Utilization Review Nurse jobs at AmeriHealth Caritas - 35 jobs

**$5,000.00 SIGN ON BONUS** Our Utilization Management Reviewers evaluate medical necessity for inpatient and outpatient services, ensuring treatment aligns with clinical guidelines, regulatory requirements, and patient needs. This role requires reviewing provider requests, gathering necessary medical documentation, and making determinations based on clinical criteria. Using professional judgment, the Clinical Care Reviewer assesses the appropriateness of services, identifies care coordination opportunities, and ensures compliance with medical policies. When necessary, cases are escalated to the Medical Director for further review. The reviewer independently applies medical and behavioral health guidelines to authorize services, ensuring they meet the patient's needs in the least restrictive and most effective manner. The Utilization Management Reviewer must maintain a strong working knowledge of federal, state, and organizational regulations and consistently apply them in decision-making. Productivity expectations include meeting established turnaround times, quality benchmarks, and efficiency metrics in a fast-paced environment. **Work Arrangement** + Candidates are required to work 4 out of 5 days a week at our AmeriHealth Caritas DC office located at1201 Maine Avenue, S.W., Suite 1000, 10th Floor, Washington DC 20024 + Monday through Friday, 8:00 AM to 5:00 PM + 4 recognized company holidays to include Thanksgiving and Christmas (rotating) + Weekends based on business needs **Responsibilities** + Conduct utilization management reviews by assessing medical necessity, appropriateness of care, and adherence to clinical guidelines + Collaborate with healthcare providers to facilitate timely authorizations and optimize patient care + Analyze medical records and clinical data to ensure compliance with regulatory and payer guidelines + Communicate determinations effectively, providing clear, evidence-based rationales for approval or denial decisions + Identify and escalate complex cases requiring physician review or additional intervention + Ensure compliance with Medicaid industry standards + Maintain productivity and efficiency by meeting established performance metrics, turnaround times, and quality standards in a high-volume environment **Education and Experience** + Associate's Degree in Nursing (ASN) required; Bachelor's Degree in Nursing (BSN) preferred + Minimum of 3 years of diverse clinical experience as a Registered Nurse in an Intensive Care Unit (ICU), Emergency Department (ED), Medical-Surgical (Med-Surg), Skilled Nursing Facility (SNF), Rehabilitation, or Long-Term Acute Care (LTAC), home health care, or medical office setting + Minimum of 2 years of experience applying evidence-based criteria (e.g. InterQual) to complete prior authorization and concurrent reviews for inpatient and/or outpatient services + Experience conducting utilization management reviews for an insurance company (e.g. Medicaid, Medicare or commercial plan) preferred **Licensure** + Active and unencumbered Registered Nurse license in the District of Columbia + Valid and current driver's license required **Skills and Abilities** + Proficiency using Electronic Medical Record Systems to efficiently document and assess patient cases + Strong understanding of utilization review processes, including medical necessity criteria, care coordination, and regulatory compliance + Working knowledge of InterQual criteria + Demonstrated ability to meet productivity standards in a fast-paced, high-volume utilization review environment + Proficiency using MS Office to include Excel, Word, Outlook, and Teams The range displayed in this job posting reflects the minimum and maximum for new hire salaries for the position in the Washington DC area. Within the range, individual pay is determined by additional factors, including, without limitation, job-related skills, experience, and relevant education, certifications, or training. AmeriHealth Caritas associates are eligible to participate in our annual incentive program and will also receive our benefits package, consisting of medical, vision, dental, life insurance, disability insurance, 401(k), paid time off and more. The targeted hiring range for this role is expected to be between $84,400.00 or $40.10/hour and $113,600.00 or $54.62/hour. At AmeriHealth Caritas, we're passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we'd like to hear from you. Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at ************************** . **Our Comprehensive Benefits Package** Flexible work solutions include remote options, hybrid work schedules, competitive pay, paid time off, holidays and volunteer events, health insurance coverage for you and your dependents on Day 1, 401(k) tuition reimbursement, and more. As a company, we support internal diversity through: Recruiting. We are an equal opportunity employer. We do not discriminate on the basis of age, race, ethnicity, gender, religion, sexual orientation, or disability. Our inclusive, equitable approach to recruiting and hiring reinforces our commitment to DEI.

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 optimized. Ready to make a difference? Join us to start Caring. Connecting. Growing together We're making a solid connection between exceptional patient care and outstanding career opportunities. The result is a culture of performance that's driving the health care industry forward. As a Case Manager RN, you'll support a diverse member population with education, advocacy and connections to the resources they need to feel better and get well. Instead of seeing a handful of patients each day, your work may affect millions for years to come. If you are located within Essex County, New Jersey, territory and willing to travel up to 80% of your time to assigned territory, you will have the flexibility to work remotely as you take on some tough challenges Primary Responsibilities: Comprehensive Assessment & Care Planning Conduct thorough health assessments, including medical history, chronic conditions, behavioral health, and social determinants of health Develop individualized care plans that address medical, rehabilitation, behavioral health, and social needs Create personalized interventions that integrate medical treatment, support services, and community resources Member Engagement, Education & Self-Management Build and maintain relationships with an established caseload of high-risk members Provide education to members and caregivers on disease processes, treatment adherence, and lifestyle changes Encourage self-management strategies that support long-term wellness and reduce complications Maintain consistent outreach to support adherence to care plans and monitor evolving needs Intensive Care Coordination Coordinate services across providers, including PCPs, specialists, hospitals, LTSS, behavioral health, and pharmacy. Facilitate referrals for home health, hospice, palliative care, and DME Collaborate with Medical Directors during interdisciplinary rounds to review and align care for complex cases Discharge Planning & Transitional Care Support members through transitions of care such as hospitalization, skilled nursing, and rehabilitation Conduct "welcome home" and follow-up calls to ensure post-discharge services, medications, and follow-up appointments are in place Deliver intensive outreach during the 30-day post-discharge period to reduce avoidable readmissions and ED utilization Advocate for safe, coordinated, and timely transitions of care that align with the member's individualized care plan Field-Based Care Management (20% of Time) Conduct home and hospital visits in North Jersey as required by program guidelines Perform in-person assessments and provide care coordination to address high-risk needs and ensure continuity of care Collaborate directly with providers, facilities, and families during field visits to close care gaps and reinforce the care plan Monitoring & Clinical Oversight Monitor members' clinical conditions, care plan progress, and treatment adherence Reassess care plans regularly and adjust interventions based on changing needs or barriers Identify red-flag conditions and escalate urgent or complex cases for higher-level review and intervention Documentation, Compliance & Quality Outcomes Document all assessments, care plans, interventions, and communications per NCQA, CMS, and state regulatory requirements Ensure care management services align with DSNP/NCQA standards and contract requirements Track outcomes tied to quality metrics (HEDIS, STARs), utilization management, and member satisfaction Maintain audit readiness through timely, accurate, and comprehensive documentation You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications: Current, unrestricted RN license in New Jersey 2+ years of Case Management Experience serving complex, elderly and disabled Experience with government health programs (Medicaid/Medicare) Proficient in Microsoft Office Suite; tech-savvy with ability to navigate multiple systems simultaneously Demonstrated ability to talk and type proficiently at the same time Access to reliable transportation and the ability to travel up to 80% within assigned territory. Available for occasional in-person meetings as needed Preferred Qualifications: Certified Case Manager (CCM) Experience working with populations with special needs (DSNP) Experience with Managed Care Population Bilingual - English/Spanish Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $40.00 to $54.00 per hour based on full-time employment. We comply with all minimum wage laws as applicable. At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission. UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations. UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

