Nurse Case Manager jobs at Fallon Health

This position covers Boston/Suffolk County plus surrounding Middlesex County including Allston, Ashland, Auburndale, Babson Park, Belmont, Boston/East Boston, Brighton, Brookline, Brookline Village, Cambridge, Charlestown, Chestnut Hill, Dover, Framinham, Hyde Park, Jamaica Plain, Mattapan, Natick, Needham, Needham Heights, Newton, Newtonville, Nonatum, North Waltham, Waltham, Readville, Roslindale, Sherborn, Somerville, Waban, Watertown, Waverley, Wayland, Wellesely, West Newton, West Roxbury and Weston. About us: Fallon Health is a company that cares. We prioritize our members-always-making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, Fallon Health delivers equitable, high-quality, coordinated care and is continually rated among the nation's top health plans for member experience, service, and clinical quality. We believe our individual differences, life experiences, knowledge, self-expression, and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status, and other characteristics that make people unique. Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs-including Medicare, Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)- in the region. Learn more at fallonhealth.org or follow us on Facebook, Twitter and LinkedIn. Brief summary of purpose: The Nurse Case Manager (NCM) is an integral part on an interdisciplinary team focused on care coordination, care management and improving access to and quality of care for Fallon members. NCM seeks to establish telephonic and/or face to face relationships with the member/caregiver(s) to better ensure ongoing service provision and care coordination, consistent with the member specific care plan developed by the NCM and Care Team. Responsibilities may include conducting in home face to face visits for member identified as needing face to face visit interaction and assessments with the goal to coordinate and facilitate services to meet member needs according to benefit structures and available community resources. The NCM may conduct assessments and may determine the number of hours' members require for MassHealth programs such as the personal care attendant program, adult foster care, group adult foster care, and other programs per product benefits and guidelines. The NCM may utilize an ACD line to support department and incoming/outgoing calls with the goal of first call resolution with each interaction. Responsibilities Note: Job Responsibilities may vary depending upon the member's Fallon Health Product Member Assessment, Education, and Advocacy Telephonically assesses and case manages a member panel May conduct in home face to face visits for onboarding new enrollees and reassessing members, utilizing a variety of interviewing techniques, including motivational interviewing, and employs culturally sensitive strategies to assess a Member's clinical/functional status to identify ongoing special conditions and develops and implements an individualized,coordinated care plan, in collaboration with the member, the Clinical Integration team, and Primary Care Providers, Specialist and other community partners, to ensure a cost effective quality outcome Performs medication reconciliations Performs Care Transitions Assessments - per Program and product line processes Utilizing clinical judgment and nursing assessment skills, may complete NaviCare Program Assessment Tools and Minimum Data Set Home Care (MDS HC) Form when a member's medical/functional status changes that warrants a change in rating category to ensure members are in the correct State defined rating category Maintains up to date knowledge of Program and product line benefits, Plan Evidence of Coverage details, and department policies and processes and follows policies and processes as outlined to be able to provide education to members and providers; performing a member advocacy and education role including but not limited to member rights Serves as an advocate for members to ensure they receive Fallon Health benefits as appropriate and if member needs are identified but not covered by Fallon Health, works with community agencies to facilitate access to programs such as community transportation, food programs, and other services available through senior centers and other external partners Follows department and regulatory standards to authorize and coordinate healthcare services ensuring timeliness in compliance with documented care plan goals and objectives Assesses the Member's knowledge about the management of current disease processes and medication regimen, provides teaching to increase Member/caregiver knowledge, and works with the members to assist with learning how to self- manage his or her health needs, social needs or behavioral health needs Collaborates with appropriate team members to ensure health education/disease management information is provided as identified Collaborates with the interdisciplinary team in identifying and addressing high risk members Educate members on preventative screenings and other health care procedures such as vaccines, screenings according to established protocols and program processes such initiatives involving Key Metrics outreach Ensures members/PRAs participate in the development and approval of their care plans in conjunction with the interdisciplinary primary care team Strictly observes HIPAA regulations and the Fallon Health Policies regarding confidentiality of member information Supports Quality and Ad-Hoc campaigns Care Coordination and Collaboration Provides culturally appropriate care coordination, i.e. works with interpreters, provides communication approved documents in the appropriate language, and demonstrates culturally appropriate behavior when working with member, family, caregivers, and/or authorized representatives With member/authorized representative(s) collaboration develops member centered care plans by identifying member care needs while completing program assessments and working with the Navigator to ensure the member approves