AlphaForce Technology Solutions

Clinical Review Nurse - Prior Authorization

Posted on:

March 19, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

LPN/LVN

State License:

Indiana

Position: Clinical Review Nurse - Prior Authorization Location: Remote – Indiana Potential to Extend: Yes 3 Months Pay-Rate: $45/Hr. on W2 Shift: 8AM-5PM EST Monday – Friday (training and work schedule) Disqualifiers: No computer literacy, add reasoning for big gaps in employment, NEED a professional environment (childcare needed if applicable) Analyzes all prior authorization requests to determine medical necessity of service and appropriate level of care in accordance with national standards, contractual requirements, and a member's benefit coverage. Provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care.

Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 - 4 years of related experience. Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. Required Skills/Experience: Bachelor’s degree in Nursing and 2 - 4 years of related experience LPN - Licensed Practical Nurse - State Licensure required Authorization requests and determine medical necessity of service Medicare and Medicaid regulations Utilization management processes InterQual knowledge

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

Cortex

Telehealth Registered Nurse - Remote RTM & PCM

Posted on:

March 19, 2025

Job Type:

Part-Time

Role Type:

Telehealth

License:

RN

State License:

Compact / Multi-State

Remote Contractor RN - Chronic Care Management (CCM) Position Overview: We are seeking a dedicated and detail-oriented Registered Nurse (RN) with a compact state license to join our team as a remote RN specializing in Remote Therapeutic Monitoring and Principle Care Management. The ideal candidate will have exceptional patient phone-side manner, strong documentation skills, and the ability to build rapport and trust with patients while working independently in a remote environment.

Valid Compact (multi-state) U.S. RN license (required). Prior experience in Chronic Care Management or Remote Patient Monitoring (RMP) is a plus. Proficient in using computers, EMRs, and related systems. Exceptional interpersonal and communication skills (both written and oral). Reliable, detail-oriented, and able to follow standard operating procedures. Positive, professional, and team-oriented attitude. A dedicated quiet workspace with high-speed, reliable internet. Access to a working and up-to-date computer or laptop, along with a quality headset.

Provide high-quality services to assigned patients. Complete patient caseloads efficiently each week, adhering to company guidelines and SOPs. Maintain exceptional patient interactions via phone, building trust and rapport with empathy and professionalism. Document all patient encounters accurately and comprehensively in accordance with program requirements. Collaborate with the care team and other healthcare professionals as needed to ensure continuity of care. Utilize strong computer skills to navigate software systems, maintain patient records, and communicate effectively.

HCA Healthcare

Virtual RN PRN

Posted on:

March 19, 2025

Job Type:

Role Type:

Triage

License:

RN

State License:

Tennessee

Provide appropriate compassionate advice to callers using evidence based clinical decision tools to help callers make personal health decisions. Make cross referrals as indicated. Facilitate referrals and event registration through internal transfer mechanisms.

KNOWLEDGE, SKILLS AND ABILITIES: Demonstrates knowledge and understanding of organizational and departmental policies, procedures and systems Communicates clearly and concisely both verbally and in writing Establishes and maintains long-term customer relationships, building trust and respect Demonstrates good judgment in handling situations not covered by written or verbal instructions Able to work effectively with internal and external customers Able to perform basic mathematical calculations, balance and reconcile figures, punctuate properly, spell correctly, and transcribe accurately Able to handle multiple priorities and manage stress appropriately EDUCATION: The position requires an entry knowledge level generally obtained through completion of an Associate Degree or an equivalent in demonstrated work experience. EXPERIENCE: 1 year of clinical nursing experience required; 3 years preferred CERTIFICATE/LICENSE: Active RN license in state of residence required and ability to obtain licensure in all states served by HCA.

Utilizes nursing skill and along with approved protocols to provide telephone nurse triage and/or health advice to consumers with clinical questions or symptoms. Facilitates referrals for health services as appropriate via telephone and performs all components of call processing Ensures performance standards are met and accepts constructive feedback Speaks with a pleasant, professional phone voice and provides superior customer service to create an exceptional patient experience. Documents caller information and outcomes in a relational database system in accurately and as prescribed by current standards and policies Maintains confidentiality, HIPAA and PHI compliance Communicates appropriately and clearly with departmental management, co-workers and callers and exhibits willingness to master new work routines and methods Practices and adheres to HCA’s “Code of Conduct” and “Mission and Value Statement” Provides homecare, advice and/or education to callers that respects the cultural, spiritual, intellectual/educational, and psychosocial differences of individuals and preserves caller’s autonomy, dignity and rights. Maintains and contributes to a collaborative professional and ethical work environment. Actively participates in team meetings and engages in the processes of the contact center

NantHealth

Director, Clinical Solutions | Remote | AirStrip

Posted on:

March 19, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Texas

Are you ready to link your passion with a purpose? At AirStrip, we build technology that enables clinicians to diagnose earlier than ever before, accelerate life-saving interventions, reduce the cost of care, and save lives. We provide mobile-first clinical surveillance and alarm communication management technology that unlocks siloed data from patient monitors and transforms it into contextually rich information easily accessible on mobile devices and the Web. We’re seeking innovative thinkers who love doing meaningful work. If you’re looking to bring your skills and expertise to a growing technology company, it’s time for you to join us!

AirStrip is adding a Director, Clinical Solutions to our team. In this role, you will develop clinical strategies to support both Delivery PMO, Sales and Product Development vision for the Clinical Solutions team to enhance patient outcomes and expand industry market share. As a leader within the Delivery Project Management Office, you will lead building and growing a team of Clinical Consultants (CCs) to support the execution of all AirStrip product implementation. You'll lead the development of clinical relationships with healthcare institutions for net-new prospects and identified expansion opportunities to grow relationships in existing accounts. You'll establish goals and metrics for the clinical consultants, developing department processes and report to the leadership team key metrics that drive business and staff success. You'll work closely with R&D, Product, Marketing, Sales and Delivery PMO to remain current on all Clinical Solutions product offerings in order to successfully educate both our internal and external customers. Please note, this position requires 75-80% travel. You are regularly traveling Monday-Friday to client locations across the United States, multiple weeks in a row.

Education & Experience Requirements: Bachelor’s of Science in Nursing 10+ years of experience supporting selling activities and service delivery in healthcare software and solutions with a sustained and demonstrable record of success in Digital Health, Healthcare IT, Alarm Management, Clinical Communications and Patient Monitoring 5+ years of experience in acute care clinical workflows, including the knowledge to effectively establish credibility and the ability to provide solutions targeting clinical and operational workflow improvements Required Knowledge, Skills, and Abilities: A passion for patient safety and workflow improvement A high degree of passion, respect and listening skills Previous management experience Must possess excellent presentation skills Willingness to travel up to 80% Ability to work in a team environment that collaborates with multilevel disciplines, including excellent interpersonal and communication skills with the willingness to work with cross functional teams and individuals General office technology skills required (MacBook Laptop, Microsoft Applications, MS Teams, Zoom, WebEx) Ability to comply with AirStrip regulatory guidelines Ability to prioritize and manage time effectively Must possess excellent organizational skills to determine workload priorities Critical thinking/problem solving. Exercise sound business reasoning to assess issues, make decisions, and overcome challenges

Interface at all levels within a customer’s clinical organization and coordinate highly clinical information and unit-based workflow requirements Support delivery of clinical programs pre and post-sale to include ADPIE deliverables including clinical assessments, clinical design strategy, user acceptance testing, go-live support and ongoing customer clinical engagements. Manage budget, resource allocation and operational efficiency for the Clinical department. Hire, coach and direct a team of Clinical Consultants Provide emerging customer clinical requirements feedback to Product Management and serve as an active participant on the new product release committee Effectively communicate project goals and expectations to team members and stakeholders in a timely and clear fashion Develop and maintain clinical learning materials and manage delivery and access of materials. Establish key clinical stakeholder relationships Develop leading clinical practices and tools for project execution, management, training and support Design and present user stories, use cases, site assessments, clinical requirements, and workflow diagrams

NantHealth

Clinical Consultant | Remote | AirStrip

Posted on:

March 19, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Texas

Are you ready to link your passion with a purpose? At AirStrip, we build technology that enables clinicians to diagnose earlier than ever before, accelerate life-saving interventions, reduce the cost of care, and save lives. We provide mobile-first clinical surveillance and alarm communication management technology that unlocks siloed data from patient monitors and transforms it into contextually rich information easily accessible on mobile devices and the Web. We’re seeking innovative thinkers who love doing meaningful work. If you’re looking to bring your skills and expertise to a growing technology company, it’s time for you to join us!

AirStrip is adding a Clinical Consultant to our team. In this role, you serve as one of AirStrip’s clinical workflow and informatics SME's during technology implementations with clients. You engage directly with clients’ clinical champions, end users, including both nurses and physicians, clinical IT staff and partner vendors to optimize the value of AirStrip's tech solutions. Drawing upon your previous clinical experience and expertise, you'll assist as an internal resource for pre-sales activities, implementation, training support and strategic product discussions. Please note, this position requires 75-80% travel. You are regularly traveling Monday-Friday to client locations across the United States, multiple weeks in a row.

Education & Experience Requirements: Bachelor's of Science in Nursing (or other health care related BS AND MSN), along with an active RN license Recent clinical experience (within last 5 years) in adult critical care, Telemetry, or Emergency Department 5+ years or more overall clinical experience in one or more of the above-mentioned areas. 2+ years of experience supporting clinical workflow initiatives in a hospital system involving clinical informatics, deployment of new technologies with successful adoption among physician and nurse users, including EMR, Monitoring alarms and mHealth technologies (strongly preferred) Required Knowledge, Skills, and Abilities: Demonstrable advanced clinical skills and knowledge in cardiac and critical care nursing and standards of care for critical care patients. Solid clinical workflow knowledge, including how departments relate to one another and process flows in between them Excellent verbal and written communication skills, including demonstrated ability to develop and deliver presentations, workflow designs, and training materials Strong ability to explain data and insights concepts to non-technical audiences and to communicate clinical informatics concepts and tasks to cross-functional teams Ability to instill confidence and persuade customers and coworkers Deep knowledge and experience with electronic medical records and workflow of medical and nursing staff around use of EMRs and other automated systems. Demonstrated project management, organizational and interpersonal skills Self-assured and results oriented, able to work independently as well as collaboratively. Strong analytical skills – understands how to collect, analyze, and leverage data to achieve clinical/business objectives Experienced knowledge of computer operations and ability to competently use MS Office – i.e. Word, Excel, Outlook, Visio, and other applications.

Employ clinical knowledge and understanding of clinical workflow design / redesign to propose AirStrip solutions that improve and optimize client’s workflow and processes Conduct clinical workflow design sessions at project sites, gathering data and working with the client’s clinical staff in developing new processes and workflow improvements Develop drafts of clinical documentation and assist with clinical marketing and support of new products and services Conduct hospital level training or facilitate client team meetings prior to or during initial deployment of solutions to ensure that physicians and nurses drive key use cases within their workflows to generate value and data required for clinical effectiveness. Participate with AirStrip innovation, engineering, and operations teams to ensure an efficient and comprehensive interaction with clients at the assessment, testing, validation, initial deployment, and steady state phases of the client relationship Interact with client physicians and nursing champions through planning, go-live, and post-deployment to enable adoption of AirStrip solutions and communicate feedback Deliver AirStrip solutions focused presentations to groups and demo how AirStrip solutions will meet prospect and customer needs​ Lead and coach customers to success through ADPIE methodology including workflow “day in the life” positioning​, go live support and ongoing education Manage multiple, simultaneous projects from assessment through clinical implementation Assist Sales team with sales calls and clinical discovery sessions to accelerate new account development and expansions​ Develop leading clinical practices and tools for project execution, management, training and support​ Design and present user stories, use cases, site assessments, clinical requirements, and workflow diagrams​

HCA Healthcare

Triage LPN

Posted on:

March 19, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

LPN/LVN

State License:

Tennessee

The Licensed Practical Nurse/Licensed Vocational Nurse (LVN/LPN) delivers high quality, patient-centered care by performing a variety of delegated basic patient care services. In collaboration with the RN and other members of the care team, the LPN/LVN provides individualized, comprehensive care consistent with the scope and standards of the specialty. Licensed Practical Nurse (LPN)Identifies care compliance and/or knowledge deficits; delivers appropriate, evidence-based information pertaining to medical conditions, procedures and services; provides guidance to applicable resources

Completion of an accredited Licensed Practical Nurse program and NCLEX exam Minimum of 1 year experience in a hospital or clinic setting (working in the role/title of an LPN) – Telehealth experience preferred Must possess and maintain a LPN licensure in state of residence; Other state licensures may be required based on business needs and direction from site leadership. Additional state licensures identified at time of hire, applications to be submitted within 120 days of employment Additional requests for licensure as identified during employment, applications to be submitted within 45 days of request Employee is responsible for licensure fees; company compensation available for costs incurred to meet business needs that are outside of required criteria for state of residence

Performs all components of call processing for inbound and outbound contacts; Ensures complete, timely and accurate documentation of call handling in applicable system(s) Utilizes approved forms, files, protocols and systems for intake and delivery to support clinical material provided Able to identify emergent clinical concerns and promote safe outcomes under the direction of a Registered Nurse Escalates calls to an RN warranting comprehensive assessments/ clinical triage Demonstrates effective time management skills in all aspects in their role as LPN within NCCM Assists with Intake Orders and process for follow-up; provides clarification with provider as needed Assists with referrals/appointments Speaks with customers, patients and stakeholders in a pleasant and professional tone; demonstrates superior customer service Preserves caller’s autonomy, dignity and rights Receptive to constructive feedback and coaching; Demonstrates the ability to be kind, compassionate, considerate, approachable, friendly and open-minded Maintains confidentiality and HIPAA compliance on all internal and external channels Ensures individual performance, productivity and quality standards are met Functions within the scope of an LPN as defined by local, state and federal regulations/guidelines ; Adheres to NCCM clinical SOPs Promotes and adheres to Code of Conduct Maintains positive work environment; Communicates appropriately and clearly with department leadership and co-workers; Escalates issues/concerns to Leadership as appropriate Understands, supports and adheres to the NCCM vision and strategy Suggests ideas for positive changes to department policies and procedures Easily adapts to changes in work environment or job assignment; Exhibits willingness to master new work routines and methods Performs other duties as assigned DUTIES AND RESPONSIBILITIES, Licensed Practical Nurse (LPN) – Senior: Demonstrates and maintains previous level responsibilities Goal-oriented, focused team player Maintains positive working relationships and fosters cooperative work environment; Demonstrates ability to positively influence others; Finds and establishes win-win situations Capable and available to provide floor and call/work flow implementation and support to LPN(s) as needed Performs one-on-one feedback to meet clinical objectives as directed by leadership Actively participates in meetings and engages in process development Serves as a subject matter expert on policies and procedures, call handling and database software; Qualified to train and mentor LPNs Able to facilitate crucial conversations at all levels and in all directions Maintains professionalism in high-stress environment; ability to meet established deadlines as defined by leadership Demonstrates a level of business acumen and maturity that would be reasonably expected for this mentor level position Attends all site meetings as directed by leadership

CVS Health

Case Manager RN- Work From Home- San Antonio, TX

Posted on:

March 19, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Texas

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

This Case Manager RN role is fully remote; however, candidates must reside within 45 minutes (reasonable driving distance) from the local office located at 7034 Alamo Downs Pkwy, San Antonio, TX 78238. No weekends or holidays will be required. The Case Manager RN 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. The Case Manager RN 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.