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. We're making a solid connection between exceptional patient care and outstanding career opportunities. The result is a culture of performance that's driving the health care industry forward. As a Telephone Case Manager RN, you'll support a diverse member population with education, advocacy and connections to the resources they need to feel better and get well. Instead of seeing a handful of patients each day, your work may affect millions for years to come. Ready for a new path? Apply today! If you are located within Northern New Jersey territory and willing to travel up to 20% of your time to assigned territory, you will have the flexibility to work remotely as you take on some tough challenges. Primary Responsibilities: Comprehensive Assessment & Care Planning Conduct thorough health assessments, including medical history, chronic conditions, behavioral health, and social determinants of health Develop individualized care plans that address medical, rehabilitation, behavioral health, and social needs Create personalized interventions that integrate medical treatment, support services, and community resources Member Engagement, Education & Self-Management Build and maintain relationships with an established caseload of high-risk members Provide education to members and caregivers on disease processes, treatment adherence, and lifestyle changes Encourage self-management strategies that support long-term wellness and reduce complications Maintain consistent outreach to support adherence to care plans and monitor evolving needs Intensive Care Coordination Coordinate services across providers, including PCPs, specialists, hospitals, LTSS, behavioral health, and pharmacy. Facilitate referrals for home health, hospice, palliative care, and DME Collaborate with Medical Directors during interdisciplinary rounds to review and align care for complex cases Discharge Planning & Transitional Care Support members through transitions of care such as hospitalization, skilled nursing, and rehabilitation Conduct "welcome home" and follow-up calls to ensure post-discharge services, medications, and follow-up appointments are in place Deliver intensive outreach during the 30-day post-discharge period to reduce avoidable readmissions and ED utilization Advocate for safe, coordinated, and timely transitions of care that align with the member's individualized care plan Field-Based Care Management (20% of Time) Conduct home and hospital visits in North Jersey as required by program guidelines Perform in-person assessments and provide care coordination to address high-risk needs and ensure continuity of care Collaborate directly with providers, facilities, and families during field visits to close care gaps and reinforce the care plan Monitoring & Clinical Oversight Monitor members' clinical conditions, care plan progress, and treatment adherence Reassess care plans regularly and adjust interventions based on changing needs or barriers Identify red-flag conditions and escalate urgent or complex cases for higher-level review and intervention Documentation, Compliance & Quality Outcomes Document all assessments, care plans, interventions, and communications per NCQA, CMS, and state regulatory requirements Ensure care management services align with DSNP/NCQA standards and contract requirements Track outcomes tied to quality metrics (HEDIS, STARs), utilization management, and member satisfaction Maintain audit readiness through timely, accurate, and comprehensive documentation You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications: Current, unrestricted RN license in New Jersey 2+ years of Case Management Experience serving complex, elderly and disabled Experience with government health programs (Medicaid/Medicare) Proficient in Microsoft Office Suite; tech-savvy with ability to navigate multiple systems simultaneously Demonstrated ability to talk and type proficiently at the same time Access to reliable transportation and the ability to travel up to 20% within assigned territory. Available for occasional in-person meetings as needed Preferred Qualifications: Certified Case Manager (CCM) Experience working with populations with special needs (DSNP) Experience with Managed Care Population Bilingual - English/Spanish *All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $28.27 to $50.48 per hour based on full-time employment. We comply with all minimum wage laws as applicable. At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission. UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations. UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.

Job Description Hi, we're Oscar. We're hiring a Physician Reviewer to join our Utilization Management team. Oscar is the first health insurance company built around a full stack technology platform and a relentless focus on serving our members. We started Oscar in 2012 to create the kind of health insurance company we would want for ourselves-one that behaves like a doctor in the family. About the role: You will determine the medical appropriateness of inpatient, outpatient, and pharmacy services by reviewing clinical information and applying evidence-based guidelines. Hours: 8am - 5pm in your local time zone Call rotation - 1 weekend every 16 weeks You will report into the Associate Medical Director, Utilization Management. Work Location: This is a remote position, open to candidates who reside in: Arizona; Florida; Georgia; or Texas. While your daily work will be completed from your home office, occasional travel may be required for team meetings and company events. #LI-Remote Pay Transparency: The base pay for this role is: $211,200 - $ 277,200 per year. You are also eligible for employee benefits, participation in Oscar's unlimited vacation, and annual performance bonuses. Responsibilities: Provide timely medical reviews that meet Oscar's stringent quality parameters. Provide clinical determinations based on evidence-based criteria and Oscar internal guidelines and policies, while utilizing clinical acumen. Clearly and accurately document all communication and decision-making in Oscar workflow tools, ensuring a member could easily reference and understand your decision (Flesch-Kincaid grade level). Use correct templates for documenting decisions during case review. Meet the appropriate turn-around times for clinical reviews. Receive and review escalated reviews. Conduct timely peer-to-peer discussions with treating providers to clarify clinical information and to explain review outcome decisions, including feedback on alternate treatment based on medical necessity criteria and evidence-based research. Compliance with all applicable laws and regulations Other duties as assigned Requirements: Board certification as an MD or DO Licensed in FL or NC and/or active Interstate Medical Licensure Compact (IMLCC) or eligible to apply for IMLCC. 6+ years of clinical practice 1+ years of utilization review experience in a managed care plan (health care industry) Bonus points: Licensure in multiple Oscar states BC in Cardiology, Radiation/Oncology, or Neurology Experience with care management within the health insurance industry. Willing and able to obtain additional state licensure as needed, with Oscar's support This is an authentic Oscar Health job opportunity. Learn more about how you can safeguard yourself from recruitment fraud here. At Oscar, being an Equal Opportunity Employer means more than upholding discrimination-free hiring practices. It means that we cultivate an environment where people can be their most authentic selves and find both belonging and support. We're on a mission to change health care -- an experience made whole by our unique backgrounds and perspectives. Pay Transparency: Final offer amounts, within the base pay set forth above, are determined by factors including your relevant skills, education, and experience. Full-time employees are eligible for benefits including: medical, dental, and vision benefits, 11 paid holidays, paid sick time, paid parental leave, 401(k) plan participation, life and disability insurance, and paid wellness time and reimbursements. Artificial Intelligence (AI): Our AI Guidelines outline the acceptable use of artificial intelligence for candidates and detail how we use AI to support our recruiting efforts. Reasonable Accommodation: Oscar applicants are considered solely based on their qualifications, without regard to applicant's disability or need for accommodation. Any Oscar applicant who requires reasonable accommodations during the application process should contact the Oscar Benefits Team (accommodations@hioscar.com) to make the need for an accommodation known. California Residents: For information about our collection, use, and disclosure of applicants' personal information as well as applicants' rights over their personal information, please see our Privacy Policy.

Hi, we're Oscar. We're hiring a Utilization Review Nurse to join our Utilization Review team. Oscar is the first health insurance company built around a full stack technology platform and a relentless focus on serving our members. We started Oscar in 2012 to create the kind of health insurance company we would want for ourselves-one that behaves like a doctor in the family. About the role: You will perform frequent case reviews, check medical records and speak with care providers regarding treatment as needed. You will make recommendations regarding the appropriateness of care for identified diagnoses based on the research results for those conditions. You will report into the Supervisor, Utilization Review. Work Location: This is a remote position, open to candidates who reside in: Texas, Georgia, Arizona, and Florida. While your daily work will be completed from your home office, occasional travel may be required for team meetings and company events. #LI-Remote Pay Transparency: The base pay for this role is: $35.00 - $45.94 per hour. You are also eligible for employee benefits and monthly vacation accrual at a rate of 15 days per year. Responsibilities: Complete medical necessity reviews and level of care reviews for requested services using clinical judgment and Oscar Clinical Guidelines, Milliman Care Guidelines Obtain the information necessary (via telephone and fax) to assess a member's clinical condition, and apply the appropriate evidence-based guidelines Meet required decision-making SLAs Refer members for further care engagement when needed Compliance with all applicable laws and regulations Other duties as assigned Requirements: Active, unrestricted RN licensure from the United States in [state], OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC) Associate Degree or Bachelors Degree - Nursing or Graduate of Accredited School of Nursing MCG or InterQual tooling experience Ability to obtain additional state licenses to meet business needs 1+ year of utilization review experience in a managed care setting 1+ years of clinical experience (including at least 1+ year clinical practice in an acute care setting, i.e., ER or hospital) Bonus points: BSN Previous experience conducting concurrent or inpatient reviews for a managed care plan This is an authentic Oscar Health job opportunity. Learn more about how you can safeguard yourself from recruitment fraud here. At Oscar, being an Equal Opportunity Employer means more than upholding discrimination-free hiring practices. It means that we cultivate an environment where people can be their most authentic selves and find both belonging and support. We're on a mission to change health care -- an experience made whole by our unique backgrounds and perspectives. Pay Transparency: Final offer amounts, within the base pay set forth above, are determined by factors including your relevant skills, education, and experience. Full-time employees are eligible for benefits including: medical, dental, and vision benefits, 11 paid holidays, paid sick time, paid parental leave, 401(k) plan participation, life and disability insurance, and paid wellness time and reimbursements. Artificial Intelligence (AI): Our AI Guidelines outline the acceptable use of artificial intelligence for candidates and detail how we use AI to support our recruiting efforts. Reasonable Accommodation: Oscar applicants are considered solely based on their qualifications, without regard to applicant's disability or need for accommodation. Any Oscar applicant who requires reasonable accommodations during the application process should contact the Oscar Benefits Team (accommodations@hioscar.com) to make the need for an accommodation known. California Residents: For information about our collection, use, and disclosure of applicants' personal information as well as applicants' rights over their personal information, please see our Privacy Policy.