their care plan Manages NaviCare members in conjunction with the Navigator, Behavioral Health Case Manager, Aging Service Access Point Geriatric Support Service Coordinator, contracted Primary Care Providers and others involved/authorized in the member's care Manages ACO members in conjunction with the Navigator, Social Care Managers, ACO Partners, Community Partners, Behavioral Health Partners and others involved/authorized in the member's care Monitors progression of member goals and care plan goals, provides feedback and works collaboratively with care team members and work effectively in a team model approach to coordinate a continuum of care consistent with the Member's health care goals and needs Works collaboratively with Fallon Health Pharmacist, referring members in need of medication review based upon Program process Develops and fosters relationships with members, family, caregivers, PRAs, vendors and providers to ensure good collaboration and coordination by streamlining the focus of the Member's healthcare needs utilizing the most optimal treatment approach, promoting timely provision of care, enhancing quality of life, and promoting cost-effectiveness of care Actively participates in clinical rounds Provider Partnerships and Collaboration May attend in person care plan meetings with providers and office staff and may lead care plan review with providers and care team as applicable. Demonstrates positive customer service actions and takes responsibility to ensure member and provider requests and needs are met Regulatory Requirements - Actions and Oversight Completes Program Assessments, Notes, Screenings, and Care Plans in the Centralized Enrollee Record according to product regulatory requirements and Program policies and processes Knowledge of and compliance with HEDIS and Medicare 5 Star measure processes, performing member education, outreach, and actions in conjunction with the Navigator and other members of the Clinical Integration and Partner Teams Performs other responsibilities as assigned by the Manager/designee Supports department colleagues, covering and assuming changes in assignment as assigned by Manager/designee Qualifications Education: Graduate from an accredited school of nursing mandatory and a Bachelors (or advanced) degree in nursing or a health care related field preferred. License: Active, unrestricted license as a Registered Nurse in Massachusetts Certification: Certification in Case Management strongly desired Other: Satisfactory Criminal Offender Record Information (CORI) results and reliable transportation Experience: • 1+ years of clinical experience as a Registered Nurse managing chronically ill members or experience in a coordinated care program required • Understanding of Hospitalization experiences and the impacts and needs after facility discharge required • Experience working face to face with members and providers preferred • Experience with telephonic interviewing skills and working with a diverse population, that may also be Non-English speaking, required • Home Health Care experience preferred • Effective case management and care coordination skills and the ability to assess a member's activities of daily function and independent activities of daily function and the ability to develop and implement a care plan that meets the member's need working in partnership with a care team preferred • Familiarity with NCQA case management requirements preferred Performance Requirements including but not limited to: • Excellent communication and interpersonal skills with members and providers via telephone and in person • Exceptional customer service skills and willingness to assist ensuring timely resolution • Excellent organizational skills and ability to multi-task • Appreciation and adherence to policy and process requirements • Independent learning skills and success with various learning methodologies including but not limited to: self-study, mentoring, classroom, and group education • Working with an interdisciplinary care team as a partner demonstrating respect and value for all roles and is a positive contributor within job role scope and duties • Willingness to learn insurance regulatory and accreditation requirements • Knowledgeable about software systems including but not limited to Microsoft Office Products - Excel, Outlook, and Word • Familiar with Excel spreadsheets to manage work and exposure and familiarity with pivot tables • Accurate and timely data entry • Effective case management and care coordination skills and the ability to assess a member's activities of daily function and independent activities of daily function and the ability to develop and implement a care plan that meets the member's need • Knowledge about community resources, levels of care, criteria for levels of care and the ability to appropriately develop and implement a care plan following regulatory guidelines and level of care criteria • Ability to effectively respond and adapt to changing business needs and be an innovative and creative problem solver Competencies: • Demonstrates commitment to the Fallon Health Mission, Values, and Vision • Specific competencies essential to this position: Problem Solving Asks good questions Critical thinking skills; looks beyond the obvious Adaptability Handles day to day work challenges confidently Willing and able to adjust to multiple demands, shifing priorities, ambiguity, and rapid change Demonstrates flexibility Written Communication Is able to write clearly and succinctly in a variety of communication settings and styles. Pay Range Disclosure: In accordance with the Massachusetts Wage Transparency Act, the pay range for this position is $88,000 - $95,000 per year, which reflects what we reasonably and in good faith expect to pay at the time of posting. Final compensation will depend on the candidate's experience, skills, and fit with the role's responsibilities. Fallon Health 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. #P01 Not Ready to Apply? Join our Talent Community now!