Required Qualifications: Must have an active current and unrestricted RN multi state licensure in Texas Willingness to obtain additional state licenses will be required upon hire (expenses will be covered by company). 3+ years clinical practice experience as an RN required 1+ year(s) experience utilizing multiple computer systems and applications including Microsoft Word, Excel, Outlook, and web-based applications Must reside within 45 minutes (reasonable driving distance) from the local office located at 7034 Alamo Downs Pkwy, San Antonio, TX 78238. Travel to the San Antonio office may be required for quarterly meetings or PRN meetings. Must be able to work Monday through Friday 8:00am-5:00pm CST with flexibility to rotate to 10:00am-7:00pm CST on occasion when required to meet business needs. Preferred Qualifications: Case Management in an integrated model Bilingual in Spanish and English Strong computer skills Education: Associates Degree required BSN preferred

Through the use of clinical tools and information/data review, conducts an evaluation of member’s needs and benefit plan eligibility and facilitates integrative functions as well as smooth transition to Aetna programs and plans. Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and barriers and address complex health and social indicators which impact care planning and resolution of member issues. Assessments consider 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.

Molina Healthcare

IRIS SDPC (RN)

Posted on:

March 19, 2025

Job Type:

Full-Time

Role Type:

Care Management

License:

RN

State License:

Wisconsin

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.

Are you seeking a unique nursing position that gives you a great work/life balance and lets you support people to live the lives that they choose? Then you’ll want to keep reading about this rewarding work opportunity! We are currently looking for a Registered Nurse licensed in Wisconsin to become our next IRIS Self-Directed Personal Care (SDPC) RN. This is a remote position, where you will partner with people in your community who are enrolled in the Wisconsin IRIS program – a Medicaid long-term care option for older adults and people with disabilities. People in the IRIS program who need personal care services have the choice to enroll in the IRIS Self-Directed Personal Care (IRIS SPDC) option. You can learn more about IRIS SDPC on the Wisconsin Department of Health Services website here, and learn about the IRIS program here. While this role is home-based, you will have regularly scheduled visits with people in their homes and communities. As an IRIS SDPC RN, you’ll provide oversight and guidance to the people enrolled in the IRIS SDPC option. You’ll also build relationships with the people you partner with and ensure that they’re getting the most out of the IRIS Self-Directed Personal Care option through assessment, oversight, training and education. IRIS SDPC RNs are responsible for administering the Wisconsin Personal Care Screening Tool; creating person-centered plans of care; providing personal care oversight to a group of people in IRIS, providing education and training for IRIS participants and care providers, and conducting the required documentation and follow-up. As an IRIS SDPC RN, you’ll play an important role in helping people of various backgrounds and abilities live their lives the way they choose.

REQUIRED EDUCATION: Associates Degree in Nursing REQUIRED EXPERIENCE: Minimum 2 years of experience in nursing with at least one year of home health serving individuals with developmental disabilities, physical disabilities, or the elderly. Demonstrated computer and software skills required, proficiency with Microsoft Office Suite and database operation/maintenance skills and data entry experience. Excellent written and verbal communication skills required and the ability to adapt communication styles to fit situation. Strong teaching and mentoring skills. Strong analytical and problem-solving skills. Good organizational and time management skills with ability to manage tasks independently. Flexibility in the work environment and willingness and ability to adapt to changing organizational needs. REQUIRED LICENSE, CERTIFICATION, ASSOCIATION: Current unrestricted license in the state of Wisconsin as a Registered Nurse. Valid Driver’s License PREFERRED EDUCATION: Bachelor’s Degree in Nursing PREFERRED EXPERIENCE: Experience providing care through the Wisconsin Medicaid Personal Care Program or one year of home care experience

Provides personal care assessments and oversight to the My Cares Groups by administering the Wisconsin Personal Care Screening Tool and addendums as required Documents assessment as required by individual tool and Department of Health Services policies and by completing oversight visits and calls as required Oversees a My Cares Groups of participants, develops individual plans of care, ensures physician orders for care are obtained and reviews and revises plan of care as needed Submits for Prior Authorization for personal care services Complies with all Department of Health Services policies and SDPC Guidelines, procedures, and practices along with documentation and program regulations Provides personal care training to participants or care providers as requested and provides educational materials as needed Completes collateral contacts with IRIS Consultants and Long-Term Care Functional Screeners and physicians to ensure care needs are met Completes other duties as assigned Overtime work may be required May be required to drive 50% of the time during a given day of member home visits Exposure to members homes which may include navigating stairs, exposure to different environments, and pets

Oula

Manager of Clinical Informatics

Posted on:

March 19, 2025

Job Type:

Part-Time

Role Type:

Informatics

License:

None Required

State License:

New York

Oula delivers maternity care built around our patients – offering comprehensive support before, during, and after pregnancy. With fewer C-sections and higher VBAC success rates, our research-backed approach is delivering better outcomes. Our team of trusted midwives, OBGYNs and dedicated care navigators ensure our patients get the type of care they need in the moments that matter most. Since launching in 2021, we’ve expanded our services to include Preconception and Miscarriage Care, Pregnancy Care, Hospital-Based Delivery, Postpartum Support, and Gynecology. We have 3 clinics in New York, with exciting expansion on the Horizon! Come join our team of clinicians, innovators, operators, and technologists, passionate about setting a new standard in maternity care.

We’re looking for a Manager of Clinical Informatics to own Oula’s EMR workflows. Oula clinicians work in their respective health system’s EMR systems, and Oula’s technology integrates with each of those systems. We’re looking for someone to serve as an internal expert in the capabilities of the systems and act as a conduit between IT teams and our clinicians’ needs. This role reports to the Director of Clinical Services Implementation. This is a part-time position of 20 hours/week the role is remote with a compensation range of $60-$65/hr.

5+ years in clinical informatics or project management within healthcare IT Direct experience optimizing workflows within EPIC General understanding of EPIC's API capabilities and use cases, preferred. A track record of project management experience acting as a conduit between IT and Clinical. Experience collaborating with both IT and clinical stakeholders. Detail oriented and highly organized.

Build upon Oula’s playbook of must-have EMR configurations, particularly in Epic, that guide each health system implementation toward efficient and compliant clinical workflows. Work closely with the IT teams at health systems, Oula’s internal IT & engineering teams, as well as with third-party integration experts, to scope and advocate for Oula’s configuration needs. Align new EMR system settings and parameters with existing clinical standards. Customize templates, order sets, alerts, and other system components to align with Oula’s standard of care, best practices and regulatory standards. Serve as Oula’s internal owner of clinical EMR workflows, collaborating with healthcare providers and IT teams to understand workflow requirements and operational challenges. Develop and maintain documentation related to EMR configuration, workflows, and user manuals. Manage EPIC configuration meeting structure, cadence, invitations between Oula and health system partners, focused on speed-to-launch.

Oula

Perinatal RN

Posted on:

March 19, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Compact / Multi-State

Oula delivers maternity care built around our patients – offering comprehensive support before, during, and after pregnancy. With fewer C-sections and higher VBAC success rates, our research-backed approach is delivering better outcomes. Our team of trusted midwives, OBGYNs and dedicated care navigators ensure our patients get the type of care they need in the moments that matter most. Since launching in 2021, we’ve expanded our services to include Preconception and Miscarriage Care, Pregnancy Care, Hospital-Based Delivery, Postpartum Support, and Gynecology. We have 3 clinics in New York, with exciting expansion on the Horizon! Come join our team of clinicians, innovators, operators, and technologists, passionate about setting a new standard in maternity care.

We are looking for a Remote Perinatal Nurse to support our patients in between their visits at our clinic. We’re searching for someone empathetic and detail-oriented to answer patient questions, review labs and imaging results, and support care coordination to provide high-quality patient-centric care. You will work directly with our provider and customer experience teams to provide a best-in-class experience for our patients. This role reports to the Senior Director of Care Continuity

Three or more years as an OB/GYN nurse in the field of obstetrics/gynecology or women’s health with experience providing and/or coordinating perinatal care A bachelor’s and/or nursing degree from an accredited program Active Compact RN License Additional Benefit: NY license in addition to compact Strong computer skills and familiarity with EMRs (experience with Athena is a bonus) Experience with maternal-fetal medicine support and strong ultrasound interpretation experience is highly desired Familiarity with outpatient perinatal care workflows and high risk pregnancies Passionate about improving perinatal care through a combination of clinical care, technology, patient empowerment and education An empathetic listener and communicator with the ability to connect with a wide variety of audiences and respond to a wide variety of needs A cultural carrier with full alignment to Oula’s commitment to deliver the highest degree of patient centered care Organized as it relates to daily tasks and as well as an ability to work towards longer term goals and projects Flexible in your approach and ability to adapt to changing circumstances Comfortable working across distance and maintaining east coast hours regardless of location Ability to work on a strong team of professionals in a culturally diverse environment Spanish or non-English language proficiency is considered a bonus

Provide first-line review for all lab and imaging results, including communicating with patients regarding results per Oula clinical policy Answer inbound clinical questions from patients via messages in the Oula Patient Portal and phone calls within RN scope of practice Lead clinical portions of our new patient screening and onboarding process, including review of risk factors/medical history as needed and review of medical records for patients transferring care to Oula Partner with OB, midwife, NP, and care coordination teams to deliver high-quality continuity of care for our patients Coordinate with external clinical partners (e.g. maternal-fetal medicine, labs, imaging partners) where needed to ensure Oula patients are getting the care they need outside of our ecosystem Communicate MFM consultation results to patients in a timely, clear, and supportive manner Assist in coordinating follow-up care based on MFM recommendations Support basic ultrasound interpretation and documentation within RN scope of practice Collaborate with the clinical team to ensure seamless integration of MFM insights into patients' care plans

A&C Private HomeCare

Registered Nurses, PRN or Consultant

Posted on:

March 18, 2025

Job Type:

Contract

Role Type:

Clinical Operations

License:

RN

State License:

Georgia

A&C Private Home Care is currently looking for RNs Consultants. Retired RNs willing to remain engaged in the profession are welcome to apply. The positions are flexible schedules to meet the needs of our private home care business throughout Georgia. The RNs will help oversee all clinical needs, follow up with case management agencies' recommendations, along with guidance with medication and prescription management.

Experience in Community Health and/or Home Health Care Possesses all credentials required by State and Federal Law Valid Driver's license with good driving record The RNs will assist with the quality assurance and compliance with Rules and Regulations.

Assess health needs, develop and implement appropriate plans of interventions, assess and modify plans in response to changing health care needs of individuals served and interface with case management agencies. Interact with other support staff to ensure continuity and coordination of care. Effectively use community back up support in providing care. Document information and treatments in accordance with rules and regulations Communicate effectively with the Director of Nursing, other support staff, clients, families and outside agencies, as appropriate. Participate in client-centered meetings and staff meetings, as appropriate. Review the implementation of medically prescribed client care plan. Respond to crises and interventions, as needed. Recommend policies and procedures on health issues. Participate in appropriate professional growth and continuing education opportunities. Schedule and conduct monthly staff meetings with LPN's and supporting staff. Provide continues support while at assigned location though out workdays. Must successfully complete and demonstrate proficiency in all areas of required training. Other responsibilities may be assigned

Samaritan Health Services

HRSN Specialist RN I

Posted on:

March 18, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Oregon

Samaritan Health Plans (SHP) provides health insurance options to Samaritan employees, community employers, and Medicare and Medicaid members. SHP operates a portfolio of health plan products under several different legal structures: InterCommunityHealth Plans, Inc. (IHN) is designated as a regional Coordinated Care Organization (CCO) for Medicaid beneficiaries; Samaritan Health Plans, Inc. offers Medicare Advantage, Commercial Large Group, and Commercial Large Group PPO and EPO plans; SHP is also the third-party administrator for Samaritan Health Services’ self-funded employee health benefit plan.

As part of an Integrated Delivery System, Samaritan Health Plans is strategically and operationally aligned with Samaritan Health Services’ mission of Building Healthier Communities Together. This is a remote position in which we are able to employ in the following states: Arizona, Arkansas, Connecticut, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Mexico, North Carolina, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, or Wisconsin Candidates residing out of state will need to be able to work Pacific Time Zone hours.

EXPERIENCE/EDUCATION/QUALIFICATIONS: Current unencumbered Oregon RN License required. BSN preferred. One (1) year clinical nursing experience required. Experience or training in the following required: Health care delivery systems and/or managed care patients. Computer applications including electronic documentation (e.g., MS Office, EPIC, Clinical Care Advanced). Experience in the following preferred: Utilization management. Medicare and Medicaid rules and regulations and health plan benefit structure and policy. KNOWLEDGE/SKILLS/ABILITIES: Knowledge of social determinants of health (SDoH) and the relationship to the member’s overall wellbeing. Knowledge of HRSN benefit, managed care principles, OHA requirements and OHP benefits and ability to incorporate this information into the HRSN coordination process. Knowledge of principles and processes for providing customer and personal services, including customer needs assessment, meeting quality standards for services and evaluation of customer service satisfaction. Ability to work, function and communicate on a multi-disciplinary team. Possess the knowledge and skills to develop constructive and cooperative working relationships with others and maintain them over time. Ability to work with all levels within the organization, facilitate communication, and effectively document related activities. Ability to identify complex problems, review related information, employ creativity and alternative thinking to develop and evaluate options and implement solutions respond quickly and appropriately. Ability to organize, plan and prioritize work to complete within required time frames and to follow-up on pending issues. Knowledge of medical terminology, ICD, CPT, and HCPCS codes. Strong communication skills (telephone skills with members, CBOs, interdepartmental communication).

Reviews, assesses, and evaluates clinical information used to support the HRSN (health-related social needs) benefit decisions based on established clinical criteria and applies intermediate knowledge of coding and medical record research. Facilitates professional communication to ensure the HRSN process is completed in a patient centered manner with adherence to quality and timeline standards. Applies knowledge of applicable Medicaid (OHA) rules and regulations to the authorization process.