Hi, we're Oscar. We're hiring a Physician Reviewer to join our Utilization Management team. Oscar is the first health insurance company built around a full stack technology platform and a relentless focus on serving our members. We started Oscar in 2012 to create the kind of health insurance company we would want for ourselves-one that behaves like a doctor in the family. About the role: You will determine the medical appropriateness of inpatient, outpatient, and pharmacy services by reviewing clinical information and applying evidence-based guidelines. Hours: 8am - 5pm in your local time zone Call rotation - 1 weekend every 16 weeks You will report into the Associate Medical Director, Utilization Management. Work Location: This is a remote position, open to candidates who reside in: Arizona; Florida; Georgia; or Texas. While your daily work will be completed from your home office, occasional travel may be required for team meetings and company events. #LI-Remote Pay Transparency: The base pay for this role is: $211,200 - $ 277,200 per year. You are also eligible for employee benefits, participation in Oscar's unlimited vacation, and annual performance bonuses. Responsibilities: Provide timely medical reviews that meet Oscar's stringent quality parameters. Provide clinical determinations based on evidence-based criteria and Oscar internal guidelines and policies, while utilizing clinical acumen. Clearly and accurately document all communication and decision-making in Oscar workflow tools, ensuring a member could easily reference and understand your decision (Flesch-Kincaid grade level). Use correct templates for documenting decisions during case review. Meet the appropriate turn-around times for clinical reviews. Receive and review escalated reviews. Conduct timely peer-to-peer discussions with treating providers to clarify clinical information and to explain review outcome decisions, including feedback on alternate treatment based on medical necessity criteria and evidence-based research. Compliance with all applicable laws and regulations Other duties as assigned Requirements: Board certification as an MD or DO Licensed in FL or NC and/or active Interstate Medical Licensure Compact (IMLCC) or eligible to apply for IMLCC. 6+ years of clinical practice 1+ years of utilization review experience in a managed care plan (health care industry) Bonus points: Licensure in multiple Oscar states BC in Cardiology, Radiation/Oncology, or Neurology Experience with care management within the health insurance industry. Willing and able to obtain additional state licensure as needed, with Oscar's support This is an authentic Oscar Health job opportunity. Learn more about how you can safeguard yourself from recruitment fraud here. At Oscar, being an Equal Opportunity Employer means more than upholding discrimination-free hiring practices. It means that we cultivate an environment where people can be their most authentic selves and find both belonging and support. We're on a mission to change health care -- an experience made whole by our unique backgrounds and perspectives. Pay Transparency: Final offer amounts, within the base pay set forth above, are determined by factors including your relevant skills, education, and experience. Full-time employees are eligible for benefits including: medical, dental, and vision benefits, 11 paid holidays, paid sick time, paid parental leave, 401(k) plan participation, life and disability insurance, and paid wellness time and reimbursements. Artificial Intelligence (AI): Our AI Guidelines outline the acceptable use of artificial intelligence for candidates and detail how we use AI to support our recruiting efforts. Reasonable Accommodation: Oscar applicants are considered solely based on their qualifications, without regard to applicant's disability or need for accommodation. Any Oscar applicant who requires reasonable accommodations during the application process should contact the Oscar Benefits Team (accommodations@hioscar.com) to make the need for an accommodation known. California Residents: For information about our collection, use, and disclosure of applicants' personal information as well as applicants' rights over their personal information, please see our Privacy Policy.

About us: Good things are happening at Berkshire Hathaway GUARD Insurance Companies. We provide Property & Casualty insurance products and services through a nationwide network of independent agents and brokers. Our companies are all rated A+ “Superior” by AM Best (the leading independent insurance rating organization) and ultimately owned by Warren Buffett's Berkshire Hathaway group - one of the financially strongest organizations in the world! Headquartered in Wilkes-Barre, PA, we employ over 1,000 individuals (and growing) and have offices across the country. Our vision is to be a leading small business insurance provider nationwide. Founded upon an exceptional culture and led by a collaborative and inclusive management team, our company's success is grounded in our core values: accountability, service, integrity, empowerment, and diversity. We are always in search of talented individuals to join our team and embark on an exciting career path! Benefits: We are an equal opportunity employer that strives to maintain a work environment that is welcoming and enriching for all. You'll be surprised by all we have to offer! Competitive compensation Healthcare benefits package that begins on first day of employment 401K retirement plan with company match Enjoy generous paid time off to support your work-life balance plus 9 ½ paid holidays Up to 6 weeks of parental and bonding leave Hybrid work schedule (3 days in the office, 2 days from home) Longevity awards (every 5 years of employment, receive a generous monetary award to be used toward a vacation) Tuition reimbursement after 6 months of employment Numerous opportunities for continued training and career advancement And much more! Responsibilities The Utilization Review Nurse's duties will include, but are not limited to: Support internal claims adjusting staff in the review of workers' compensation claims Review records and requests for UR, which may arrive via mail, e-mail, fax, or phone Meet required decision-making timeframes Clearly document all communication and decision-making within our insurance software system Establish collaborative relationships and work as an intermediary between clients, patients, employers, providers, and attorneys Utilize good clinical judgment, careful listening, and critical thinking and assessment skills Track ongoing status of all UR activity so that appropriate turn-around times are met Maintain organized files containing clinical documentation of interactions with all parties of every claim Send appropriate letters on each completed UR Qualifications Active Licensed Practical Nurse and/or Registered Nurse License 1+ years of utilization review experience at a managed care plan or provider organization 2 + years' clinical experience preferably in case management, rehabilitation, orthopedics, or utilization review Excellent oral and written communication skills, including outstanding phone presence Strong interpersonal and conflict resolution skills Experience in a fast-paced, multi-faceted environment The ability to set priorities and work both autonomously and as a team member Well-developed time-management and organization skills Excellent analytical skills Working knowledge of: Microsoft Word, Excel, and Outlook