Allied Digestive Health is one of the largest integrated networks of gastroenterology care centers in the nation with over 200 providers and 60 locations throughout New Jersey and New York. As a fast-growing physician-led organization, our dynamic structure encourages physician input and decision-making, while simultaneously offering operational support. Our dedicated, compassionate team of providers prioritize personalized treatment plans for patients that deliver the highest quality of care. All of our doctors are board-certified in gastroenterology and hepatology. Several of them serve as chief of gastroenterology at nearby hospitals, and a number of them have been recognized as top-quality physicians in publications, including but not limited to: Best Doctors in America and Top Doctors New Jersey, and US News Health - US News & World Report. We are excited to announce that we are looking for a Full-Time Nurse Manager at Albany Gastroenterology Consultants of Albany New York. To Learn more about our practice please click the link below ********************* Job Summary: The Nurse Manager is responsible for managing and supervising various departments within the Practice. They have a wide range of knowledge of basic patient wellbeing. Experienced in both nursing and management, the nurse manager is also trained to supervise and guide nurses and nursing programs. The Nurse Manager Responsibilities are: Promote and restore patients' health by developing day-to-day management Direct and develop nursing staff by creating schedules, offering advice, and answering any health-related questions Collaborates with providers Enforces adherence to the state board of nursing and state nurse practice requirements. Maintains nursing staff by recruiting, selecting, orienting, and training nurses and auxiliary staff. Completes patient care requirements by scheduling and assigning nursing and staff. Maintains nursing staff by coaching, counseling, and disciplining through monitoring and appraising nurses' job performance. Provides information to patients and the health care team by answering questions and requests. Maintains a safe and clean working environment by designing health procedures and protocols. Maintains a cooperative relationship among health care teams by communicating information and participating in team-building exercises. The Nurse Manager must have the following qualifications and experience: Associates or bachelor's degree in nursing from an accredited college or university Registered Nurse (RN) required Minimum of 5 years nursing experience Minimum of 3-4 years management experience with the ability to provide leadership to the department Key Benefits: Health Benefits Day one to include Major Medical, Dental, Vision, Prescription, Life insurance, and disability 401K 3% safe harbor contribution Sign on Bonus of $500.00 PTO Employee Assistance Program Commuter Benefits About the Community: Located in Albany, NY is located on the historic Hudson River. Albany has a vibrant culture with influence from NYC to the south, and Montreal to the North! There are beautiful festivals, and theater productions! Great neighborhoods and schools make Albany a great location to grow a practice in a vibrant community

VNS Health Home Care RNs redefine the standard of patient-centered care for New Yorkers while keeping them out of the crowded hospital system so they can heal and age where they are most comfortable- in their homes and community. Our nurses provide the Future of Care by meeting patients where they are. We design and deliver individualized care plans and exceptional clinical outcomes to our neighbors most in need. Be part of our 130-year history and innovative Future of Care built by visiting nurses like you. Bilingual Skills Required: Cantonese or Mandarin What We Provide Attractive sign-on bonus and referral bonus opportunities Generous paid time off (PTO), starting at 31 days and 9 paid company holidays No employee contribution cost or annual deductible for health insurance including Medical, Dental, and Vision for you and your loved ones w (Medical, Dental, Vision); Life and Disability Insurance Training: 4-weeks paid clinical orientation, preceptorship, and ongoing skills labs Tuition reimbursement following 6 months and CEU credits Employer-matched retirement savings program Personal and financial wellness programs Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care Opportunities to contribute to clinical research and other organizational projects What You Will Do Practice independently in the community as part of an interdisciplinary care team. Deliver personalized nursing and care management to patients in their home or care facilities. Constantly evaluate evolving patient needs and respond with plan of care adjustments. Qualifications Current license to practice as a Registered Nurse in New York State Minimum of one year nursing experience in a medical/surgical environment Valid driver's license or NYS Non-Driver photo ID card may be required Wound Care Certification preferred Certification in Hospice and Palliative Care Nursing preferred Cantonese or Mandarin bilingual skills required Pay Range USD $112,209.00 - USD $138,409.00 /Yr. About Us VNS Health is one of the nation's largest nonprofit home and community-based health care organizations. Innovating in health care for more than 130 years, our commitment to health and well-being is what drives us - we help people live, age and heal where they feel most comfortable, in their own homes, connected to their family and community. On any given day, more than 10,000 VNS Health team members deliver compassionate care, unparalleled expertise and 24/7 solutions and resources to the more than 43,000 “neighbors” who look to us for care. Powered and informed by data analytics that are unmatched in the home and community-health industry, VNS Health offers a full range of health care services, solutions and health plans designed to simplify the health care experience and meet the diverse and complex needs of the communities and people we serve in New York and beyond.