River Valley Child Development Services (RVCDS)

Child Care Nurse Health Cons - MountainHeart North

Posted on:

March 18, 2025

Job Type:

Full-Time

Role Type:

License:

RN

State License:

West Virginia

Title: Child Care Nurse Health Consultant Program: WVECTCR Worksite: Remote Home Office (located within or close to the service region) Reports to: Project Manager FLSA Status: Exempt Classification: Full-time Position Summary: Provide technical assistance and develop and conduct professional development trainings on specialized health, safety, caring for children with special health needs, and nutrition topics.

Knowledge, Skills & Abilities: Abide by all applicable Federal, State, and local laws, rules, regulations, and policies related to the program and relevant grants. Excellent verbal and written communication skills. Utilize technology to enter, retrieve, and process information and communicate electronically. Excellent interpersonal, negotiation, problem solving, and conflict resolution skills. Excellent organizational skills and attention to detail. Excellent time management skills with a proven ability to meet deadlines. Remain aware of emerging trends and best practices for health, safety, and nutrition as it relates to childcare settings. Act with integrity, professionalism, and confidentiality. Work collaboratively. Education Required: Associate’s degree from an accredited college or university in nursing. Experience Preferred: Two (2) years of teaching and training experience. Employment Conditions: Successfully clearing the background check process, which may include: criminal background check, education verification, references, drug testing, motor vehicle records, sex offender registry, Child Protective Services check, and federal grants debarred list. WV RN license, current and unrestricted. Valid driver’s license and reliable transportation. Able to travel extensively; requires the need for flexible scheduling, including occasional evening, weekend, and/or overnight hours. Adhere to the National Association for the Education of Young Children (NAEYC) Code of Ethics. Maintain STARS career pathway enrollment and STARS Specialty Professional Development Provider. Business casual apparel. Environmental Conditions: Indoors in a normal office environment with little exposure to temperature changes at least fifty percent (50%) of the time. Prolonged sitting at a desk viewing a computer screen and keyboard typing. Frequent face-to-face, electronic, and virtual interactions with internal and external customers. Frequently work at a fast pace with unscheduled interruptions. Public contact position. This position may be eligible to work remotely up to two days per week following a successful 90-day review. Physical Demands: Mobility within the office including movement from floor to floor. Access information using a computer. Must be able to lift 25 pounds at times.

Essential Functions: Develop and conduct face-to-face and online professional development sessions on health and safety topics as they relate to the state childcare licensing requirements and national health and safety standards based on the educational needs of childcare providers. Provide consultation to childcare providers and families on health, safety, caring for children with special health needs, and nutrition topics based on research and best practice. Develop and disseminate informational materials to childcare providers on a variety of health, safety, and nutrition related topics. Traverse various terrain to access visitation sites. Remain stationary up to 50% of the time. Marginal Functions: Establish contacts, build relationships and collaborate with stakeholders. Work collaboratively as a member of the comprehensive Child Care Nurse Health Consultant team. Maintain social media account for Child Care Nurse Health Consultants. Ensure all Child Care Nurse Health Consultant information is current and up-to-date on WVECTCR website. Compile and submit reports within established timelines. Respond to any inquiries within a timely manner. Participate in all required committees, conferences, meetings and training relevant to the program and/or agency. Participate in ongoing monitoring and continuous improvement activities. Any other duties as assigned.

MDS Solutions

MDS Solutions - Clinical Reimbursement Specialist

Posted on:

March 18, 2025

Job Type:

Contract

Role Type:

Clinical Operations

License:

RN

State License:

Florida

At Key Rehab, we’re shaking up rehab services with a fresh, standout approach. We offer a wide range of services, stick to top-notch systems, and work in strategic locations to get the best results for our patients and support our clients' goals. We’re all about clear communication, using our deep experience to deliver therapy that's both effective and affordable. Our reputation is built on great patient care, happy clients and staff, and solid management. We are proud to exceed expectations for patients, families, healthcare providers, and businesses. We prioritize both exceptional patient care and the well-being of our employees. We are committed to delivering compassionate, results-driven therapy while offering the flexibility and comprehensive benefits needed to thrive in today’s healthcare environment. Our team is large enough to offer competitive pay and benefits but small enough to ensure personalized attention and support for your career aspirations. Whether you’re looking for a role that accommodates family commitments, travel plans, home projects, or future savings, we provide tailored solutions to fit your lifestyle. Join us and experience a workplace that values your individual needs and career goals. Come experience a rewarding career where you’re valued and supported every step of the way. We offer a creative, engaging, and flexible work environment, alongside a comprehensive benefits package designed to support your success and well-being: Competitive salaries with bonus opportunities Ample opportunities for promotion, transfer, and advancement Work that is meaningful, fulfilling, and provides high job satisfaction Reasonable working hours promoting work-life balance Continuing education (CE) opportunities for ongoing professional development Generous paid time off Comprehensive health, dental, and life insurance packages 401K with discretionary matching Mileage and licensure reimbursements Flexible Spending Account (FSA) and Health Savings Account (HSA) options

MDS Solutions, a division of Key Rehabilitation, is looking for fun, energetic, and self-driven team members to join our remote MDS division as a Clinical Reimbursement Specialist. Clinical Reimbursement Specialist (CRS) The Clinical Reimbursement Specialist (CRS) plays a critical role in supporting clients through specialized project work, including conducting RAI assessments, developing comprehensive care plans, and delivering targeted education and training to MDS Coordinators on the Resident Assessment Instrument (RAI) process. This work is performed in strict alignment with applicable laws, regulations, and company standards. The CRS also reviews reimbursement systems for PDPM and Case Mix to ensure accurate and optimized reimbursement. Additionally, the CRS provides support with interim long-term and short-term contract coordination, ensuring the smooth completion of these efforts

Bachelor’s degree in nursing from an accredited college or university, with at least five (5) years of clinical experience, including 3+ years specializing in the RAI process. Current and unrestricted RN ,along with active RAC-CT certification, ensuring adherence to industry standards and best practices. Possesses exceptional critical thinking skills, with the proven ability to make informed decisions, demonstrate sound clinical judgment, and apply expert knowledge in quality improvement concepts and processes. Demonstrates strong leadership abilities and excels in interpersonal communication, fostering collaboration, and guiding teams to achieve optimal clinical outcomes.

Serve as a trusted advisor to healthcare agencies and facilities, offering expert guidance and insights to optimize their operations. Assist clients in assessing, planning, developing, and implementing systems and processes related to reimbursement, tailored to the specific needs and contracts established with each client. Provide consulting services and technical expertise, including interim MDS management, ensuring providers receive the support they need to achieve optimal outcomes. Stay up-to-date on professional standards of clinical care, federal and state regulations, QM measures, and the RAI process to ensure the delivery of accurate, compliant, and effective solutions. Deliver high-quality, professional services that encompass reimbursement optimization, staff education, in-depth research, system analysis, creative problem-solving, and the presentation of actionable recommendations to clients. Identify and address training needs, developing and conducting training sessions or in-service programs as requested by clients to enhance staff competency and performance. Operate within the defined scope of work, maintaining strict adherence to client agreements and expectations. Uphold client confidentiality and ensure full compliance with HIPAA regulations, safeguarding sensitive information throughout the engagement.

Planned Parenthood of the Rocky Mountains

Virtual Registered Nurse (RN)

Posted on:

March 18, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Colorado

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

This position is open to Colorado and New Mexico Applicants Position: Virtual Care Center Registered Nurse Responsible To: Virtual Care Center Licensed Assistant Manager Remote: 80% On site: 20% You may work from home or the office, making outbound and taking inbound calls from patients to address their follow up plans or concerns. If you work from home, this position runs software that requires high-speed internet with 25 MB download and 15 MB upload speeds. The ability to consistently run this software is a requirement to be successful in this position. If you work from home, you will need a quiet space that is free of distractions, so that you can focus on your job responsibilities. Background noise should be limited, and you must be able to maintain a space that provides patient confidentiality. You may be required to be in the office occasionally for administrative duties, training, or teambuilding. Schedule: Full Time 37.5 Hours/Week Monday - Friday: 9am - 5pm Rotating Saturday: 8am - 3pm Full Position Salary Range: $ $33.88 / hour - $ $42.92 / hour Starting Pay: Although our full pay range is included above, the budgeted hiring range for this position is $ 33.88 / hour - $ 38.40 / hour Hourly, non-exempt The Objective: To provide educational, supportive, and empathetic patient care and quality assurance as outlined in PPRM Medical Polices. Success: You will know you are successful when all patients who receive follow-up care or telehealth services through the Virtual Care Center (VCC) have their needs met in a patient centered manner and in accordance with PPRM medical policies. Snapshot: Much of your time will be spent on the computer in a virtual environment providing daily expert care to patients receiving abortion, family planning and gender affirming care. You will make outbound and take inbound calls from patients to address their follow-up plans or concerns. Much of your time will be spent using Electronic Health Records, documenting patient interactions and running reports. Some of your time will be spent interacting with team members and collaborating with other departments. You may work from home or the office. You may be required to be in the office occasionally for administrative duties, training, or teambuilding.

Qualifications: You must have active Registered Nurse licensure in Colorado, New Mexico, or Wyoming and must be willing to obtain a license in each state. You are experienced in providing empathetic, patient-centered care. You are experienced in multitasking, meeting deadlines, and prioritizing work independently with little supervision. Previous experience working in reproductive health, abortion care, gender affirming care or family planning preferred. Experienced in delivering sensitive information and education while reducing stigma required. You are detail oriented and skilled in technology and able to efficiently manage multiple competing tasks and priorities. You have strong computer skills and ability to navigate all Microsoft Suite applications. Bilingual (English/Spanish) preferred but not required. If you work from home, you will need a reliable internet connection, quiet space that is free of distractions, so that you can focus on your job responsibilities. Background noise should be limited, and you must be able to maintain a space that provides patient confidentiality Please complete this Pre-Hire VCC RN Skills Self-Assessment along with this application.

Provide Outstanding Patient Care: At its core, your work is about providing care to patients in the highest degree of competence and quality. To do this you will: Triage medical questions and concerns, including providing daytime Call for Abortion patients in accordance with PPRM’s Medical Standards and Guidelines (MS&Gs). As defined by PPRM’s MS&Gs, you will provide patient care, notification, and follow-up of normal and abnormal labs, review the Provider Approval Queue (PAQ) and sign-off or delegate results and create appropriate follow-up plans as needed for laboratory results for the organization. Manage organizational wide results for Pregnancy of Unknown Location and HCG Quants, ensuring accurate and timely follow up with patients. Act as a professional, nonjudgmental source of education to patients by offering information on reproductive, sexual health issues and gender affirming care. Answer patient questions received via the Patient Portal. Provide professional, comprehensive, and non-judgmental virtual medical assessment, evaluation, and advice to patients within PPRM protocols. Provide excellent customer service to both internal and external customers by working towards a positive outcome with any problems encountered. Run reports from the Electronic Health Record (EHR), and document accurately, appropriately, and efficiently all interactions with patients in their medical chart in the EHR and Electronic Plan Management (EPM) systems. Assist with scheduling patient appointments as needed. You will perform mandatory STI reporting to Colorado, New Mexico, and Wyoming State Departments of Health, when indicated. Support Capacity-Building Efforts Internally: You will work to build capacity in others who see patients, serving as a leader with expertise and knowledge that can support others. To do this you will: Maintain an organized tracking system for all on-going follow-up activity. Work with the Patient Care Coordinators to ensure that support staff are following all PPRM policies and procedures and the MS&Gs to ensure timely and accurate follow-up notification. Assist the Quality Management Team with related quality assurance functions such as reporting deficiencies and developing corrective action plans. Engage in continuous learning and stay current on all relevant protocol requirements. Complete all responsibilities according to established protocols, policies and standard practices in the areas of customer service, quality assurance and regulatory compliance programs such as HIPAA (Health Information Portability & Accountability Act), OSHA (Occupational Safety & Health Administration) and CLIA (Clinical Laboratory Improvement Act). Abortion Care: We all work in abortion care, whether it is referrals, information, education, counseling, performing, scheduling, etc. In this role, you will be caring for patients who have or may be seeking abortion care with PPRM.

LTC Ally

Remote Case Manager Coordinator (SNF)

Posted on:

March 18, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Arizona

We are looking for a Registered Nurse Case Manager Coordinator to enhance the quality of patient management, maximize satisfaction and promote cost effectiveness. Case manger will obtain insurance authorization, responsible for facilitating interdisciplinary plans and assuring progress reports are completed and provided to payor as required; Also serves as liaison between care team members, and payor, by coordinating, monitoring, and communicating patient’s progress. Negotiates appropriate level of care within contract terms with the payor case manager. The successful candidate will be accountable for the full patient care cycle in several skilled nursing facilities. Case manager duties include assessing, planning, implementing, monitoring and evaluating actions to ensure all patients are covered financially and clinically throughout the length of their stay.

Skills: Proven working experience in case management or other nursing home/insurance duties, including as a registered nurse, medical, health care manager or a related job in a SNF such as BOM or Admissions Coordinator. Excellent knowledge of case management principles, healthcare management and reimbursement Fast paced environment Effective communication skills Excellent organizational and time management skills Problem solving skills and ability to multi-task SNF: 3 years (Preferred) License/Certification: RN/LPN License (Preferred)

Coordinate and ensure that the SNFs are providing care that is safe, timely, effective, efficient, equitable, and client-centered Facilitate multiple care aspects (case coordination, information sharing, etc.) Help patients make informed decisions by acting as their advocate regarding their clinical status and treatment options Develop effective working relations and cooperate with medical team throughout the entire case management process Act as liaison between nursing homes staff and insurance case managers

Alacura Medical Transportation Management, LLC

Utilization Review Nurse / Nurse Coordinator

Posted on:

March 18, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Compact / Multi-State

POSITION TITLE: Utilization Review Nurse/ Transfer Center Nurse Coordinator Schedule: Full-time, Monday-Friday, 8:00 AM - 5:00 PM or 9:00 AM-6:00 PM Start Date: April 7, 2025 Location: Training is required at our Dallas office; candidates must be located in the area and able to come in for training. After training, this is primarily a work-from-home (WFH) position, contingent on maintaining productivity standards. DEPARTMENT: Utilization Management REPORTS TO: VP of Clinical Operations SUMMARY: Utilization Review Nurse/Transfer Center Nurse Coordinator The Utilization Management (UM) Nurse will collaborate with all stakeholders, utilizing their critical nursing expertise, judgment, and skills to assess the medical appropriateness of ambulance transportation. This includes determining the appropriate level of care and mode of transport. The UM Nurse will conduct utilization management reviews, which involve taking verbal reports over the phone and reviewing clinical documentation.