Nurse Reviewer PT (20-30 hours week) - Remote Work Environment Non-Exempt: $40.00 hour Supports Medical Review Services. The Nurse Reviewer plays a critical role in supporting the Medical Review Services department by performing comprehensive medical necessity reviews and policy reviews for Medicaid claims. This involves meticulous examination of claims and medical records to ensure compliance with established guidelines and regulations. The RN will work closely with the Team Lead, Physician Peer Reviewer and contract team. Reviews must be completed timely. Essential Duties and Responsibilities: Conduct comprehensive medical record reviews to assess medical necessity and compliance with established standards of care and applicable policies Manage end-to-end case screening processes, ensuring all activities are completed within established deadlines Document evidence-based criteria applicable to specific contract requirements Record and report screening results, including relevant referral questions, into a centralized database Evaluate medical claims against industry standards, utilizing research of relevant ICD-10, CPT, and HCPCS codes to determine medical necessity Maintain expert knowledge of evolving multi-state Medicaid policies and vendor expectations Participate in ongoing training and consistently meet or exceed productivity and quality assurance standards Knowledge, Experience, Skills and Education: Medical terminology, ICD-10, CPT and HCPCS Clinical criteria (InterQual and MCG) Utilization/Medical record review and chart abstraction Current standards of medical practice Comply with HIPAA/HITECH laws and regulations Experience in: At least three- five years performing medical record review and/or abstraction (Utilization Review experience preferred) Experience performing medical record review, audit for federal or state contracts Knowledge and experience of Medicare and Medicaid policy Proficiency with Microsoft Office (Word, Excel, and Outlook) Proficiency with Adobe PDF files and features Generating accurate, timely, and understandable correspondence Current experience (within the last 3 years) in the application of clinical screening criteria (InterQual and MCG) Skills Requirements include: Professional interpersonal skills; ability to interact with providers, physicians and peers Solid analytical, assessment and documentation skills Effective written and verbal communication, both internally and externally Strong attention to detail Strong attention to deadlines Organizational skills including effective time management, priority setting and process improvement Ability to work independently and as a member of a team Adapt to changing work situations and readily adjusts schedules, tasks and priorities when necessary to meet business fluctuations Educational Background: BSN with active RN licensure in good standing Physical Demands: Remote Work, Prolonged Sitting, Screen Exposure This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee. Duties, responsibilities and activities may change or new ones may be assigned at any time with or without notice. Healthcare Quality Strategies, Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. This position qualifies for the following Company benefits: Medical/Dental/Vision, FSA and HSA, group life/AD&D, voluntary life/AD&D, 401k For immediate consideration, please apply via the HQSI Careers Page at: ************ > Careers > Current Employment Opportunities EOE: Minorities/Females/Disabled/Veterans Healthcare Quality Strategies, Inc. is Equal Opportunity, Affirmative Action Employer and an Alcohol/Drug Free Workplace Healthcare Quality Strategies, Inc. is an E-Verify Employer

Nurse Reviewer PT (20-30 hours week) - Remote Work Environment Non-Exempt: $40.00 hour Supports Medical Review Services. The Nurse Reviewer plays a critical role in supporting the Medical Review Services department by performing comprehensive medical necessity reviews and policy reviews for Medicaid claims. This involves meticulous examination of claims and medical records to ensure compliance with established guidelines and regulations. The RN will work closely with the Team Lead, Physician Peer Reviewer and contract team. Reviews must be completed timely. Essential Duties and Responsibilities: Conduct comprehensive medical record reviews to assess medical necessity and compliance with established standards of care and applicable policies Manage end-to-end case screening processes, ensuring all activities are completed within established deadlines Document evidence-based criteria applicable to specific contract requirements Record and report screening results, including relevant referral questions, into a centralized database Evaluate medical claims against industry standards, utilizing research of relevant ICD-10, CPT, and HCPCS codes to determine medical necessity Maintain expert knowledge of evolving multi-state Medicaid policies and vendor expectations Participate in ongoing training and consistently meet or exceed productivity and quality assurance standards Knowledge, Experience, Skills and Education: Medical terminology, ICD-10, CPT and HCPCS Clinical criteria (InterQual and MCG) Utilization/Medical record review and chart abstraction Current standards of medical practice Comply with HIPAA/HITECH laws and regulations Experience in: At least three- five years performing medical record review and/or abstraction (Utilization Review experience preferred) Experience performing medical record review, audit for federal or state contracts Knowledge and experience of Medicare and Medicaid policy Proficiency with Microsoft Office (Word, Excel, and Outlook) Proficiency with Adobe PDF files and features Generating accurate, timely, and understandable correspondence Current experience (within the last 3 years) in the application of clinical screening criteria (InterQual and MCG) Skills Requirements include: Professional interpersonal skills; ability to interact with providers, physicians and peers Solid analytical, assessment and documentation skills Effective written and verbal communication, both internally and externally Strong attention to detail Strong attention to deadlines Organizational skills including effective time management, priority setting and process improvement Ability to work independently and as a member of a team Adapt to changing work situations and readily adjusts schedules, tasks and priorities when necessary to meet business fluctuations Educational Background: BSN with active RN licensure in good standing Physical Demands: Remote Work, Prolonged Sitting, Screen Exposure This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee. Duties, responsibilities and activities may change or new ones may be assigned at any time with or without notice. Healthcare Quality Strategies, Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. This position qualifies for the following Company benefits: Medical/Dental/Vision, FSA and HSA, group life/AD&D, voluntary life/AD&D, 401k For immediate consideration, please apply via the HQSI Careers Page at: ************ > Careers > Current Employment Opportunities EOE: Minorities/Females/Disabled/Veterans Healthcare Quality Strategies, Inc. is Equal Opportunity, Affirmative Action Employer and an Alcohol/Drug Free Workplace Healthcare Quality Strategies, Inc. is an E-Verify Employer

Nurse Reviewer PT (20-30 hours week) - Remote Work Environment Non-Exempt: $40.00 hour Supports Medical Review Services. The Nurse Reviewer plays a critical role in supporting the Medical Review Services department by performing comprehensive medical necessity reviews and policy reviews for Medicaid claims. This involves meticulous examination of claims and medical records to ensure compliance with established guidelines and regulations. The RN will work closely with the Team Lead, Physician Peer Reviewer and contract team. Reviews must be completed timely. Essential Duties and Responsibilities: Conduct comprehensive medical record reviews to assess medical necessity and compliance with established standards of care and applicable policies Manage end-to-end case screening processes, ensuring all activities are completed within established deadlines Document evidence-based criteria applicable to specific contract requirements Record and report screening results, including relevant referral questions, into a centralized database Evaluate medical claims against industry standards, utilizing research of relevant ICD-10, CPT, and HCPCS codes to determine medical necessity Maintain expert knowledge of evolving multi-state Medicaid policies and vendor expectations Participate in ongoing training and consistently meet or exceed productivity and quality assurance standards Knowledge, Experience, Skills and Education: Medical terminology, ICD-10, CPT and HCPCS Clinical criteria (InterQual and MCG) Utilization/Medical record review and chart abstraction Current standards of medical practice Comply with HIPAA/HITECH laws and regulations Experience in: At least three- five years performing medical record review and/or abstraction (Utilization Review experience preferred) Experience performing medical record review, audit for federal or state contracts Knowledge and experience of Medicare and Medicaid policy Proficiency with Microsoft Office (Word, Excel, and Outlook) Proficiency with Adobe PDF files and features Generating accurate, timely, and understandable correspondence Current experience (within the last 3 years) in the application of clinical screening criteria (InterQual and MCG) Skills Requirements include: Professional interpersonal skills; ability to interact with providers, physicians and peers Solid analytical, assessment and documentation skills Effective written and verbal communication, both internally and externally Strong attention to detail Strong attention to deadlines Organizational skills including effective time management, priority setting and process improvement Ability to work independently and as a member of a team Adapt to changing work situations and readily adjusts schedules, tasks and priorities when necessary to meet business fluctuations Educational Background: BSN with active RN licensure in good standing Physical Demands: Remote Work, Prolonged Sitting, Screen Exposure This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee. Duties, responsibilities and activities may change or new ones may be assigned at any time with or without notice. Healthcare Quality Strategies, Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. This position qualifies for the following Company benefits: Medical/Dental/Vision, FSA and HSA, group life/AD&D, voluntary life/AD&D, 401k For immediate consideration, please apply via the HQSI Careers Page at: ************ > Careers > Current Employment Opportunities EOE: Minorities/Females/Disabled/Veterans Healthcare Quality Strategies, Inc. is Equal Opportunity, Affirmative Action Employer and an Alcohol/Drug Free Workplace Healthcare Quality Strategies, Inc. is an E-Verify Employer