Full Time Nurse Manager Allied Digestive Health is one of the largest integrated networks of gastroenterology care centers in the nation with over 200 providers and 60 locations throughout New Jersey and New York. As a fast-growing physician-led organization, our dynamic structure encourages physician input and decision-making, while simultaneously offering operational support. Our dedicated, compassionate team of providers prioritize personalized treatment plans for patients that deliver the highest quality of care. All of our doctors are board-certified in gastroenterology and hepatology. Several of them serve as chief of gastroenterology at nearby hospitals, and a number of them have been recognized as top-quality physicians in publications, including but not limited to: Best Doctors in America and Top Doctors New Jersey, and US News Health - US News & World Report. We are excited to announce that we are looking for a Full-Time Nurse Manager at Albany Gastroenterology Consultants of Albany New York. The Nurse Manager is responsible for managing and supervising various departments within the Practice. They have a wide range of knowledge of basic patient wellbeing. Experienced in both nursing and management, the nurse manager is also trained to supervise and guide nurses and nursing programs. The Nurse Manager Responsibilities are : Promote and restore patients' health by developing day-to-day management Direct and develop nursing staff by creating schedules, offering advice, and answering any health-related questions Enforces adherence to the state board of nursing and state nurse practice requirements. Maintains nursing staff by recruiting, selecting, orienting, and training nurses and auxiliary staff. Completes patient care requirements by scheduling and assigning nursing and staff. Maintains nursing staff by coaching, counseling, and disciplining through monitoring and appraising nurses' job performance. Provides information to patients and the health care team by answering questions and requests. Maintains a safe and clean working environment by designing health procedures and protocols. Maintains a cooperative relationship among health care teams by communicating information and participating in team-building exercises. The Nurse Manager must have the following qualifications and experience: Associates or bachelor's degree in nursing from an accredited college or university Registered Nurse (RN) required Minimum of 5 years nursing experience Minimum of 3-4 years management experience with the ability to provide leadership to the department Health Benefits Day one to include Major Medical, Dental, Vision, Prescription, Life insurance, and disability ~Sign on Bonus of $500.00 ~ Employee Assistance Program ~ About the Community: Great neighborhoods and schools make Albany a great location to grow a practice in a vibrant community

Charles Taylor is a highly successful global provider of professional services to the insurance industry. We are seeking an experienced Workers Compensation Field Case Manager to join our team in the Cincinnati-North Dayton-Columbus, OH area. This is a remote, contracted role. Job Summary The Field Case Manager is responsible for assisting our clients injured workers with case management and return to work services. Essential Duties and Responsibilities * Provide field case management services for our clients injured workers, including onsite attendance at doctor's appointments * Perform case assessments and develop action plans to support recovery and timely return to work * Coordinate timely access to needed medical services and maintain proactive communications * Cultivate excellent relationships with all parties (AE's, IWs, providers, clients) * Provide written reports on case status and updates (post, physician visit/weekly/monthly) and submits timely monthly billing to billing specialist. Contracted CM Requirements * Prior Field Case Management - workers' compensation experience preferred * Active Registered nurse (R.N. License and possess the ability to be licensed as a registered nurse in multiple states without restrictions) * Understanding and working knowledge of ODG Guidelines * Seasoned professional nurse with clinical nursing experience and at least 2-years case management experience with injured workers * Understanding of case management processes * Excellent interpersonal communication skills - both oral and written * Professional certifications such as: CDMS, CRRN, COHN, or CCM are a plus Values At Charles Taylor, our values define our identity, principles and conduct. This person will demonstrate and champion Charles Taylor Values by ensuring Agility, Integrity, Care, Accountability and Collaboration. AAP/EEO Statement Here at Charles Taylor we are proud to be an Inclusive Employer. We provide an environment of mutual respect with zero tolerance to discrimination of any kind regardless of age, disability, gender identity, marital/ family status, race, religion, sex, or sexual orientation. Our external partnerships and the dedicated work we do in promoting a transparent and fair recruitment and selection process all contribute to the successful, inclusive, and diverse culture and environment which we are proud to be a part of at Charles Taylor.