Minimum Qualifications: Active and unrestricted RN license to practice medicine in Texas (individual must be licensed in the state in which they reside) is required (Compact Licensure acceptable). [1] Managed care experience preferred. 4+ years of clinical practice experience in the areas of either emergency room, ICU, critical care or flight nursing experience sufficient to enable person to make medical judgments as to appropriateness of care and medical necessity.[2] Previous administrative medical experience such as clinical coordination, medical management, utilization review preferred. Demonstrated understanding of the health care delivery system including, but not limited to, familiarity with outpatient, outpatient facility, inpatient care, and ambulance transportation business models including reimbursement. Good communication skills, primarily over the phone in requesting and receiving medical information to determine the medical necessity of ambulance services and levels of care. Demonstrated ability to make evidence based decisions – review past history, benefit information, applicable policies as well as other data to make sound, informed decisions in a timely manner. Computer skills such as a working basic and operational knowledge of Microsoft Outlook and Word. Demonstrated effective written and verbal communication skills with the ability to engage and influence all levels of audiences. RELATIONSHIPS: Interfaces To: Executive staff, employees, vendors, healthcare providers, and customers QUALIFICATIONS: PREFERRED: Education: Bachelor’s degree in Nursing. Master’s degree in healthcare related field (MPH, MHA, MBA) Experience: 4+ years of nursing experience, acute care, ambulance/transport, or managed care preferred Licenses & Certificates: Texas Licensed or Compact State RN, unrestricted licensure. JOB SPECIFICATIONS: Language Skills: Highest Mathematical Skills: Very High Reasoning Ability: Highest PHYSICAL DEMANDS: Physical demands described here are representative of those that must be met by an employee to successfully perform essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions. While performing duties of this job, the employee is frequently required to sit. The employee is occasionally required to stand, walk, climb or balance, stoop, kneel, crouch or crawl, reach with hands and arms, use hands to finger, handle or feel, talk, hear and smell. The employee is required to maintain adequate physical conditioning to be able to perform job duties. Job duties are often performed at high stress levels requiring employee to function effectively and independently while maintaining good working relationships with partners, employees, and customers. The employee may frequently lift and/or move up to 25 pounds and may occasionally lift and/or move between 26-100 pounds. There are no specific vision abilities required to perform this job. WORK ENVIRONMENT: Work environment characteristics described here are representative of those an employee encounters while performing essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions. Employee shall typically be working from a home environment.

UM NURSE COORDINATOR: Receive cases for review within Alacura’s Utilization Management software for identified clients. These cases can be prospective, concurrent, or retrospective in nature. Review of clinical information and medical necessity against evidence-based criteria, and review cases within set timeframes. Receives transfer requests from referring facilities for patients with emergent and urgent medical conditions. Obtains a comprehensive understanding of the patient’s medical condition. Applies approved clinical criteria to evaluate appropriateness of transfer and level of care. Documents findings based on department standards. Assists with clinical aspects of insurance precertification & authorizations for transportation. Assists with logistics involved in transporting patients. Coordinates with the aviation and ground dispatch personnel to identify the most appropriate servicing provider and crew to support the patient’s transport needs and coordinates patient transfer to receiving facility Facilitates all communication between referring and receiving hospitals/physicians in a professional and effective manner. Provides follow-up calls and communications with both internal and external customers to ensure stakeholder’s needs are met. Exemplifies highest level of customer service skills and etiquette with internal and external customers, striving to be friendly and helpful. Distributes surveys to all parties after completion of flight and updates provider database with results. Maintains knowledge base of processes and systems by attending meetings and reviewing training materials and identifies, addresses, and works to resolve system problems impacting transfers. Escalates issues as appropriate to management. Assists with quality assurance (QA), identifying areas where process improvement is needed and helps drive change (i.e. day to day workflow, education, process improvements, customer service, etc.). Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor and resource to less experienced staff. Rotates on-call duties. Other duties as assigned.

Oak Street Health

Call Center Triage Nurse

Posted on:

March 18, 2025

Job Type:

Full-Time

Role Type:

Triage

License:

RN

State License:

Illinois

Oak Street Health is on a mission to “Rebuild healthcare as it should be'', providing personalized primary care for older adults on Medicare, with the goal of keeping patients healthy and living life to the fullest. Our innovative care model is centered right in our patient’s communities, and focused on the quality of care over volume of services. We’re an organization on the move! With over 150 locations and an ambitious growth trajectory, Oak Street Health is attracting and cultivating team members who embody “Oaky” values and passion for our mission.

Company: Oak Street Health Title: Triage Nurse I Location: Downers Grove, Charlotte, Remote Role Description: The Triage RN I effectively extends care during and outside of regular Oak Street Health clinic hours by addressing patients’ medical, social, and psychological needs telephonically.

A minimum tenure of 6 months in the Triage RN I role Consistently demonstrates strong problem-solving abilities, effective communication, and a thorough understanding of customer needs Demonstration of a strong desire to learn and grow in their role Introductory learning of all the skills and working toward meeting “Exceptional” performance metrics for all job skills: Average Unavailable Time Average Handle Time Average Calls per Hour Quality Metrics Care Req Reduction as assigned CET (Clinical Escalation Tracker) Management as assigned Demonstrate proven reliability and satisfactory attendance The progression path from Level I to Level II positions within the Triage RN team is a structured path that encourages nurses to widen their knowledge base, take on more responsibility, demonstrate expertise, and reward team members for their proven success and dedication. Each role level builds upon the skills learned in the previous one, with the ultimate goal of enabling technicians to provide superior support and contribute to the overall success of the contact center. Remote Work Requirements: Proficient PC skills, computer literacy, basic Google Suite skills, and ability to navigate systems Prior remote work experience Ability to obtain high-speed internet and hardwire equipment to router/modem Distraction-free and private remote work environment required as well as reliable dependent care during working hours Ability to provide own transportation for instances where on-site support is required for employees located within 50 miles of a physical OSH location/center https://www.oakstreethealth.com/locations Call center/home office locations: Downers Grove, IL; Chicago, IL; Charlotte, NC Ability to participate in classroom-style remote training sessions An understanding of the high level of conscientiousness, professionalism, and reliability that is required in a remote work environment What are we looking for? Active, non-probationary state Registered Nurse license in all states of OSH practice Proactive maintenance of licenses without prompt or audit Ability to manage time and work autonomously with consistent reliability High-level of conscientiousness Focus on delivering an Unmatched Patient Experience on every call and interaction Motivated to complete all CE (Continuing Education) and licensure requirements without being prompted Ability to work flexible shifts outside of core business hours, such as evenings, weekends, and holidays US work authorization Someone who embodies being “Oaky” What does being “Oaky” look like? Radiating positive energy Assuming good intentions Creating an unmatched patient experience Driving clinical excellence Taking ownership and delivering results Being relentlessly determined

Provide confident and professional service to OSH patients Follow current Prescription Refill policy Remain engaged with patients without background distraction. Clear and precise documentation while on a call Complete documentation for all patient requests prior to ending a call Check the CareReq queue and ensure CareReqs are complete Complete all tasks or requests that are within the scope and ability of the role Schedule appointments for patients that may be off-cadence or are requesting an appointment Arrange transportation for clinic visits Aware of organizational goals and visibly strives to meet departmental metrics Other duties as assigned

IntellaTriage

Remote Hospice Triage RN- PT 1-2 shift 3:30p-9:30p + rotating Sat & Sun 3:30-12a

Posted on:

March 18, 2025

Job Type:

Part-Time

Role Type:

Triage

License:

RN

State License:

Compact / Multi-State

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

We invite you to join our growing team! IntellaTriage Nurses enjoy the benefits of working from home, providing care, without the stress and expense of commuting each day! **MUST have or be willing to obtain a Compact RN license **MUST live in/work from a Compact US state **Experience with end-of-life care is required **Must have high speed internet **Must be tech savvy, enjoy a fast-paced environment, and have keyboard competence **Part-time nurses only work 4 days out of a 14-day pay period Part- time schedule: Work a minimum 1-2 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

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

Partners Health Management

BH Utilization Management Reviewer (Remote Option)

Posted on:

March 18, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

North Carolina

Office Location: Remote option; Available for any of Partners' locations Projected Hiring Range: Depending on Experience Closing Date: Open Until Filled Schedule: First Position: Mon, Tue, Thur, and Fri 7AM-5:30PM; Second Position: Mon - Fri 7AM-3:30PM Primary Purpose of Position: This position will evaluate medical necessity, appropriateness and efficiency of the services requested for authorization against established criteria adopted by the LME/MCO.

Knowledge, Skills and Abilities: Comprehensive knowledge of mental illness and appropriate treatment for major diagnostic categories; behavioral health principles, techniques, and practices, and their application to complex treatment and service provision Considerable knowledge of person-centered and recovery philosophies and interventions Considerable knowledge of assessments and interventions for mental health, developmental disability and substance use disorders; Knowledge of the 1915 (b) (c) waiver Knowledge of psychiatric medications and side effects Knowledge of evidence-based practices Awareness of cultural diversity Excellent computer skills including proficiency in Microsoft Office products (such as Word, Excel, Outlook, etc.) Ability to engage providers in collegial discussions about plans of care and best clinical practices for consumer Ability to establish and maintain effective working relationships with consumers and their families as well as civic, legal, medical, social, and religious stakeholders Ability to express ideas clearly and concisely orally and in writing, and to plan and execute work effectively and efficiently Ability to utilize complex telephone and computer systems, and to read and document information electronically Ability to make prompt decisions based on relevant facts Detail oriented, able to independently organize multiple tasks and priorities, and to effectively manage an assigned caseload under pressure of deadlines Education/Experience Required: A Master’s Degree in a Human Services field with clinical licensure and two (2) years of post-Master’s experience in BH or a Registered Nurse with two (2) years of experience in BH, post RN degree. Must reside in North Carolina. Education/Experience Preferred: Registered Nurse in North Carolina by the N.C. Board of Nursing with experience in psychiatric nursing services. Licensure/Certification Requirements: Current unrestricted license with the appropriate professional board of licensure in the state of North Carolina. Licensed to practice as a Registered Nurse in North Carolina by the N. C. Board of Nursing or Independent License in NC as a LCSW, LCMHC, LPA, LMFT. An Associate license does not meet the requirements. An employee may be dual licensed with one of the specialties listed here can also be licensed as an LCAS. NC DMA contract requirements does not allow for an LCAS to be a standalone license for working in UM. Employee is responsible for complying with respective licensure board’s continuing education/training requirements to maintain an active license.

To respond to all requests for authorizations from the provider community with appropriate authorization decision that is guided by medical necessity and clinical guidelines Services are authorized based on individual need and standardized procedures Review and authorize initial requests, concurrent requests, urgent requests and retrospective requests Consulting with providers regarding authorization requests Consultation with Partners BHM physician regarding requests in which there is a question regarding authorization, enrollee health and safety issues, medication issues, lack of response to services and need for Peer Review when the MHSU Utilization Management Reviewer cannot approve the request for treatment Development of letters that communicate to enrollees and providers the reason for any adverse decision and offers information regarding the options to appeal any adverse decision

Arkansas Blue Cross and Blue Shield

RN Utilization Management- Off Shift

Posted on:

March 18, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Akansas

Applicants must be eligible to begin work on the date of hire. Applicants must be currently authorized to work in the United States on a full-time basis. ARKANSAS BLUE CROSS BLUE SHIELD will NOT sponsor applicants for work visas in this position. Arkansas Blue Cross is only seeking applicants for remote positions from the following states: Arkansas, Florida, Georgia, Illinois, Kansas, Louisiana, Minnesota, Mississippi, Oklahoma, South Carolina, Tennessee, Texas, Virginia and Wisconsin.

The RN Utilization Management Nurse performs clinical review of prior approvals, network exceptions, benefit inquiries, inpatient medical/surgical admissions and outpatient procedures for providers, and all other contracted lines of business. This role assesses and evaluates the efficiency and appropriateness of services for medical necessity through interpretation and review with evidenced-based criteria, clinical guidelines, corporate guidelines and policies and mandates and standards. Incumbent also facilitates and promotes appropriate care and quality toward cost effective and cost containment measures based on evidence. This role is responsible for providing utilization management services over the weekend, outside of normal business week hours.

EDUCATION: Bachelor's degree in Nursing preferred. LICENSING/CERTIFICATION: Registered Nurse (RN) with current active state license in good standing in the state(s) where job duties are performed required. EXPERIENCE: Minimum four (4) years' clinical practice nursing experience consisting of some experience in each of the following areas: medical-surgical nursing, surgical nursing, intensive care or critical care nursing. Experience in utilization management and/or medical review required. Note: Employees meeting these qualifications and accepting this role with this schedule will be provided a $ 5,000 premium added to their base salary. ESSENTIAL SKILLS & ABILITIES: Oral & Written Communication Attention to Detail Proficiency using basic computer skills in Microsoft Office such as Word, Excel, and Outlook, including the ability to navigate multiple systems and keyboarding. Ability to prioritize and make sound nursing judgments through critical thinking. Ability to build collaborative relationships. Skills: Active Listening, Analytical Decision Making, Critical Thinking, Data Analysis, Educational Development, Interpersonal Relationship Management, Microsoft Outlook, Microsoft SharePoint, Microsoft Word, Oral Communications, Problem Sensitivity, Sound Judgment, Team Development, Time Management, Written Communication

Collaborates with healthcare providers and internal staff to promote quality of care, cost effectiveness, accessibility and appropriateness of service levels., Conducts and monitors clinical review cases to ensure medical necessity of inpatient and outpatient services, diagnostic procedures, out-ofnetwork services, and surgery; documenting all relevant and specific information; and screens, prioritizes and organizes determination requests according to mandates and standards., Practices nursing within the scope of licensure and adheres to policies, procedures, regulations, URAC standards and individual state regulations; Making decisions based on facts and evidence to ensure compliance, appropriate level of care, and patient safety., Promotes appropriate care and quality toward cost effective and cost containment measures based on evidence., Provides primary utilization management review and communication for both scheduled workdays during the regular workweek AND scheduled weekend period., Remains current with up-to-date medical and surgical procedures, products, healthcare services and drugs, general trends in health care delivery; and enterprise procedures, policies and contracts., Works incoming and outbound calls and/or queues from multiple sources within mandated requirements proactively and effectively.

Humana

Utilization Management Registered Nurse

Posted on:

March 18, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Compact / Multi-State

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.

Required Qualifications: Active licensed Registered Nurse (RN) in the state of Virginia or obtain a multi-state license in a state that participates in the enhanced licensure, (eNLC) with no disciplinary action. At least 2 years prior clinical experience preferably in an acute care, (Heart, Lung, Critical 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 strong oral, written, and interpersonal communication skills, problem-solving skills, facilitation skills, Ability to work independently under general instructions and with a team Preferred Qualifications: BSN or Bachelor's degree in a related field Previous experience in utilization management Health Plan experience, Medicare/Medicaid 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.