Nurse Reviewer PT (20-30 hours week) - Remote Work Environment Non-Exempt: $40.00 hour Supports Medical Review Services. The Nurse Reviewer plays a critical role in supporting the Medical Review Services department by performing comprehensive medical necessity reviews and policy reviews for Medicaid claims. This involves meticulous examination of claims and medical records to ensure compliance with established guidelines and regulations. The RN will work closely with the Team Lead, Physician Peer Reviewer and contract team. Reviews must be completed timely. Essential Duties and Responsibilities: Conduct comprehensive medical record reviews to assess medical necessity and compliance with established standards of care and applicable policies Manage end-to-end case screening processes, ensuring all activities are completed within established deadlines Document evidence-based criteria applicable to specific contract requirements Record and report screening results, including relevant referral questions, into a centralized database Evaluate medical claims against industry standards, utilizing research of relevant ICD-10, CPT, and HCPCS codes to determine medical necessity Maintain expert knowledge of evolving multi-state Medicaid policies and vendor expectations Participate in ongoing training and consistently meet or exceed productivity and quality assurance standards Knowledge, Experience, Skills and Education: Medical terminology, ICD-10, CPT and HCPCS Clinical criteria (InterQual and MCG) Utilization/Medical record review and chart abstraction Current standards of medical practice Comply with HIPAA/HITECH laws and regulations Experience in: At least three- five years performing medical record review and/or abstraction (Utilization Review experience preferred) Experience performing medical record review, audit for federal or state contracts Knowledge and experience of Medicare and Medicaid policy Proficiency with Microsoft Office (Word, Excel, and Outlook) Proficiency with Adobe PDF files and features Generating accurate, timely, and understandable correspondence Current experience (within the last 3 years) in the application of clinical screening criteria (InterQual and MCG) Skills Requirements include: Professional interpersonal skills; ability to interact with providers, physicians and peers Solid analytical, assessment and documentation skills Effective written and verbal communication, both internally and externally Strong attention to detail Strong attention to deadlines Organizational skills including effective time management, priority setting and process improvement Ability to work independently and as a member of a team Adapt to changing work situations and readily adjusts schedules, tasks and priorities when necessary to meet business fluctuations Educational Background: BSN with active RN licensure in good standing Physical Demands: Remote Work, Prolonged Sitting, Screen Exposure This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee. Duties, responsibilities and activities may change or new ones may be assigned at any time with or without notice. Healthcare Quality Strategies, Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. This position qualifies for the following Company benefits: Medical/Dental/Vision, FSA and HSA, group life/AD&D, voluntary life/AD&D, 401k For immediate consideration, please apply via the HQSI Careers Page at: ************ > Careers > Current Employment Opportunities EOE: Minorities/Females/Disabled/Veterans Healthcare Quality Strategies, Inc. is Equal Opportunity, Affirmative Action Employer and an Alcohol/Drug Free Workplace Healthcare Quality Strategies, Inc. is an E-Verify Employer

Nurse Reviewer PT (20-30 hours week) - Remote Work Environment Non-Exempt: $40.00 hour Supports Medical Review Services. The Nurse Reviewer plays a critical role in supporting the Medical Review Services department by performing comprehensive medical necessity reviews and policy reviews for Medicaid claims. This involves meticulous examination of claims and medical records to ensure compliance with established guidelines and regulations. The RN will work closely with the Team Lead, Physician Peer Reviewer and contract team. Reviews must be completed timely. Essential Duties and Responsibilities: Conduct comprehensive medical record reviews to assess medical necessity and compliance with established standards of care and applicable policies Manage end-to-end case screening processes, ensuring all activities are completed within established deadlines Document evidence-based criteria applicable to specific contract requirements Record and report screening results, including relevant referral questions, into a centralized database Evaluate medical claims against industry standards, utilizing research of relevant ICD-10, CPT, and HCPCS codes to determine medical necessity Maintain expert knowledge of evolving multi-state Medicaid policies and vendor expectations Participate in ongoing training and consistently meet or exceed productivity and quality assurance standards Knowledge, Experience, Skills and Education: Medical terminology, ICD-10, CPT and HCPCS Clinical criteria (InterQual and MCG) Utilization/Medical record review and chart abstraction Current standards of medical practice Comply with HIPAA/HITECH laws and regulations Experience in: At least three- five years performing medical record review and/or abstraction (Utilization Review experience preferred) Experience performing medical record review, audit for federal or state contracts Knowledge and experience of Medicare and Medicaid policy Proficiency with Microsoft Office (Word, Excel, and Outlook) Proficiency with Adobe PDF files and features Generating accurate, timely, and understandable correspondence Current experience (within the last 3 years) in the application of clinical screening criteria (InterQual and MCG) Skills Requirements include: Professional interpersonal skills; ability to interact with providers, physicians and peers Solid analytical, assessment and documentation skills Effective written and verbal communication, both internally and externally Strong attention to detail Strong attention to deadlines Organizational skills including effective time management, priority setting and process improvement Ability to work independently and as a member of a team Adapt to changing work situations and readily adjusts schedules, tasks and priorities when necessary to meet business fluctuations Educational Background: BSN with active RN licensure in good standing Physical Demands: Remote Work, Prolonged Sitting, Screen Exposure This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee. Duties, responsibilities and activities may change or new ones may be assigned at any time with or without notice. Healthcare Quality Strategies, Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. This position qualifies for the following Company benefits: Medical/Dental/Vision, FSA and HSA, group life/AD&D, voluntary life/AD&D, 401k For immediate consideration, please apply via the HQSI Careers Page at: ************ > Careers > Current Employment Opportunities EOE: Minorities/Females/Disabled/Veterans Healthcare Quality Strategies, Inc. is Equal Opportunity, Affirmative Action Employer and an Alcohol/Drug Free Workplace Healthcare Quality Strategies, Inc. is an E-Verify Employer

Hi, we're Oscar. We're hiring a Physician Reviewer to join our Utilization Management team. Oscar is the first health insurance company built around a full stack technology platform and a relentless focus on serving our members. We started Oscar in 2012 to create the kind of health insurance company we would want for ourselves-one that behaves like a doctor in the family. About the role: You will determine the medical appropriateness of inpatient, outpatient, and pharmacy services by reviewing clinical information and applying evidence-based guidelines. Hours: 8am - 5pm in your local time zone Call rotation - 1 weekend every 16 weeks You will report into the Associate Medical Director, Utilization Management. Work Location: This is a remote position, open to candidates who reside in: Arizona; Florida; Georgia; or Texas. While your daily work will be completed from your home office, occasional travel may be required for team meetings and company events. #LI-Remote Pay Transparency: The base pay for this role is: $211,200 - $ 277,200 per year. You are also eligible for employee benefits, participation in Oscar's unlimited vacation, and annual performance bonuses. Responsibilities: Provide timely medical reviews that meet Oscar's stringent quality parameters. Provide clinical determinations based on evidence-based criteria and Oscar internal guidelines and policies, while utilizing clinical acumen. Clearly and accurately document all communication and decision-making in Oscar workflow tools, ensuring a member could easily reference and understand your decision (Flesch-Kincaid grade level). Use correct templates for documenting decisions during case review. Meet the appropriate turn-around times for clinical reviews. Receive and review escalated reviews. Conduct timely peer-to-peer discussions with treating providers to clarify clinical information and to explain review outcome decisions, including feedback on alternate treatment based on medical necessity criteria and evidence-based research. Compliance with all applicable laws and regulations Other duties as assigned Requirements: Board certification as an MD or DO Licensed in FL or NC and/or active Interstate Medical Licensure Compact (IMLCC) or eligible to apply for IMLCC. 6+ years of clinical practice 1+ years of utilization review experience in a managed care plan (health care industry) Bonus points: Licensure in multiple Oscar states BC in Cardiology, Radiation/Oncology, or Neurology Experience with care management within the health insurance industry. Willing and able to obtain additional state licensure as needed, with Oscar's support This is an authentic Oscar Health job opportunity. Learn more about how you can safeguard yourself from recruitment fraud here. At Oscar, being an Equal Opportunity Employer means more than upholding discrimination-free hiring practices. It means that we cultivate an environment where people can be their most authentic selves and find both belonging and support. We're on a mission to change health care -- an experience made whole by our unique backgrounds and perspectives. Pay Transparency: Final offer amounts, within the base pay set forth above, are determined by factors including your relevant skills, education, and experience. Full-time employees are eligible for benefits including: medical, dental, and vision benefits, 11 paid holidays, paid sick time, paid parental leave, 401(k) plan participation, life and disability insurance, and paid wellness time and reimbursements. Artificial Intelligence (AI): Our AI Guidelines outline the acceptable use of artificial intelligence for candidates and detail how we use AI to support our recruiting efforts. Reasonable Accommodation: Oscar applicants are considered solely based on their qualifications, without regard to applicant's disability or need for accommodation. Any Oscar applicant who requires reasonable accommodations during the application process should contact the Oscar Benefits Team (accommodations@hioscar.com) to make the need for an accommodation known. California Residents: For information about our collection, use, and disclosure of applicants' personal information as well as applicants' rights over their personal information, please see our .

