse - Remote in New York

Care Manager- Telephonic Nurse PT - After Hours & Weekends

Registered Nurse, Telehealth, Part Time (Spanish Bilingual)

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

Transitional Care Coordinator - CMA or LVN

Virtual Triage RN

Intake Coordinator

Payment Integrity Clinician - (Remote)

Case Management Clinical Quality Analyst, Registered Nurse

Remote Senior Program Manager - Nurse Call Center

Remote Quality Assurance Program Manager - Nurse Call Center

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

Clinical Quality Management Specialist II (Remote) 2025-1419

Quality Management Specialist (Remote) 2025-1418

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

Clinical Appeals Nurse (medical necessity)

Utilization Management RN /LPN

Applied Behavior Analysis - Quality Monitor Clinician

Population Health Program Nurse

Chronic Account Manager - Remote

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

Clinical Services Leader

Telephonic Case Manager (RN) - Illinois ONLY

Bilingual Nurse

Manager, Care Management

Bilingual Care Manager (Spanish)

Clinician, C365

Utilization Management Coordinator - OK

Remote Supv, Care Management BH team - TX ONLY

Utilization Review Nurse, RN

Clinical Documentation Integrity Specialist

Trauma Performance Improvement Coordinator

Trauma Abstractor

Registered Nurse - Atrium Health Virtual Care Remote FT Days

LPN Care Review Clinician, Prior Authorization Remote in WA state

Triage RN (Remote)

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

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

RN Overnight Telehealth Administrator on Call, Remote

Registered Nurse

Health Home Care Manager (Remote) - Full Time

REMOTE Certified Tumor Registrar

Business Intelligence Analyst
analyzes All metrics, Audits Expenses, Establishes Projections,
Shares Insight & Suggestions

SEO, SEM, Ranking Experts
‍Keyword Research, Meta & Link Optimizing, Campaign Creation, Curated Linking, Builds Strategies, Writing, Testing, and Optimizing

$149
One time payment for lifetime access & more!