Humana

Utilization Management Behavioral Health Registered Nurse

Posted on:

March 18, 2025

Job Type:

Full-Time

Role Type:

Behavioral Health

License:

RN

State License:

Compact / Multi-State

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

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

Required Qualifications: Active unrestricted registered nurse license in the state of Virginia or obtain a multi-state license in a state that participates in the enhanced compact licensure, (eNLC) Minimum one, (1) year of post-degree clinical experience in private practice or other clinical patient care setting Minimum one, (1) year of managed care experience 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 Strong oral, written, and interpersonal communication skills, problem-solving skills, facilitation skills Preferred Qualifications: Experience with utilization review process Experience with behavioral change, health promotion, coaching and wellness Knowledge of community health and social service agencies and additional community resources

The Utilization Management Behavioral Health 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. Nursing license is required. 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, andrequires minimal direction and receives guidance where needed. Follows established guidelines/procedures.

Apex Health Solutions

UM Reviewer

Posted on:

March 18, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Texas

Apex Health Solutions powers payers and providers choosing to engage in value-based risk contracting. Apex’s unique solutions create alignment between payers and providers, generating unparalleled value. Combined with Apex’s experienced and successful industry leadership, our focal point remains on improvement in patient quality, satisfaction and overall cost of care.

The UM Reviewer serves as a contact and resource person to Health Solutions’ members for the utilization review (UR) of healthcare services. The UM Reviewer will be responsible for complying with utilization review procedures in accordance with Texas UR Certification requirements, as well as carrying out day today pre-authorization functions. The Utilization Review Nurse will also be responsible for issuing pre-authorization approvals/denials, notifying providers/enrollees of denials verbally and in writing. They will also coordinate pending cases for a review determination with Health Solutions Medical Director, coordinate pre-authorization activities with affiliated health plans and interface with network physician office staff when benefit coverage or UR questions or issues arise. To support care management initiatives, the UM Reviewer should also identify enrollees in need of case/disease management services so that proactive interventions can occur.

Education/Licenses/Certifications: Graduate of an accredited school of nursing (Associates of Nursing or Bachelor of Nursing) Licenses/Certifications: Current, unrestricted Texas licensure to practice as a Registered Nurse or Licensed Vocational Nurse required and current unrestricted Certification in Utilization Review/Utilization Management preferred Qualifications: One (1) to two (2) years’ experience in a Managed Care environment performing preauthorization, concurrent review or case management Knowledgeable and compliant with all relevant laws, rules, regulations and accreditation standards and requirements Strong clinical background in nursing Knowledge of insurance terminology Basic knowledge of computer systems Excellent verbal and written communication skills Ability to perform multiple tasks simultaneously, work under pressure, and meet critical deadlines Excellent typing skills Ability to understand and recognize ICD-9/CPT/HCPC coding Ability to work independently, manage time and prioritize projects. Note, there are weekends/holidays included in the schedule

Serves as a resource to the Claims Department in determining the medical necessity of claims submitted by network physicians according to Health Solutions payor’s prospective review criteria and authorization procedures. Coordinates pre-certification activities with contracted health plans and interfaces with providers and/or enrollees when pre-certification issues arise. Educates and affords training to network physicians/office staff on prospective review/precertification requirements. Collects and/or documents all required enrollee clinical and co-morbidity information during the pre-authorization process to support care management initiatives and sound decision-making for review determinations. Utilizes InterQual, Milliman and other Medical Management/health plan endorsed or developed criteria when evaluating cases for pre-authorization; considers special needs and other unique medical needs of enrollees as part of the evaluation process Provides direction and answers phone inquiries from providers and enrollees regarding Health Solutions’ pre-authorization program. Routes provider related UM complaints to the correct department for documentation and investigation when calls are received directly from providers or enrollees. Conducts timely medical necessity reviews of all covered services in accordance with TDI, CMS and other regulatory bodies and adheres to required timelines. Establishes/maintains a good rapport with providers to obtain information necessary for review determinations. Present all cases that do not meet clinical criteria, questionable admissions, and prolonged lengths of stays to the Medical Director for determination. Collect accurate data for system input by using correct coding of diagnoses and/or procedures and utilizing complete and concise documentation of all pertinent information obtained. Assists the Director and Medical Director in identifying additional guidelines or protocols needing either development or refinement in order to support an efficient, effective and quality-oriented pre-authorization process Serves as a liaison with participating hospitals' Case Management staff in order to be apprised of inpatient admission status and care management needs; serves as a resource to the hospital staff by assisting in alternative care placements incompliance to the applicable managed care plan or certified workers’ compensation network benefit coverage requirements Identifies enrollees in need of case/disease management services and makes referrals to Case Management staff Follows other procedures to make appropriate referrals relative to individual cases (Case management, Stop Loss, etc.) Educates providers and other physicians about the Health Solutions case management referral program as potential enrollees are identified via the pre-authorization process. Identifies potential quality of care issues as relates to data collected as part of the preauthorization process; flags cases for review by the Appeals & Outcomes Coordinator Reports potential risk management cases or situations to the Medical Management Manger/Director for immediate intervention or investigation. Tracks enrollee cases for prospective QI study or as needed for reporting, as maybe delegated by the Quality & Outcomes Coordinator. Adheres to and apply all Health Solutions policies, procedures, and guidelines appropriately. Attends all in-service and trainings as required Processes and maintain confidential information according to confidentiality policy. Performs other related duties as requested by Supervisor, Manager, or Director. Achieves an in-depth knowledge of client benefit plans. Maintains a 90% or greater score on the quarterly audit tool and IRR testing Communicate, collaborate and cooperate with internal and external stakeholders. Adheres to all Compliance/Program Integrity requirements. Complies with HIPAA Regulations. Adheres to all company policies, procedures, and standards within budgetary specifications, including time management, supply management, productivity and quality of service. Promotes individual professional growth and development by meeting requirements for mandatory/ continuing education and skills competency; supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor and resource to less experienced staff.

Mission Behavioral Health Hospital

SW, LPN, RN's- Weekend Intake "On Call" Position - fully remote

Posted on:

March 18, 2025

Job Type:

Part-Time

Role Type:

License:

RN

State License:

Indiana

We are seeking a dedicated and detail-oriented individual for the Weekend Intake On Call Position for a 16-bed inpatient older adult psychiatric hospital. This role is fully remote, essential in providing exceptional customer service and administrative support for our Hospital environment. The ideal candidate will be responsible for managing patient intake processes, ensuring accurate admission paperwork, and maintaining excellent customer service. This position will begin on call Fridays at 6:00PM EST through Monday, 8:00AM EST.

Experience: Previous experience in customer service is essential, preferably in a healthcare or hospital setting. Familiarity with medical processes and administrative duties is highly desirable. Experience with health information management systems is a plus. Strong organizational skills and attention to detail are required to manage multiple tasks effectively. Ability to work independently while also being a team player in a fast-paced environment.

Greet patients and families and assist with the intake process, ensuring a welcoming call. Schedule appointment for admission and referral assessment. Manage patient records and maintain confidentiality in accordance with HIPAA regulations. Provide administrative support, including answering phone calls and responding to inquiries. Keeping up with Intake call log. Utilize health information management systems such as indidcated to update patient information accurately. Perform data entry tasks, to ensure all records are up-to-date. Collaborate with clinical staff to facilitate smooth operations within the hospital. Coordinate Hospital transfer to facility. Perform Intake screening tool, review packet of patient information, and review with provider.

Tufts Medicine Integrated Network

Utilization Specialist II

Posted on:

March 17, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Massachusetts

Our Integrated Network brings together a diversity of experienced private practice and employed physicians as well as community and academic providers. While we are one unified network, we focus on different geographic regions, with local care teams convening to ensure healthy, happy neighborhoods throughout the greater Boston region.

Ensures continuous, efficient and smooth flow of communication and administrative support activities for the Utilization and Case Management departments. This position is well versed in insurance coordination, financial counselling, and patient level of care. Interfaces with payers and communicates changes in level of care with the appropriate departments. Responsible for managing all UM clinical documentation. Remote with occasional onsite requirements. Full time 8:30 AM - 5 PM Monday - Friday.

Minimum Qualifications: Bachelor’s degree in Nursing. Massachusetts RN Licensure. Obtain appropriate state board where services will be provided as a registered professional nurse OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC) within three (3) months of hire. Three (3) years hospital/health care experience in the area of Utilization Management. Basic Life Support Certification OR Obtain within three (3) months. Preferred Qualifications: Five (5) years hospital/health care experience in the areas of Utilization Management with acute, subacute, home care, palliative care and hospice experience. Case Management experience. Case Management Certification. Physical Requirements: Professional office environment with typical office requirements such as computers, phones, photocopiers, filing cabinets, etc. This is largely a sedentary role, which involves sitting most of the time, but may involve movements such as walking, standing, reaching, ascending / descending stairs and operate office equipment. Frequently required to speak, hear, communicate and exchange information. Able to see and read computers displays, read fine print, and/or normal type size print and distinguish letters, numbers and symbols. Occasionally lift and/or move up to 25 pounds. Skills & Abilities: Knowledge of hospital and medical terminology and insurances. Familiarity with the target community and feels connected to that community. Excellent relationship management skills, including a high degree of psychological sophistication and non-aggressive assertiveness. Demonstrated ability to problem solve complex, multifaceted, emotionally charged situations. Excellent communication skills (telephonically and face-to-face). Ability to work well with people of various ages, backgrounds, ethnicities, and life experiences. A robust understanding of chronic health condition management and population management. Motivational Interviewing proficiency. Ability to prioritize and resolve critical issues efficiently and effectively. Detail oriented, with strong organizational skills and multi-tasking abilities. Very strong working knowledge and proficiency with technology and business software (Word, Excel, Outlook), e-mail and automated scheduling software and the ability to navigate through hospital-based computer systems. Experience with Electronic Medical Records and possess a willingness and ability to learn and utilize new technology and procedures that will continue to develop in their role and throughout the organization. Ability to work independently with minimal supervision and as part of a team. Strong understanding of and ability to interact with various care settings, including post-acute settings, community-based options, and home care resources. Proficient with InterQual criteria and guidelines.

Manages clinical review process, including collaboration with inpatient and post- acute providers, leads UM meetings with Medical Directors. Authorizes levels of care including Inpatient and SNF. Manages and oversees peer to peer reviews including tracking reviews. Scans all documents for future reference. Coordinates continuity of care by addressing requests for discharge summaries. Whenever possible creates computer files by scanning in lieu of paper files. Provides assistance to case managers as needed. Participates in team meetings and in quality improvement projects. Maintains collaborative, team relationships with peers and colleagues in order to effectively contribute to the working group’s achievement of goals, and to help foster a positive work environment. Attends all necessary meetings.

DocGo

Telehealth Advanced Practice Provider, PA or FNP

Posted on:

March 17, 2025

Job Type:

Full-Time

Role Type:

Telehealth

License:

NP/APP

State License:

New York

DocGo is leading the proactive healthcare revolution with an innovative care delivery platform that includes mobile health services, population health, remote patient monitoring, and ambulance services. DocGo disrupts the traditional four-wall healthcare system by providing high quality, highly affordable care to patients where and when they need it. DocGo's proprietary, AI-powered technology, logistics network, and dedicated field staff of over 5,000 certified health professionals elevate the quality of patient care and drive efficiencies for municipalities, hospital networks, and health insurance providers. With Mobile Health, DocGo empowers the full promise and potential of telehealth by facilitating healthcare treatment, in tandem with a remote physician, in the comfort of a patient's home or workplace. Together with DocGo's integrated Ambulnz medical transport services, DocGo is bridging the gap between physical and virtual care. 

Title: Fully Remote Telehealth PA or FNP – Work from Anywhere/Flexible/No Commute Location:  Remote NY, Must have NY license Employment Type: Per-Diem Compensation: $75/Hour for Virtual Projects

Maintain all paperwork and medical licenses as required for medical malpractice insurance coverage. Complete and/or provide any and all paperwork, onboarding materials and or screenings, including for background and sanction screenings prior to the commencement date of your performance of work under this Agreement as requested by Corporation. Immediately inform the Corporation of any medical malpractice litigation or restrictions on driver’s license or ability to operate a vehicle. Establish a collaborative/supervisory practice agreement based on state and licensure requirements. Must be licensed in the state(s) that you will be providing medical care under this Agreement. Must hold active Board Certification.

Provide professional and competent medical care to patients assigned by Corporation within Independent Contractor’s scope of licensure to patients using best practices and otherwise consistent with applicable law, regulations, and Corporation policies. Participate in professional activities including development of a clinical ladder and future APP Corporation councils. Maintain professional interaction(s) with medical staff, including other physicians, nurses, EMTs, paramedics, and first responders at all events and sites. An essential element of the role is the ability to meet the patient’s medical and psychosocial needs. Demonstrate passion for the purpose of serving underrepresented populations. Each day, you will maintain patient medical records and medical documentation consistent with state regulations, Corporation standards, and policy through our HealthPoint system as well as Athena EMR System Participate in continuing education as required by the state where you are licensed Prescribe medication as permitted by your state prescribing authority. Interview and examine patients to formulate a diagnosis. Order tests to assess the nature and extent of illnesses and injuries. Suggest lifestyle changes to remedy medical problems. Identify the appropriate treatment of wounds and be able to recognize and treat orthopedic injuries with proper referrals as needed. Diagnose and prescribe appropriate anti-infectives as per the most up-to-date guidelines and Corporation’s policy. Order and evaluate the need to administer vaccines to eligible patients. Provide care with cultural sensitivity and compassion while prioritizing customer service. Such other duties and responsibilities may be determined by the Corporation.

HCA Healthcare

Infection Data Abstractor

Posted on:

March 17, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Tennessee

Experience the HCA Healthcare difference where colleagues are trusted, valued members of our healthcare team. Grow your career with an organization committed to delivering respectful, compassionate care, and where the unique and intrinsic worth of each individual is recognized. Submit your application for our Infection Data Abstractor opening with Work from Home today and find out what it truly means to be a part of the HCA Healthcare team.

We are seeking an Infection Data Abstractor for our team to ensure that we continue to provide all patients with high quality, efficient care. Did you get into our industry for these reasons? We are an amazing team that works hard to support each other and are seeking a phenomenal addition like you who feels patient care is as meaningful as we do. We want you to apply! Job Summary and Qualifications As an Infection Data Abstractor II, you will be responsible for abstraction of infectious disease data.

Undergraduate (Associate or Bachelor) degree in a healthcare related field required. Extensive experience (5 years or more) may be considered in lieu of formal education. Completion of a certified coding or nursing program preferred 1-3 years in Health Information Management; Coding, Nursing, and/or Health Registry abstraction experience required RHIT, RHIA, CCS, LVN or RN preferred

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 instructions to abstract all reportable cases. Assist with case follow-up as requested. Attend educational activities as approved by Manager 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.