Nurse Reviewer PT (20-30 hours week) - Remote Work Environment Non-Exempt: $40.00 hour Supports Medical Review Services. The Nurse Reviewer plays a critical role in supporting the Medical Review Services department by performing comprehensive medical necessity reviews and policy reviews for Medicaid claims. This involves meticulous examination of claims and medical records to ensure compliance with established guidelines and regulations. The RN will work closely with the Team Lead, Physician Peer Reviewer and contract team. Reviews must be completed timely. Essential Duties and Responsibilities: Conduct comprehensive medical record reviews to assess medical necessity and compliance with established standards of care and applicable policies Manage end-to-end case screening processes, ensuring all activities are completed within established deadlines Document evidence-based criteria applicable to specific contract requirements Record and report screening results, including relevant referral questions, into a centralized database Evaluate medical claims against industry standards, utilizing research of relevant ICD-10, CPT, and HCPCS codes to determine medical necessity Maintain expert knowledge of evolving multi-state Medicaid policies and vendor expectations Participate in ongoing training and consistently meet or exceed productivity and quality assurance standards Knowledge, Experience, Skills and Education: Medical terminology, ICD-10, CPT and HCPCS Clinical criteria (InterQual and MCG) Utilization/Medical record review and chart abstraction Current standards of medical practice Comply with HIPAA/HITECH laws and regulations Experience in: At least three- five years performing medical record review and/or abstraction (Utilization Review experience preferred) Experience performing medical record review, audit for federal or state contracts Knowledge and experience of Medicare and Medicaid policy Proficiency with Microsoft Office (Word, Excel, and Outlook) Proficiency with Adobe PDF files and features Generating accurate, timely, and understandable correspondence Current experience (within the last 3 years) in the application of clinical screening criteria (InterQual and MCG) Skills Requirements include: Professional interpersonal skills; ability to interact with providers, physicians and peers Solid analytical, assessment and documentation skills Effective written and verbal communication, both internally and externally Strong attention to detail Strong attention to deadlines Organizational skills including effective time management, priority setting and process improvement Ability to work independently and as a member of a team Adapt to changing work situations and readily adjusts schedules, tasks and priorities when necessary to meet business fluctuations Educational Background: BSN with active RN licensure in good standing Physical Demands: Remote Work, Prolonged Sitting, Screen Exposure This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee. Duties, responsibilities and activities may change or new ones may be assigned at any time with or without notice. Healthcare Quality Strategies, Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. This position qualifies for the following Company benefits: Medical/Dental/Vision, FSA and HSA, group life/AD&D, voluntary life/AD&D, 401k For immediate consideration, please apply via the HQSI Careers Page at: ************ > Careers > Current Employment Opportunities EOE: Minorities/Females/Disabled/Veterans Healthcare Quality Strategies, Inc. is Equal Opportunity, Affirmative Action Employer and an Alcohol/Drug Free Workplace Healthcare Quality Strategies, Inc. is an E-Verify Employer

Hi, we're Oscar. We're hiring a Case Management Nurse to join our Case Mangement team. Oscar is the first health insurance company built around a full stack technology platform and a relentless focus on serving our members. We started Oscar in 2012 to create the kind of health insurance company we would want for ourselves-one that behaves like a doctor in the family. About the role: You will educate members on improving health outcomes, assist with transitions from care settings, participate in process improvement and other pilot programs as they arise, and work with support teams to ensure exceptional care for our members. You will report into the Associate Director, Clinical. Work Location: This is a remote position, open to candidates who reside in: Arizona; Florida; Georgia; or Texas. While your daily work will be completed from your home office, occasional travel may be required for team meetings and company events. #LI-Remote Pay Transparency: The base pay for this role is: $39.28 - $45.94 per hour. You are also eligible for employee benefits and monthly vacation accrual at a rate of 15 days per year. Responsibilities: Assist in the coordination of care across a variety of settings (inpatient, outpatient, post acute, ER, home care) Actively reach out to members undergoing difficult health challenges and develop care plans Proactively reach out to hospital case managers to assist with discharge planning Communicate with members via phone or secure messaging to provide education on health conditions, new medications, and procedures. Compliance with all applicable laws and regulations Other duties as assigned Requirements: Active, unrestricted RN licensure from the United States in [state], OR, active compact multistate unrestricted RN license Ability to obtain additional state licenses to meet business needs 2+ years of clinical experience to include payer, hospital, outpatient or community based care management 1+ years of experience in Care Coordination and Navigation Bonus points: CCM Certification Bilingual in Spanish and/or creole reading, writing, speaking BSN Working knowledge of Milliman Guidelines This is an authentic Oscar Health job opportunity. Learn more about how you can safeguard yourself from recruitment fraud here. At Oscar, being an Equal Opportunity Employer means more than upholding discrimination-free hiring practices. It means that we cultivate an environment where people can be their most authentic selves and find both belonging and support. We're on a mission to change health care -- an experience made whole by our unique backgrounds and perspectives. Pay Transparency: Final offer amounts, within the base pay set forth above, are determined by factors including your relevant skills, education, and experience. Full-time employees are eligible for benefits including: medical, dental, and vision benefits, 11 paid holidays, paid sick time, paid parental leave, 401(k) plan participation, life and disability insurance, and paid wellness time and reimbursements. Artificial Intelligence (AI): Our AI Guidelines outline the acceptable use of artificial intelligence for candidates and detail how we use AI to support our recruiting efforts. Reasonable Accommodation: Oscar applicants are considered solely based on their qualifications, without regard to applicant's disability or need for accommodation. Any Oscar applicant who requires reasonable accommodations during the application process should contact the Oscar Benefits Team (accommodations@hioscar.com) to make the need for an accommodation known. California Residents: For information about our collection, use, and disclosure of applicants' personal information as well as applicants' rights over their personal information, please see our Privacy Policy.