CVS Health

Transition of Care Associate (Must reside in New Jersey or New York)

Posted on:

March 17, 2025

Job Type:

Full-Time

Role Type:

Coaching

License:

LPN/LVN

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.

Help us elevate our member care to a whole new level! Join our Aetna Team as an industry leader in serving dual eligible populations by utilizing best-in-class operating and clinical models. You can have life-changing impact on our members, who are enrolled in Care Management and present with a wide range of complex health and social challenges. With compassionate attention and excellent communication, we collaborate with members, providers, and community organizations to address the full continuum of our members' health care and social determinant needs. Join us in this exciting opportunity as we grow and expand our Care Management Programs to change lives in new markets across the country. The Transition of Care Coach is responsible for care coordination of our members who are experiencing a significant change in health status which has resulted in the necessity of an emergency department visit, inpatient, skilled nursing, or rehabilitative stay.

Required Qualifications: This position is a REMOTE position but the candidate must reside in either New Jersey Compact or New York 2+ years LPN nursing experience Self-motivated, energetic, detail-oriented, highly organized, tech-savvy Licensed Practical Nurses Discharge planning Advanced proficiency in Microsoft Word, Excel, and Outlook Ability to multitask, prioritize, and effectively adapt to a fast-paced changing environment while providing outstanding care Effective verbal and written communication skills Preferred Qualifications: Bilingual (English and Spanish) Education: High School Diploma/GED or equivalent experience (REQUIRED) Licensed Practical Nurse (LPN) (REQUIRED) Associate's Degree or Bachelor's Degree (PREFERRED)

Under the direction of a Registered/Licensed RN, the TOC Coach ensures the member experiences a seamless transition to their next care setting and facilitates post-discharge goal attainment by: Complete post-discharge questionnaire, which may be market specific. Ensures the member has filled/received their medication(s) and has an understanding on how to take their ordered medications. Benefit education Monitor members in low CM level for alerts or changes in condition to be transitioned back to RN. Complete post discharge call and required assessments (RAP), medication reconciliation (if within scope of practice), fall assessment if fall risk identified. Complete inpatient confinement calls and monitoring for discharge. Management of warm transfers form concierge and engagement hub Provides clinical assistance to determine appropriate services and supports due to member’s health needs (including but not limited to: Coordination with PCP and Specialty providers, Condition Management information and education, Medication management, Community Resources and supports) Evaluation of health and social indicators Identifies and engages barriers to achieving optimal member health. Uses discretion to apply strategies to reduce member risk. Facilitates overall care coordination with the care team to ensure member achieves optimal wellness within the confines of the member’s condition(s) and abilities to self-manage. Coordinates post-discharge meal delivery, assists with securing DME, and helps to ensure timely physician follow-up. Understands Payer/Plan benefits, policies, procedures, and can articulate them effectively to providers, members, and other key personnel. Our TOC Coaches are frontline advocates for members who cannot advocate for themselves. The TOC team will review prior claims to address potential impact on current case management and eligibility status. Focus assessments and/or questionnaires are designed to use a holistic approach to identify the need for a referral to clinical resources for assistance in functionality. Job Responsibilities: Responsible for completing outreach cadence calls and post-discharge questionnaires within required compliance driven timelines. Utilizes weekly and daily reporting to identify utilization for the purpose of reducing Emergency Department Utilization and 30-day hospital readmissions. Follows members identified as inpatient in hospitals (whether planned or unplanned admission) and then throughout the subsequent care continuum until member can return to prior level of functioning in the community. Facilitates Interdisciplinary Care Team Meetings with Social Services, Care Management, PCP and other key players to discuss service needs and support safe transitions.

Osara Health

Health Coach

Posted on:

March 17, 2025

Job Type:

Full-Time

Role Type:

Coaching

License:

None Required

State License:

New York

Osara Health’s mission is to transform cancer care by empowering people and organisations affected by cancer to thrive, using expertise, empathy and technology. By combining digital tools, dedicated health coaching and evidence-based educational resources, we give people impacted by cancer the opportunity to feel supported, informed and in control. We work with insurers and employers to make our programs available to their members and employees.

Location: Remote (United States) Language requirement: Fluency in English and Spanish Position type: 2 days per week initially – will increase to 3 days p/w over time Application: Please submit your application through this link: https://airtable.com/appA43kEgq1AtitKd/shrsTdnkV7bxu87xo Salary: $24-35 p/h Osara Health’s coaches help empower individuals who have been diagnosed with cancer, or those who are caregivers of those with cancer, to engage in behaviours proven by clinical evidence to improve their clinical outcomes – for example exercise, diet, or symptom tracking. Our coaches use empathy and accountability to help participants develop and work towards health goals. Their role is to ask questions, provide actionable suggestions and practical tools to assist patients and caregivers to take back control of their health. An Osara health coach’s primary function is to take our participants, from various customer types, through our Osara programs via email, calls and SMS.

Educational Requirements: Healthcare background in the US Fluency in English and Spanish required A relevant qualification and/or 1 – 3 years previous experience in healthcare ie nursing, allied, public health. And/or, previous health coaching training/experience Essential Skills: Strong interpersonal and communication skills to help build strong relationships with participants Works well in teams Empathy, patience, compassion and positive attitude Proactive with their work Strong computer/IT skills, comfortable working remotely Desirable Skills: Health coaching accreditation Previous health coaching training/experience Experience of oncology in Canada

Program phone calls covering the core elements of holistic cancer support (for both patients and caregivers) Communicate via SMS and email to provide follow-up support and schedule calls Work with the product team to improve program offerings and coaching processes Call people with a cancer diagnosis to assist with enrolling them onto the program

Long Tail Health Solutions Inc.

Manager, Utilization Review

Posted on:

March 17, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Illinois

Long Tail Health Solutions is a provider advocate, delivering a suite of technology-enabled services which discover and operationalize payer rules and behaviors to improve the visibility, execution, and outcomes of utilization review, case management, and revenue cycle functions. Our mission is to optimize the financial performance and work-lives of healthcare providers by eliminating administrative waste with modern technology applied to long tail problems.

Manages and provides oversight for the concurrent utilization review process and coordination of responses to all requests and regulatory requirements for commercial payors, the Centers for Medicare and Medicaid Services (CMS), audit and denial programs. A 100% remote work force will require very strong communication and remote relationship building skills.

Bachelor’s degree in healthcare related field; Master’s degree preferred 3-5 years of progressive experience in healthcare leadership 3 years of utilization review, denial recovery or case management experience Clinical practice experience with healthcare licensure preferred (i.e. RN, PT, OT, LSW, LCSW, RPH) ACM or CCM certification preferred Knowledge: Knowledge of hospital revenue cycle and utilization review Proficient with principles of all payer types including managed care, Medicare/Medicaid, and private insurer reimbursement rules Knowledge of medical necessity criteria and payer reimbursement arrangements Skills Project management to ensure budgetary constraints and plan deadlines are met timely. Ability to oversee team and guide them to successful outcomes with work consistency, process improvement changes, and efficiency optimization. Advanced problem solving to address complex cases, reimbursement trends and quality assurance. Customer service for providing solutions to payers, patients, clients and team members. Organizational skills to manage multiple tasks balancing team’s strength to match department’s workload. Interpersonal skills to help interact and work with team and clients effectively. Critical thinking to optimize day to day assignments, make necessary decisions on high risk/high dollar cases and respond appropriately to demanding client and payer needs.

Interviews, hires, orients, trains, develops and evaluates the performance of and, when necessary, disciplines and/or discharges department personnel. Provides direction, as necessary, to staff regarding sensitive and/or complex work, related problems, resolves complaints and response to inquiries regarding department operations. Provides ongoing education and coaching of department staff Maintains a working knowledge of all current best practices for commercial and governmental payer denials management. Disseminates current regulatory and payer trending information as formal education to appropriate staff. Evaluates team member comprehension and understanding of education. Orchestrates performance of concurrent clinical reviews for utilization review using appropriate screening criteria completes necessary review as identified and required by payers until patient discharge. Reviews must be thorough and complete on a timely basis. Communicates with team members including physicians, RN's, utilization review staff, case managers, social workers, and other applicable interdisciplinary team members regarding utilization issues. Continual tracking of in-house patient statuses and communicates with appropriate team members including you our staff and third parties regarding status issues. Orchestrate continual reviews of in-house observation patients. Create pathways for utilization review team to identify and tracks avoidable days and care optimization opportunities. Evaluate information gathered by team and identify trends and utilization management opportunities. Work with inpatient care coordination team to help identify and reinforce proper utilization management of patients. Develops and monitors concurrent review process for accuracy and quality. Ensures all days are approved appropriately before billing. Ensure compliance with federal state and 3rd party utilization management regulatory requirements. Leads and assists the utilization review staff to overturn denials concurrently. Provides oversight and assistance staff in the investigation of denials received for lack of medical necessity, continued stay, precertification through review of medical record, physician communication, and internal department communication. Provides guidance and support for the staff with writing appeals and commercial payers. Educate departments in which billing, and charge errors occur. Participates in hospital utilization review committees. Monitors and tracks the volumes of referrals sent to physician advisor services, concurrent and retrospective denials, and performance on overturn/success rates. Ensures all cases include documentation to prove necessary regulatory and/or payer specific guidelines have been followed prior to billing so that to be readily available in the event of an audit and/or denial of payment.

UnitedHealth Group

Field Assessment Nurse in Queens, NY – Sign On Bonus for External Candidates

Posted on:

March 17, 2025

Job Type:

Full-Time

Role Type:

Behavioral Health

License:

RN

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. You push yourself to reach higher and go further. Because for you, it’s all about ensuring a positive outcome for patients. In this role, you’ll work in the field and coordinate the long-term care needs for patients in the local community. And at every turn, you’ll have the support of an elite and dynamic team. Join UnitedHealth Group and our family of businesses and you will use your diverse knowledge and experience to make health care work better for our patients.

$5,000 Sign On Bonus For External Candidates This is a full time opportunity – Monday through Friday – 8:30 am to 5:00pm EST In this Field RN role, you will be an essential element of an Integrated Care Model by relaying the pertinent information about the member needs and advocating. If you are located in New York City, NY, you will have the flexibility to work remotely* as you take on some tough challenges. You will be expected to travel within Queens, NY.

Required Qualifications: Current, unrestricted, independent licensure as a Registered Nurse 2+ years of relevant clinical work experience 1+ years of community case management experience coordinating care for individuals with complex needs Demonstrated knowledge of home health, hospice, public health or assisted living Proficiency with MS Word, Excel, and Outlook Willing or ability to travel in assigned region to visit Medicaid members in their homes and/or other settings, including community centers, hospitals, or providers’ offices New York state issued ID or ability to obtain one prior to hire Reside in New York City, NY Preferred Qualifications: Behavioral health or clinical degree Experience with electronic charting Experience with arranging community resources Field-based work experience Background in managing populations with complex medical or behavioral needs Proficient in use of UASNY

Assess, plan, and implement care strategies that are individualized by patient and directed toward the most appropriate, least restrictive level of care Utilize the NYS UAS Assessment as needed in the home or via telehealth to develop a person center service plan to meet the member’s needs Identify and initiate referrals for social service programs, including financial, psychosocial, community and state supportive services Manage the care plan throughout the continuum of care as a single point of contact Communicate with all stakeholders the required health-related information to ensure quality coordinated care and services are provided expeditiously to all members Advocate for patients and families as needed to ensure the patient’s needs and choices are fully represented and supported by the health care team

Anchored Health

Chronic Care Management Coordinator - RN/LPN/MA

Posted on:

March 17, 2025

Job Type:

Contract

Role Type:

Telehealth

License:

RN

State License:

Louisiana

Care Coordinator – Chronic Care Management (RN, LPN, or Medical Assistant) Location: Remote Position Type: Hourly Job Description: We are hiring a compassionate and detail-oriented Care Coordinator focused on Chronic Care Management. Open to RNs, LPNs, or Medical Assistants, this position ensures seamless care for patients managing chronic health conditions. You'll coordinate comprehensive care plans, educate patients, and collaborate with healthcare teams to enhance patient well-being.

Valid RN, LPN, or Medical Assistant certification/licensure. Minimum 2 years clinical or care coordination experience. Excellent organizational and communication skills. Familiarity with electronic health records (EHR).

Develop and implement individualized chronic care plans. Educate patients and families about managing chronic conditions. Facilitate communication among healthcare providers. Track patient progress and adjust care plans accordingly.

HCA Florida South Tampa Hospital

Trauma Data Abstractor

Posted on:

March 17, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Florida

Experience the HCA Healthcare difference where colleagues are trusted, valued members of our healthcare team. Grow your career with an organization committed to delivering respectful, compassionate care, and where the unique and intrinsic worth of each individual is recognized. Submit your application for our Trauma Data Abstractor opening with Parallon today and find out what it truly means to be a part of the HCA Healthcare team.

We are seeking a Trauma Data Abstractor for our team to ensure that we continue to provide all patients with high quality, efficient care. Did you get into our industry for these reasons? We are an amazing team that works hard to support each other and are seeking a phenomenal addition like you who feels patient care is as meaningful as we do. We want you to apply! Job Summary and Qualifications As a Trauma Data Abstractor, you will be responsible for abstraction of data for injured patients. You contribute to our success. Every role has an impact on our patients’ lives and you have the opportunity to make a difference. We are looking for dedicated professionals like you to be a part of our Data Abstraction team. Join us in our efforts to better our community!

High School education/GED required Undergraduate (Associate or Bachelor) degree or successful completion of a certified coding program preferred Trauma Abstracting experience preferred 1 year in Health Information Management; Coding, Nursing, and/or Health Registry abstraction experience preferred. Certificate/License: RHIA, RHIT, CSS, LVN or RN preferred

Complete abstraction process for the assigned facility/facilities, including abstraction of cases into the required system (e.g Traumabase, Digital Innovations, TraumaOne, or Imagetrend) Review medical records to abstract information according to the standards of various regulatory and accreditation agencies (e.g., ACS, NTDB, TQIP, and state regulations.). Submit data timely through the appropriate reporting system. Resolve errors resulting in the rejection of records from the data entry system.

Capital Blue Cross

Utilization Management Clinician - CCR/BH

Posted on:

March 17, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Pennsylvania

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a diverse and caring team of supportive colleagues, and be encouraged to volunteer in your community. We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live. Capital Blue Cross is an independent licensee of the Blue Cross Blue Shield Association. We are an equal opportunity/affirmative action employer and do not discriminate on the basis of race, color, religion, national origin, gender, sexual orientation, gender identity, age, genetic information, physical or mental disability, veteran status, or marital status, or any other status protected by applicable law.

Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more. At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.” This licensed clinical position is part of the Utilization Management department and is responsible for processing acute and post-acute inpatient and select outpatient higher level of care requests through clinical review and the application of approved medical necessity criteria. Collaboration within and across departments and operating professionally and efficiently within the framework of established policies and procedures is essential.

Skills: Communication, technical, analytical, organizational, and other unique skills required to succeed in the position. Demonstrated ability to critically think through processes to make clinically appropriate decisions and problem solve. Demonstrated ability to prioritize multiple clinical and administrative tasks and assignments. Demonstrated ability to work independently and as part of a team. Demonstrated ability to interact with other departments actively and proactively, as needed, to advise, educate, and/or direct members to other clinical programs and services. Demonstrates openness, flexibility, problem solving, patience, and tact when interacting with members, family, providers, and peers. Demonstrated ability to communicate in a concise and clear manner in both written and oral communications. Knowledge: Working knowledge and operation of a personal computer, including proficiency in Microsoft Office applications. Knowledge of medical coding guidelines, including ICD-10-CD, CPT, and HCPCS codes. Working knowledge of National Committee for Quality Assurance (NCQA), CMS, and other health plan UM regulations. Extensive knowledge of managed care principles and emerging health treatment modalities. Experience: A minimum 5 years’ experience working in a higher level of care clinical role including acute care hospital, post-acute care facility, residential treatment center, etc. required. 1 year UM experience in managed care required. Education and Certifications: Must have active current and unrestricted master’s level Behavioral Health clinical license in the state of Pennsylvania (LMSW, LCSW, LISW, LPC, or comparable) or Registered Nurse licensure in Pennsylvania. Certified Case Manager (CCM) or Accredited Case Manager (ACM) required.

Processes acute and post-acute inpatient medical or behavioral health and select intensive outpatient higher level of care requests through review of the submitted request and applicable clinical records and applying approved medical necessity criteria to determine medical necessity and appropriateness of the service requested. Interprets and applies InterQual criteria, CMS-issued guidelines, Capital Blue Cross Medical Policies, the CHIP handbook, FEP Medical Policies, the FEP Benefit Brochure, and/or American Society of Addiction Medicine ASAM) guidelines to these requests as applicable to the member’s product. Performs high acuity of care UM case reviews within the framework of applicable regulatory requirements and established policies and procedures of Capital’s UM department. Complies with both internal policies and all regulatory requirements regarding member’s confidentiality. Collaborates with UM department staff, including Clinical Support Specialists and Medical Directors to make a final determination, and with Care Management staff on discharge planning and transition of care activities. Participates in weekly clinical rounds to discuss complex members as needed and requested. Identifies and refers members with complex needs to the appropriate population health and/or care management program. Identifies and refers members with Potential Quality Issues (PQIs) through established processes to the applicable department for further review and investigation. Offers suggestions for improvement in departmental processes and identifies opportunities for learning and education. Attends and participates in company and departmental meetings and training sessions as required and requested. Practices within the scope of clinical license and/or certification.

WellSense Health Plan

Inpatient Utilization Management Clinician

Posted on:

March 16, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Compact / Multi-State

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members.

Remote • ID: 2015497 Full-Time/Regular It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances. Job Summary: The Inpatient Utilization Management Clinician is responsible for evaluating all inpatient medical treatments for medical necessity, monitoring ongoing treatment, facilitating discharge planning to ensure smooth and successful transitions of care, and collaborating with care management and medical directors to support members in achieving optimal health outcomes. WORK SCHEDULE WILL BE MONDAY - FRIDAY

Qualifications: Active, unrestricted RN license in state of residence. Education: Nursing degree or diploma required, bachelor’s degree in nursing Preferred/Desirable: Bachelor’s degree RN license in state of MA, NH or compact license Medicare and Medicaid knowledge Experience: 2+ years utilization review experience and evidence-based guidelines (InterQual Guidelines) Managed care experience Experience performing discharge planning All employees working remotely will be required to adhere to Wellenses’ Telecommuter Policy Licensure, Certification or Conditions of Employment: Active, unrestricted RN license in state of residence Pre-employment background check Ability to take after hours call, including evening/nights/weekends Competencies, Skills, and Attributes: Strong oral and. written communication skills. Strong clinical judgement and critical thinking skills to assess complex cases and determine appropriate levels of care. Excellent communication and interpersonal skills to engage effectively with internal and external stakeholders Ability to work independently in a remote environment while maintaining adherence to timeliness and regulatory requirements. Proficiency in Microsoft Office applications and data management systems. Demonstrated organizational and time management skills Strong analytical and clinical problem-solving abilities with focus on quality improvement initiatives Working Conditions and Physical Effort: Fully remote position with possible travel to the Charlestown, MA office for team meetings and training sessions. Fast paced and dynamic work environment requiring adaptability and focus. Minimal physical effort required; primarily desk-based tasks such as documentation and virtual meetings. Regular and reliable attendance is essential.

Performs utilization review activities, including concurrent, and retrospective reviews of inpatient cases applying evidenced-based InterQual® criteria and Medical Policy. Obtains clinical information using facility EMR, where accessible, to assess and expedite timely decisions. Determines medical appropriateness of inpatient services following evaluation of medical and contractual guidelines. Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services. Reviews, documents, and communicates all utilization review activities and outcomes including, but not limited to, all inquiries made and received regarding case communication. Refers cases to Physician Reviewer when the treatment request does not meet medical necessity per guidelines, or when guidelines are not available. Referrals must be made in a timely manner, allowing the Physician Reviewer time to make appropriate contact with the requesting provider in accordance with departmental policy and within each Medicaid, ACA, CMS or NCQA mandated turnaround times (TAT). Monitors inpatient cases for compliance with contractual obligations and regulatory requirements, ensuring timely reviews and authorizations. Demonstrates strong interpersonal and communication skills when conducting reviews, interacting with physicians and staff, and ensures compliance with training on related policies and procedures. Sends appropriate system-generated letters to provider and member Provides guidance and coaching to other utilization review nurses and participate in the orientation of newly hired utilization nurses Participates in discussions with the facility discharge planning team to improve the progression of care to the most appropriate level of care. Identify delays in care or services and manage with MD. Consults with the Medical Director, as needed, for complex cases. Follows all departmental policies and workflows in end-to-end management of cases. Participates in team meetings, education, discussions, and related activities Maintains compliance with Federal, State and accreditation organizations. Identifies opportunities for improved communication or processes May participate in audit activities and meetings Documents rate negotiation accurately for proper claims adjudication Identify and refer potential cases to Care Management Performs all other related duties as assigned

Asante Health System

Utilization Review RN ARRMC (Case Management)

Posted on:

March 16, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

Oregon

At Asante, we are guided by our values below. Explore Asante more by visiting www.asante.org/careers Excellence - Respect - Honesty - Service - Teamwork

Utilization Review RN ARRMC (Case Management) Additional Position Details: FTE: 0.900000 | Full Time | Variable Hours/Variable Days Salary: Starting at $45.26 an hour and increases are based on qualifications and years of experience in the field. Plus, you will earn extra shift differentials for weekend hours: $2.20 extra for working weekends PLEASE NOTE: This position may be remote. Candidates will be required to have reliable broadband internet and personal cell phone service. Remote work may include working day-to-day operations during Pacific Standard business hours or online training. Position Summary The Utilization Review Nurse monitors utilization practices from preadmission to discharge to assure cost-effective, quality patient care and to ensure that patient, physician, and hospital/system receive maximum benefits from the health plan. Also ensures compliance with all regulatory requirements involved in the continuum of care.

Qualifications: 2 recent years of progressive nursing experience in an acute care setting preferably within discharge, utilization and/or case management or equivalent combination of education and/or experience RN: Registered Nurse licensed by Oregon State Board of Nursing is required upon start Preferred Qualifications: Bachelor's degree in nursing CCM: Certified Case Manager ACM: Accredited Case Manager

Receiving and disseminating information related to system, departmental, and patient processes Participating in data collection activities to support departmental programs and services Monitoring and reporting on patient outcomes and actively working with other members of the interdisciplinary team to facilitate improved delivery of cost-effective services Conducting utilization review, evaluating clinical information, and communicating findings to payors within the framework of contractual and government regulations Reviewing all admissions for appropriate inpatient vs. outpatient / observation status

Asante Health System

Supv Utilization Review (Case Management)

Posted on:

March 16, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

Oregon

At Asante, we are guided by our values below. Explore Asante more by visiting www.asante.org/careers Excellence - Respect - Honesty - Service - Teamwork

Supv Utilization Review (Case Management) Additional Position Details: FTE: 1.000000 | Full Time | Primarily Mon - Fri / 8AM - 5PM PLEASE NOTE: This position may be remote. Candidates will be required to have reliable broadband internet and personal cell phone service. Remote work may include working day-to-day operations during Pacific Standard business hours or online training.

Experience: A minimum of 2 years of demonstrated leadership in utilization review/clinical documentation integrity within a health care environment, with emphasis on community health resources and program development is required An additional 2 years of nursing experience in clinical practice areas such as acute care hospital, physician clinics, quality, case management, performance improvement, informatics is required Education: Bachelor's degree in nursing, or equivalent education and experience is preferred Required Certification/Licensure RN: Registered Nurse (RN) by the Oregon State Board of Nursing or Allied Health Provider Preferred Certifications/Licensures CCM: Certified Case Manager (CCM) or ACM: Accredited Case Manager (ACM) CCS: Certified Coding Specialist (AHIMA) CPC: Certified Professional Coder (AAPC) CCS-P: Certified Coding Specialist - Physician Based (AHIMA) CRC: Certified Risk Adjustment Coder (AAPC)

The Supervisor of Utilization Review is responsible for overseeing the daily operations of the utilization review team, ensuring compliance with payer guidelines, optimizing resource utilization, and facilitating appropriate patient care decisions. This role provides leadership, training, and guidance to UR staff while collaborating with clinical teams, revenue cycle, and payer representatives to minimize denials and improve reimbursement outcomes.

Performant Financial Corporation

Medical Review Nurse II - SNF/MDS

Posted on:

March 16, 2025

Job Type:

Full-Time

Role Type:

Utilization Review

License:

RN

State License:

California

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

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

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

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

LEGACY HEALTHCARE CONSULTING LLC

Clinical Documentation Integrity Specialist

Posted on:

March 16, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

Wisconsin

We seek a dedicated and detail-oriented Clinical Documentation Improvement Specialist to join our healthcare team. This role is essential in ensuring the accuracy and completeness of clinical documentation, which is vital for patient care, compliance, and reimbursement. The ideal candidate will have a strong background in medical coding and health information management, particularly in inpatient and outpatient settings.

Educational Qualification: Must either be a Registered Nurse or a Graduate Physician CCDS-0 or CCDS is a huge plus. Coding and Billing certification is a plus. Skills: Proficient in medical coding with a strong understanding of standards related to outpatient and inpatient care. Knowledge of clinical documentation requirements required for appropriate billing and coding. Strong analytical skills to assess medical documentation for accuracy and completeness. Excellent communication skills to effectively collaborate with healthcare providers. Ability to work independently as well as part of a multidisciplinary team. Experience in health information management is preferred.

Review clinical documentation to accurately reflect the patient's condition and treatment. Collaborate with healthcare providers to clarify and improve documentation practices. Utilize coding standards such as ICD-10, CPT, HCPCS to ensure compliance with regulatory requirements. Conduct audits of medical records to identify areas for improvement in documentation. Provide education and training to clinical staff and health care providers on best practices for documentation. Stay updated on changes in coding regulations and standards that impact clinical documentation. Support the transition of documentation practices in various care settings, including primary care, specialty practices, home health, and hospice.

Children's Nebraska

Clinical Systems Analyst I

Posted on:

March 16, 2025

Job Type:

Full-Time

Role Type:

Informatics

License:

RN

State License:

Compact / Multi-State

At Children’s, the region’s only full-service pediatric healthcare center, our people make us the very best for kids. Come cultivate your passion, purpose and professional development in an environment of excellence and inclusion, where team members are supported and deeply valued. Opportunities for career growth abound as we grow our services and spaces, including the cutting-edge Hubbard Center for Children. Join our highly engaged, caring team—and join us in providing brighter, healthier tomorrows for the children we serve. Children's is committed to diversity and inclusion. We are an equal opportunity employer including veterans and people with disabilities.

Skills or Traits desired: Epic Accredited or Certified in any of the following: EpicCare Ambulatory MyChart Healthy Planet Note – this position can be a remote opportunity only for those residing in the following states that Children’s is established in: Nebraska (preferred), Iowa, Idaho, Georgia, Kansas, Missouri, North Carolina, or Tennessee. We are unable to accept candidates requiring visa sponsorships, including OPT, for this position. Applicants must have authorization to work in the United States without the need for current or future visa sponsorship. A Brief Overview Design, test, implement and maintain hospital and/or outpatient clinical IT applications. Researches and corrects system and user problems. Works with various primary care clinics, specialty departments, ancillary or inpatient units to support practice and implement changes as needed to the existing systems.

Education Qualifications: Associate's Degree from an accredited college or university in Information Technology, medical profession, or related field Required or Experience may be substituted for education. Required Bachelor's Degree Preferred Experience Qualifications: Minimum 2 years experience in Information Technology or healthcare field Preferred and Previous Epic clinical application experience Preferred and Previous systems super user and/or trainer experience Preferred Licenses and Certifications: Incumbents with a professional license must possess and maintain a current/valid license in the state of Nebraska or compact state license (i.e. RN, RT, MA etc.). Required and Must obtain EPIC certification within 9 months of hire and maintain the certification(s) for duration of employment in IT. Required Work after hours and on weekends as needed is an expectation of the job. Required

Analyze, design, configure, test and maintain Children’s Hospital & Medical Center’s clinical applications to accomplish the department goals and meet the needs of the end-users. Research, analyze and correct system and user problems in a timely manner. Actively and accurately maintain documentation of issues, resolutions and build documentation as outlined by department policies. Build and maintain positive relationships with customers through effective and consistent communication. Participate on project teams working with individual departments to define requirements for changing new & existing systems. Works with the team to define process flows & make recommendations for the most efficient utilization of applications. Analyze and translate workflow requirements into efficient/effective application solutions. Perform integrated testing of current and new vendor functionality to ensure reliability and integrity of the EMR. Assists with end-user training and development as needed Participates in on-call and monthly maintenance activities. Regular attendance at work is an essential function of the job. Perform physical requirements as described in the Physical Requirements section

Activa Home Health

Per Diem Medicare Home Health Registered Nurse for BROWARD COUNTY

Posted on:

March 16, 2025

Job Type:

Part-Time

Role Type:

License:

RN

State License:

Florida

Activa Home Health (an AccordCare Company) is a licensed Medicare certified home health agency seeking experienced field RNS for part-time work. A better quality of care comes from exceptional caregivers and Activa only hires the best! Activa is an employee-friendly company and we focus on our employees to ensure they have a healthy work and life balance. Our employees become our family, and through excellent training and support, they are ready to serve our patients.