If you're a registered nurse looking for a new opportunity to work in a fast-paced, professional environment where your talent contributes to our competitive edge, Liberty Mutual Insurance has the opportunity for you. Under general technical direction, responsible for medically managing assigned caseload and by applying clinical expertise ensure individuals receive appropriate healthcare in order to return to work and normal activity in a timely and cost effective manner. Caseload may include catastrophic/complex medical/disability cases, lost time, and/or medical only claims. Also act as a clinical resource for field claim partners. This is a remote position, however, you will be required to report into the office twice a month per business requirements if you reside within 50 miles of the following offices: Lake Oswego, OR, Chandler, AZ, Hoffman Estates, IL, Suwanee, GA, Indianapolis, IN, Plano, TX, Boston, MA, Westborough, MA, Las Vegas, NV, and Weatogue, CT . Please note this policy is subject to change. Responsibilities: Follows Liberty Mutual's established standards and protocols to effectively manage assigned caseload of medical/disability cases and by applying clinical expertise assist to achieve optimal outcome and to facilitate claim resolution and disposition. Effectively communicates with injured employees, medical professionals, field claims staff, attorneys, and others to obtain information, and to negotiate medical treatment and return to work plans using critical thinking skills, clinical expertise and other resources as needed to achieve an optimal case outcome. Utilizes the Nursing Process (assessment, diagnosis, planning, intervention and evaluation) to facilitate medical management to attain maximum medical improvement and return-to-work (RTW) per state jurisdictional requirements. Appropriately utilizes internal and external resources and referrals i.e., Utilization Review, Peer Review, Field Claims Specialists, Regional Medical Director Consults, and Vocational Rehabilitation to achieve best possible case outcome. Follows general technical direction from nurse manager, senior medical and disability case manager and/or CCMU staff to resolve highly complex medical and/or RTW issues and/or successfully manage catastrophic injuries. Documents all RN activities accurately, concisely and on a timely basis. This includes documenting the medical and disability case management strategies for claim resolution, based on clinical expertise. Adheres to confidentiality policy. Appropriately applies clinical expertise to claims and delivers services in an efficient and effective manner. Accurately and appropriately documents time tracking for work performed. Achieves annual time tracking goal. Handles special projects as assigned. Qualifications Ability to analyze and make sound nursing judgments and to accurately document activities. Strong communication skills in order to build relationships with injured employees, medical professionals, employers, field claims staff and others. Good negotiation skills to effectively establish target return to work dates and coordinate medical care. Knowledge of state, local and federal laws related to health care delivery preferred. Personal computer knowledge and proficiency in general computer applications such as Internet Explorer and Microsoft Office (including Word, Excel and Outlook). Degree from an accredited nursing school required (prefer Bachelor of Science in Nursing). Minimum of 3 to 5 years of clinical nursing experience; prefer previous orthopedic, emergency room, critical care, home care or rehab care experience. Previous medical case management experience a plus. Must also have current unrestricted registered nurse (R.N.) license in the state where the position is based and other assigned states as required by law. Must have additional professional certifications, such as CCM, COHN, CRRN, etc., where required by WC law. About Us Pay Philosophy: The typical starting salary range for this role is determined by a number of factors including skills, experience, education, certifications and location. The full salary range for this role reflects the competitive labor market value for all employees in these positions across the national market and provides an opportunity to progress as employees grow and develop within the role. Some roles at Liberty Mutual have a corresponding compensation plan which may include commission and/or bonus earnings at rates that vary based on multiple factors set forth in the compensation plan for the role. At Liberty Mutual, our goal is to create a workplace where everyone feels valued, supported, and can thrive. We build an environment that welcomes a wide range of perspectives and experiences, with inclusion embedded in every aspect of our culture and reflected in everyday interactions. This comes to life through comprehensive benefits, workplace flexibility, professional development opportunities, and a host of opportunities provided through our Employee Resource Groups. Each employee plays a role in creating our inclusive culture, which supports every individual to do their best work. Together, we cultivate a community where everyone can make a meaningful impact for our business, our customers, and the communities we serve. We value your hard work, integrity and commitment to make things better, and we put people first by offering you benefits that support your life and well-being. To learn more about our benefit offerings please visit: *********************** Liberty Mutual is an equal opportunity employer. We will not tolerate discrimination on the basis of race, color, national origin, sex, sexual orientation, gender identity, religion, age, disability, veteran's status, pregnancy, genetic information or on any basis prohibited by federal, state or local law. Fair Chance Notices California Los Angeles Incorporated Los Angeles Unincorporated Philadelphia San Francisco We can recommend jobs specifically for you! Click here to get started.

If you're a registered nurse looking for a new opportunity to work in a fast-paced, professional environment where your talent contributes to our competitive edge, Liberty Mutual Insurance has the opportunity for you. Under general technical direction, responsible for medically managing assigned caseload and by applying clinical expertise ensure individuals receive appropriate healthcare in order to return to work and normal activity in a timely and cost effective manner. Caseload may include catastrophic/complex medical/disability cases, lost time, and/or medical only claims. Also act as a clinical resource for field claim partners. This is a remote position, however, you will be required to report into the office twice a month per business requirements if you reside within 50 miles of the following offices: Lake Oswego, OR, Chandler, AZ, Hoffman Estates, IL, Suwanee, GA, Indianapolis, IN, Plano, TX, Boston, MA, Westborough, MA, Las Vegas, NV, and Weatogue, CT . Please note this policy is subject to change. Responsibilities: Follows Liberty Mutual's established standards and protocols to effectively manage assigned caseload of medical/disability cases and by applying clinical expertise assist to achieve optimal outcome and to facilitate claim resolution and disposition. Effectively communicates with injured employees, medical professionals, field claims staff, attorneys, and others to obtain information, and to negotiate medical treatment and return to work plans using critical thinking skills, clinical expertise and other resources as needed to achieve an optimal case outcome. Utilizes the Nursing Process (assessment, diagnosis, planning, intervention and evaluation) to facilitate medical management to attain maximum medical improvement and return-to-work (RTW) per state jurisdictional requirements. Appropriately utilizes internal and external resources and referrals i.e., Utilization Review, Peer Review, Field Claims Specialists, Regional Medical Director Consults, and Vocational Rehabilitation to achieve best possible case outcome. Follows general technical direction from nurse manager, senior medical and disability case manager and/or CCMU staff to resolve highly complex medical and/or RTW issues and/or successfully manage catastrophic injuries. Documents all RN activities accurately, concisely and on a timely basis. This includes documenting the medical and disability case management strategies for claim resolution, based on clinical expertise. Adheres to confidentiality policy. Appropriately applies clinical expertise to claims and delivers services in an efficient and effective manner. Accurately and appropriately documents time tracking for work performed. Achieves annual time tracking goal. Handles special projects as assigned. Qualifications Ability to analyze and make sound nursing judgments and to accurately document activities. Strong communication skills in order to build relationships with injured employees, medical professionals, employers, field claims staff and others. Good negotiation skills to effectively establish target return to work dates and coordinate medical care. Knowledge of state, local and federal laws related to health care delivery preferred. Personal computer knowledge and proficiency in general computer applications such as Internet Explorer and Microsoft Office (including Word, Excel and Outlook). Degree from an accredited nursing school required (prefer Bachelor of Science in Nursing). Minimum of 3 to 5 years of clinical nursing experience; prefer previous orthopedic, emergency room, critical care, home care or rehab care experience. Previous medical case management experience a plus. Must also have current unrestricted registered nurse (R.N.) license in the state where the position is based and other assigned states as required by law. Must have additional professional certifications, such as CCM, COHN, CRRN, etc., where required by WC law. About Us Pay Philosophy: The typical starting salary range for this role is determined by a number of factors including skills, experience, education, certifications and location. The full salary range for this role reflects the competitive labor market value for all employees in these positions across the national market and provides an opportunity to progress as employees grow and develop within the role. Some roles at Liberty Mutual have a corresponding compensation plan which may include commission and/or bonus earnings at rates that vary based on multiple factors set forth in the compensation plan for the role. At Liberty Mutual, our goal is to create a workplace where everyone feels valued, supported, and can thrive. We build an environment that welcomes a wide range of perspectives and experiences, with inclusion embedded in every aspect of our culture and reflected in everyday interactions. This comes to life through comprehensive benefits, workplace flexibility, professional development opportunities, and a host of opportunities provided through our Employee Resource Groups. Each employee plays a role in creating our inclusive culture, which supports every individual to do their best work. Together, we cultivate a community where everyone can make a meaningful impact for our business, our customers, and the communities we serve. We value your hard work, integrity and commitment to make things better, and we put people first by offering you benefits that support your life and well-being. To learn more about our benefit offerings please visit: *********************** Liberty Mutual is an equal opportunity employer. We will not tolerate discrimination on the basis of race, color, national origin, sex, sexual orientation, gender identity, religion, age, disability, veteran's status, pregnancy, genetic information or on any basis prohibited by federal, state or local law. Fair Chance Notices California Los Angeles Incorporated Los Angeles Unincorporated Philadelphia San Francisco We can recommend jobs specifically for you! Click here to get started.