Field RN Home Health Visits RN Part-Time / Per Visit Rates starting at $45 Potential transition to Full Time after 90 days . RN must live in Broward County and the surrounding areas. The RN will work to provide the highest quality of care to patients utilizing the Plan of Care provided to ensure patient's needs are met in relation to safety, well-being and satisfaction. WellSky/Kinnser & Home Health experience is a plus.

Current RN license, state of Florida 2 years of Home Health OASIS experience EMR experience, wellsky experience preferred Possess wound care and infusion skills Excellent communication skills; team player; interpersonal skills; good collaboration skills; customer service skills; ability to use the electronic health record for documentation and communication regarding client care. Required 2 years: Home Health Licenses & Certifications Required: CPR Registered Nurse License

Will be supervised by an RN Provides safe and effective care for the client based on individualized Plan of Care. Provides prompt communication of changes in patient medical status/emergencies to Team resulting in effective management of cases. Provides safe and effective nursing for the patient, based on the nursing scope of practice and individualized Plan of Care in conjunction with Nurse Supervisor/Manager of Clinical Practice. May include, but not limited to, medication administration, wound care, infusion, transferring & positioning patient, catheter care, effective communication with the client, family, and Team Case Manager Demonstrate empathy, caring and self-confidence; ability to pay attention to details resulting in thorough follow through; anticipate problems in advance and knows whether to diffuse or escalate; prioritize and demonstrate a sense of urgency.

Molina Healthcare

Registered Nurse Case Manager DSNP, LTSS Remote in NY, NJ or CT

Posted on:

March 16, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

New York

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

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. This position will be supporting our Senior Whole Health NY DSNP program. We are seeking a Registered Nurse with previous Case Management, DSNP, or LTSS experience. The candidate must be empathetic, provide great service to our member, and must be able to work independently in a high-volume environment. Further details to be discussed during our interview process. Bilingual candidates are encouraged to apply. Work hours: Monday through Friday 8:00am- 5:00PM EST Remote position within the tri-state area with field travel possible in 2026. NY RN licensure required

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) To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

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.

Molina Healthcare

Investigator, SIU RN-Remote

Posted on:

March 16, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

RN

State License:

California

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

The Special Investigation Unit (SIU) Investigator is responsible for supporting the prevention, detection, investigation, reporting, and when appropriate, recovery of money related to health care fraud, waste, and abuse. Duties include performing accurate and reliable medical review audits that may also include coding and billing reviews. The SIU Investigator is responsible for reviewing and analyzing information to make medical determinations as necessary, and applies clinical knowledge to assess the medical necessity, level of services, and/or appropriateness of care in cases. The SIU Investigator is also responsible for recognizing and adhering to national and local coding and billing guidelines in order to maintain coding accuracy and excellence. The position also entails producing audit reports for internal and external review. The position may also work with other internal departments, including Compliance, Corporate Legal Counsel, and Medical Affairs, in order to achieve and maintain appropriate anti-fraud oversight.

REQUIRED EDUCATION: Graduate from an Accredited School of Nursing. REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES: Five years clinical nursing experience with broad clinical knowledge. Five years experience conducting medical review and coding/billing audits involving professional and facility based services. Knowledge and understanding of medical terminology along with demonstrated knowledge of CPT, ICD-9, HCPCS and DRG requirements. Two years of managed care experience. REQUIRED LICENSE, CERTIFICATION, ASSOCIATION: Active, unrestricted State Registered Nursing (RN) license in good standing. PREFERRED EDUCATION: Bachelor’s Degree in Nursing PREFERRED EXPERIENCE: Experience in government programs (i.e., Medicare, Medicaid, & SCHIP). Experience in long-term care. STATE SPECIFIC REQUIREMENTS: OHIO: Transitions of Care for New Members Molina Healthcare of Ohio follows the transition of care requirements outlined below and in Appendix D of the contract for new members transitioning to the MCO from fee-for-service (FFS) or another MCO. The Transition of Care Coach will coordinate all services with new members to ensure a seamless transition and ensure continuity of care. Provision of Member Information Pre-Enrollment Planning The Molina Transition of Care Coach coordinates with and utilizes data provided by ODM, another MCO, the OhioRISE Plan (when applicable) and or collected by Molina (e.g. through assessments, new member outreach in advance of the member’s enrollment effective date) to identify existing sources of care and to ensure each new member is able to continue to receive existing services without disruption. For OhioRISE Plan enrolled members, Molina will reach out to the OhioRISE Plan and primary care coordination staff to engage the OhioRISE Plan in pre-enrollment planning Continuation of Services for Members Documentation of Transition of Services Transitions of Care Between Health Care Settings Transitions of Care Between Molina Healthcare of Ohio and the OhioRISE Plan Care Coordination Assignment Provision of Member Information Continuation of Services for Members Documentation of Transition of Services To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

Perform objective desk and onsite medical record audits to verify if services were supported by documentation, to determine if services were appropriately administered, and/or to validate coding/billing accuracy. Conduct interviews of providers and/or health plan members in order to determine whether fraud, waste, or abuse may have occurred. Coordinate with various internal customers (e.g., Provider Services, Contracting and Credentialing, Healthcare Services, Member Services, Claims) to gather documentation pertinent to investigations. Detect potential health care fraud, waste, and abuse through the identification of aberrant coding and/or billing patterns through utilization review. Incorporate leadership and communication skills to work with physicians and other health professionals when investigating cases. Generate and provide accurate and timely written reports for internal and/external use detailing audit findings. Render provider education on appropriate practices (e.g., coding) as appropriate based on national or local guidelines, contractual, and/or regulatory requirements. Identify opportunities for improvement through the audit process and provide recommendations for system enhancement in order to augment investigative outcomes and performance.

Molina Healthcare

RN Supervisor, Care Management - Behavioral Health

Posted on:

March 15, 2025

Job Type:

Full-Time

Role Type:

Leadership / Management

License:

RN

State License:

South Carolina

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.

For this position we are seeking a RN who lives in South Carolina must be licensed for the state of South Carolina. The RN Supervisor will manage a team of Case Managers that will support the South Carolina Medicaid members with Behavioral Health Diagnosis. The Supervisor will manage a team of Case Managers that will support the South Carolina Severe Mental Illness Medicaid population. Home office with internet connectivity of high speed required. Schedule: Monday thru Friday 8:00AM to 5:00PM EST. - No weekends or Holiday (Must be able to go into office for leadership meetings ((Cayce & Daniel Island)) Job Summary Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.

Required Education: 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.

CVS Health

Case Manager RN- San Antonio, Tx

Posted on:

March 15, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

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

This Case Manager RN role is with the Costco Team and is fully remote; however, candidates must reside within 45 minutes (reasonable driving distance) from the local office located at 7034 Alamo Downs Pkwy, San Antonio, TX 78238. Scheduled - Monday through Friday 8:00am-5:00pm CST with flexibility to rotate to 10:00am-7:00pm CST on occasion when required to meet business needs. No weekends or holidays will be required. The Case Manager RN 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. The Case Manager RN 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.

Required Qualifications: Must have active current and unrestricted RN multi state licensure in Texas Willingness to obtain additional state licenses will be required upon hire (expenses will be covered by company). 3+ years clinical practice experience as an RN required 1+ year(s) experience utilizing multiple computer systems and applications including Microsoft Word, Excel, Outlook, and web-based applications Must reside within 45 minutes (reasonable driving distance) from the local office located at 7034 Alamo Downs Pkwy, San Antonio, TX 78238. Travel to the San Antonio office may be required for quarterly meetings or PRN meetings. Must be able to work Monday through Friday 8:00am-5:00pm CST with flexibility to rotate to 10:00am-7:00pm CST on occasion when required to meet business needs. Preferred Qualifications Case Management in an integrated model Bilingual in Spanish and English Strong computer skills Education: Associates Degree required BSN preferred

Through the use of clinical tools and information/data review, conducts an evaluation of member’s needs and benefit plan eligibility and facilitates integrative functions as well as smooth transition to Aetna programs and plans. Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and barriers and address complex health and social indicators which impact care planning and resolution of member issues. Assessments consider 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.

Sentara Healthcare

AUTHORIZATION COORDINATOR

Posted on:

March 15, 2025

Job Type:

Full-Time

Role Type:

Clinical Operations

License:

LPN/LVN

State License:

Compact / Multi-State

At Sentara, one of our values is to keep you safe. Sentara and many other companies across the US are being targeted by cyber criminals who are impersonating representatives of the company, claiming to have job offers. Sentara will never ask you for banking or personal identification information via email or text. We will never ask an applicant to pay money for training, supplies, or other so-called expenses. If you suspect you have received a fraudulent job offer, e-mail taadmin@sentara.com. Award-winning: Sentara is a Virginia and Northeastern North Carolina based not-for-profit integrated healthcare provider that has been in business for over 131 years. Offering more than 500 sites of care including 12 hospitals, PACE (Elder Care), home health, hospice, medical groups, imaging services, therapy, outpatient surgery centers, and an 858,000 member health plan. The people of the communities that we serve have nominated Sentara “Employer of Choice” for over ten years. U.S. News and World Report has recognized Sentara as having the Best Hospitals for 15+ years. Sentara offers professional development and a continued employment philosophy!

Sentara Health is hiring an Authorization Coordinator ! This is a full-time remote position available only to candidates residing in Virginia.

High School Grad or Equivalent Related Associate level degree preferred Licensed Practical Nurse (LPN) – Nursing License – Compact/Multi-State License – required 3 years – Related clinical experience as an LPN in acute Care, managed care or clinic setting. Familiar with NCQA standards and turnaround times for prior authorizations. Familiarity with MCG and InterQual clinical decision support tools for prior authorizations and utilization review

Responsible for review of the clinical information received from physicians, department queues and other clinical providers, ensuring clinical data is substantial enough to authorize services for both 1 time visit account types and recurring accounts. Analyzes clinical information to ensure the services requested are authorized according to clinical and payer protocols. Responsible for insurance verification, member benefits, obtaining authorizations and pre-registration for the services requested. Validates accuracy of insurance enrollment information in the system prior to authorizing services, making certain policy is active. Requires knowledge of managed care contracting, clinical protocols and clinical review requirements. Requires knowledge of regulatory and compliance requirements, for both government and commercial payers. Ensures appropriate and accurate information is entered into systems for processing of patient care and reimbursement. Acts as a liaison between patients, physicians, clinical department and insurance companies.

CVS Health

Case Manager RN (Illinois)

Posted on:

March 15, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Compact / Multi-State

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

This is a full-time telework position with up to 10% travel required. Hours for this position are Monday-Friday 8:00a-5:00p in time zone of residence. A Brief Overview Administers processes to coordinate and facilitate comprehensive care for individuals by assessing their needs, developing personalized care plans, and coordinating services across healthcare providers. Serves as advocate for patients, ensuring effective communication, resource utilization, and continuous monitoring of their progress to promote positive outcomes and enhance overall well-being.

Required Qualifications: Must have active and unrestricted RN licensure in the state of IL 3+ years of clinical work experience with the adult population 1+ year(s) of Case Management experience Must be willing and able to travel up to 10% of the time. Reliable transportation required. Mileage is reimbursed per our company expense reimbursement policy Preferred Qualifications: Compact RN licensure Certified Case Manager Telephonic Nursing experience Home Health experience Customer Service experience Cold calling experience Experience with Medicare population Additional national professional certification (CRC, CDMS, CRRN, COHN) is preferred, but not required Remote working experience Education: Associate's Degree minimum required, Bachelor’s degree preferred

Administers the care coordination plan to assess patient needs and ensure seamless transitions between different care settings. Analyzes complex patient data from medical history, diagnostic test results, and treatment plans, to understand the current health status of the patient. Applies in-depth knowledge of case management and nursing practices to organize patient files in an orderly manner for easy retrieval. Communicates through internal platforms to securely exchange messages, conduct video conferences, share files, and collaborate on patient care plans. Conducts routine utilization reviews to ensure patients have access to appropriate cost-effective care. Configures the case management system to organize cases dealing with disease management and utilization review; tracks patient progress and manages specific conditions. Coordinates analytics projects to enable case managers to analyze data and generate reports on key performance health indicators. Designs complex processes to coordinate discharge planning in a safe and timely transition from the hospital to home. Develops resource management to help case managers optimize healthcare with community resources.

HireOps Staffing, LLC

Registered Nurse Case Manager

Posted on:

March 15, 2025

Job Type:

Full-Time

Role Type:

Case Management

License:

RN

State License:

Illinois

This position is a contract until 10/03. However, it is very possible that this position will be extended and be turned into a contract to hire position. Benefits are provided while on assignment with us, HireOps Staffing. JOB DESCRIPTION: Pay $45/hour to $52/hour This is a remote/work from home role, but field visits are required in assigned territory (generally the county that you live in) to conduct face to face health screenings and assessments.

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

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

Humana

Utilization Management Behavioral Health Professional

Posted on:

March 15, 2025

Job Type:

Full-Time

Role Type:

Behavioral Health

License:

RN

State License:

Compact / Multi-State

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

The Utilization Management Behavioral Health Professional 2 utilizes behavioral health knowledge and skills to support the coordination, documentation, and communication of medical services and/or benefit administration determinations. The Utilization Management Behavioral Health Professional 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

Must meet one of the following: Active unrestricted registered nurse license in the state of Virginia or obtain a multi-state license in a state that participates in the enhanced compact licensure, (eNLC) Active unrestricted LCSW, LPC, LMFT, or LCP, Licensed Clinical Psychologist to practice as a health professional within the state of Virginia Must meet all of the following: Minimum one, (1) year of post-degree clinical experience in private practice or other clinical patient care setting Minimum one, (1) year of managed care experience 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 Strong oral, written, and interpersonal communication skills, problem-solving skills, facilitation skills Preferred Qualifications: Experience with utilization review process Experience with behavioral change, health promotion, coaching and wellness Knowledge of community health and social service agencies and additional community resources Additional Information: Workstyle: Remote work at Home Location: Location for Registered Nurse: must reside in the state of Virginia or reside in a state participating in the enhanced nurse compact licensure, (eNLC) Location for Behavioral Health Licensed Professional: must be licensed in the state of Virginia Schedule: Must work a minimum of 8 hours between 8:00AM to 5:00 PM Eastern Time, may be required to work rotating holidays or weekends as determined by business needs Travel: Less than 5% to attend onsite market meetings as business needs Work at Home Guidance To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is required. Satellite, cellular and microwave connection can be used only if approved by leadership. Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense. Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

The Utilization Management Behavioral Health Professional 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.