If you're a registered nurse looking for a new opportunity to work in a fast-paced, professional environment where your talent contributes to our competitive edge, Liberty Mutual Insurance has the opportunity for you. Under general technical direction, responsible for medically managing assigned caseload and by applying clinical expertise ensure individuals receive appropriate healthcare in order to return to work and normal activity in a timely and cost effective manner. Caseload may include catastrophic/complex medical/disability cases, lost time, and/or medical only claims. Also act as a clinical resource for field claim partners. This is a remote position, however, you will be required to report into the office twice a month per business requirements if you reside within 50 miles of the following offices: Lake Oswego, OR, Chandler, AZ, Hoffman Estates, IL, Suwanee, GA, Indianapolis, IN, Plano, TX, Boston, MA, Westborough, MA, Las Vegas, NV, and Weatogue, CT . Please note this policy is subject to change. Responsibilities: Follows Liberty Mutual's established standards and protocols to effectively manage assigned caseload of medical/disability cases and by applying clinical expertise assist to achieve optimal outcome and to facilitate claim resolution and disposition. Effectively communicates with injured employees, medical professionals, field claims staff, attorneys, and others to obtain information, and to negotiate medical treatment and return to work plans using critical thinking skills, clinical expertise and other resources as needed to achieve an optimal case outcome. Utilizes the Nursing Process (assessment, diagnosis, planning, intervention and evaluation) to facilitate medical management to attain maximum medical improvement and return-to-work (RTW) per state jurisdictional requirements. Appropriately utilizes internal and external resources and referrals i.e., Utilization Review, Peer Review, Field Claims Specialists, Regional Medical Director Consults, and Vocational Rehabilitation to achieve best possible case outcome. Follows general technical direction from nurse manager, senior medical and disability case manager and/or CCMU staff to resolve highly complex medical and/or RTW issues and/or successfully manage catastrophic injuries. Documents all RN activities accurately, concisely and on a timely basis. This includes documenting the medical and disability case management strategies for claim resolution, based on clinical expertise. Adheres to confidentiality policy. Appropriately applies clinical expertise to claims and delivers services in an efficient and effective manner. Accurately and appropriately documents time tracking for work performed. Achieves annual time tracking goal. Handles special projects as assigned. Qualifications Ability to analyze and make sound nursing judgments and to accurately document activities. Strong communication skills in order to build relationships with injured employees, medical professionals, employers, field claims staff and others. Good negotiation skills to effectively establish target return to work dates and coordinate medical care. Knowledge of state, local and federal laws related to health care delivery preferred. Personal computer knowledge and proficiency in general computer applications such as Internet Explorer and Microsoft Office (including Word, Excel and Outlook). Degree from an accredited nursing school required (prefer Bachelor of Science in Nursing). Minimum of 3 to 5 years of clinical nursing experience; prefer previous orthopedic, emergency room, critical care, home care or rehab care experience. Previous medical case management experience a plus. Must also have current unrestricted registered nurse (R.N.) license in the state where the position is based and other assigned states as required by law. Must have additional professional certifications, such as CCM, COHN, CRRN, etc., where required by WC law. About Us Pay Philosophy: The typical starting salary range for this role is determined by a number of factors including skills, experience, education, certifications and location. The full salary range for this role reflects the competitive labor market value for all employees in these positions across the national market and provides an opportunity to progress as employees grow and develop within the role. Some roles at Liberty Mutual have a corresponding compensation plan which may include commission and/or bonus earnings at rates that vary based on multiple factors set forth in the compensation plan for the role. At Liberty Mutual, our goal is to create a workplace where everyone feels valued, supported, and can thrive. We build an environment that welcomes a wide range of perspectives and experiences, with inclusion embedded in every aspect of our culture and reflected in everyday interactions. This comes to life through comprehensive benefits, workplace flexibility, professional development opportunities, and a host of opportunities provided through our Employee Resource Groups. Each employee plays a role in creating our inclusive culture, which supports every individual to do their best work. Together, we cultivate a community where everyone can make a meaningful impact for our business, our customers, and the communities we serve. We value your hard work, integrity and commitment to make things better, and we put people first by offering you benefits that support your life and well-being. To learn more about our benefit offerings please visit: *********************** Liberty Mutual is an equal opportunity employer. We will not tolerate discrimination on the basis of race, color, national origin, sex, sexual orientation, gender identity, religion, age, disability, veteran's status, pregnancy, genetic information or on any basis prohibited by federal, state or local law. Fair Chance Notices California Los Angeles Incorporated Los Angeles Unincorporated Philadelphia San Francisco We can recommend jobs specifically for you! Click here to get started.

If you're a registered nurse looking for a new opportunity to work in a fast-paced, professional environment where your talent contributes to our competitive edge, Liberty Mutual Insurance has the opportunity for you. Under general technical direction, responsible for medically managing assigned caseload and by applying clinical expertise ensure individuals receive appropriate healthcare in order to return to work and normal activity in a timely and cost effective manner. Caseload may include catastrophic/complex medical/disability cases, lost time, and/or medical only claims. Also act as a clinical resource for field claim partners. This is a remote position, however, you will be required to report into the office twice a month per business requirements if you reside within 50 miles of the following offices: Lake Oswego, OR, Chandler, AZ, Hoffman Estates, IL, Suwanee, GA, Indianapolis, IN, Plano, TX, Boston, MA, Westborough, MA, Las Vegas, NV, and Weatogue, CT . Please note this policy is subject to change. Responsibilities: Follows Liberty Mutual's established standards and protocols to effectively manage assigned caseload of medical/disability cases and by applying clinical expertise assist to achieve optimal outcome and to facilitate claim resolution and disposition. Effectively communicates with injured employees, medical professionals, field claims staff, attorneys, and others to obtain information, and to negotiate medical treatment and return to work plans using critical thinking skills, clinical expertise and other resources as needed to achieve an optimal case outcome. Utilizes the Nursing Process (assessment, diagnosis, planning, intervention and evaluation) to facilitate medical management to attain maximum medical improvement and return-to-work (RTW) per state jurisdictional requirements. Appropriately utilizes internal and external resources and referrals i.e., Utilization Review, Peer Review, Field Claims Specialists, Regional Medical Director Consults, and Vocational Rehabilitation to achieve best possible case outcome. Follows general technical direction from nurse manager, senior medical and disability case manager and/or CCMU staff to resolve highly complex medical and/or RTW issues and/or successfully manage catastrophic injuries. Documents all RN activities accurately, concisely and on a timely basis. This includes documenting the medical and disability case management strategies for claim resolution, based on clinical expertise. Adheres to confidentiality policy. Appropriately applies clinical expertise to claims and delivers services in an efficient and effective manner. Accurately and appropriately documents time tracking for work performed. Achieves annual time tracking goal. Handles special projects as assigned. Qualifications Ability to analyze and make sound nursing judgments and to accurately document activities. Strong communication skills in order to build relationships with injured employees, medical professionals, employers, field claims staff and others. Good negotiation skills to effectively establish target return to work dates and coordinate medical care. Knowledge of state, local and federal laws related to health care delivery preferred. Personal computer knowledge and proficiency in general computer applications such as Internet Explorer and Microsoft Office (including Word, Excel and Outlook). Degree from an accredited nursing school required (prefer Bachelor of Science in Nursing). Minimum of 3 to 5 years of clinical nursing experience; prefer previous orthopedic, emergency room, critical care, home care or rehab care experience. Previous medical case management experience a plus. Must also have current unrestricted registered nurse (R.N.) license in the state where the position is based and other assigned states as required by law. Must have additional professional certifications, such as CCM, COHN, CRRN, etc., where required by WC law. About Us Pay Philosophy: The typical starting salary range for this role is determined by a number of factors including skills, experience, education, certifications and location. The full salary range for this role reflects the competitive labor market value for all employees in these positions across the national market and provides an opportunity to progress as employees grow and develop within the role. Some roles at Liberty Mutual have a corresponding compensation plan which may include commission and/or bonus earnings at rates that vary based on multiple factors set forth in the compensation plan for the role. At Liberty Mutual, our goal is to create a workplace where everyone feels valued, supported, and can thrive. We build an environment that welcomes a wide range of perspectives and experiences, with inclusion embedded in every aspect of our culture and reflected in everyday interactions. This comes to life through comprehensive benefits, workplace flexibility, professional development opportunities, and a host of opportunities provided through our Employee Resource Groups. Each employee plays a role in creating our inclusive culture, which supports every individual to do their best work. Together, we cultivate a community where everyone can make a meaningful impact for our business, our customers, and the communities we serve. We value your hard work, integrity and commitment to make things better, and we put people first by offering you benefits that support your life and well-being. To learn more about our benefit offerings please visit: *********************** Liberty Mutual is an equal opportunity employer. We will not tolerate discrimination on the basis of race, color, national origin, sex, sexual orientation, gender identity, religion, age, disability, veteran's status, pregnancy, genetic information or on any basis prohibited by federal, state or local law. Fair Chance Notices California Los Angeles Incorporated Los Angeles Unincorporated Philadelphia San Francisco We can recommend jobs specifically for you! Click here to get started.