Pay Range: $73,500.00 - $110,300.00 Please email HR_Talent_************************** if you are a candidate seeking a reasonable accommodation for the application and/or interview process. At BCBSRI, our greatest resource is our people. We come from varying backgrounds, different cultures, and unique experiences. We are hard-working, caring, and creative individuals who collaborate, support one another, and grow together. Passion, empathy, and understanding are at the forefront of everything we do-not just for our members, but for our employees as well. We recognize that to do your best work, you have to be your best self. It's why we offer flexible work arrangements that include remote and hybrid opportunities and paid time off. We provide tuition reimbursement and assist with student-loan repayment. We offer health, dental, and vision insurance as well as programs that support your mental health and well-being. We pay competitively, offer bonuses and investment plans, and are committed to growing and developing our employees. Our culture is one of belonging. We strive to be transparent and accountable. We believe in equipping our associates with the knowledge and resources they need to be successful. No matter where you're at in the organization, you're an integral part of our team and your input, thoughts, and ideas are valued. Join others who value a workplace for all. We appreciate and celebrate everything that makes us unique, from personal characteristics to past experiences. Our different perspectives strengthen us as an organization and help us better serve all Rhode Islanders. We're dedicated to serving Rhode Islanders. Our focus extends beyond providing access to high-quality, affordable, and equitable care. To further improve the health and well-being of our fellow Rhode Islanders, we regularly roll up our sleeves and get to work (literally) in communities all across the state-building homes, working in food pantries, revitalizing community centers, and transforming outdoor spaces for children and adults. Because we believe it is our collective responsibility to uplift our fellow Rhode Islanders when and where we can, our associates receive additional paid time to volunteer. What you will do: Manage members through evidence-based care, promoting access to the healthcare system, and assessing needs to identify appropriate interventions and support services as well as reduce barriers to evidence-based care. Member management includes, but is not limited to, conducting health assessments (telephonic and face-to-face) to identify high-risk or emerging risk members for education and intervention; evaluating and modifying action plans by working with members and collaborating with providers. Evaluate member services to ensure appropriate levels and coordination of care, including pre-authorization, concurrent review, quality-of-care screening, and discharge planning. Ensure member and provider satisfaction by demonstrating knowledge of member plan benefits and community resources. Identify opportunities to moderate claims costs for employer group and individual members. Promote and monitor use of wraparound service programs for optimal member experience while managing chronic and acute care needs. Facilitate communication between members, providers, and stakeholders to coordinate and implement action plans for improving members' total health. Provide continuity and consistency of care by building positive relationships between members, families, providers, care coordinators, social support partners, and the health plan. Engage in team operations including supervision, team huddles, staff meetings, case rounds, metric management, training opportunities, department initiatives, and projects. Work collaboratively to develop and implement solutions, identify barriers, and exemplify corporate values through accountability, collaboration, integrity, and respect. Perform other duties as assigned What you'll need to succeed: Unrestricted Rhode Island Nursing License Unrestricted Massachusetts Nursing License Three years' experience in a medical/clinical environment or managed health plan Must obtain Certified Case Manager (CCM) certification within three years of employment The extras: Bachelor's degree in nursing Certified Case Manager (CCM) Reside in Rhode Island or other Nurse Licensure Compact state (NLC) Bilingual Spanish, Portuguese Experience working in a managed care/health maintenance organization Experience implementing and upholding Quality, CMS, NCQA requirements Knowledge of utilization management and/or coordination of care Knowledge of population health and chronic condition management principles, aligning with corporate initiatives such as specialty within high-risk maternity and rising risk conditions such as diabetes, hypertension, COPD, etc. Understanding of health care delivery system access points and services Demonstration of successful (member) engagement via application of Motivational Interviewing techniques and health coaching Ability to navigate the healthcare delivery system Understanding of evidence-based care programs and approaches Strategic and critical thinking skills Strong analytical skills Strong business acumen Strong presentation negotiation, problem-solving, and decision-making skills Strong written and verbal communication skills Ability to work effectively with a wide variety of people in individual and group settings Strong organizing skills, with the ability to prioritize and respond to shifting deadlines Strong time management skills Location: BCBSRI is headquartered in downtown Providence, conveniently located near the train station and bus terminal. We actively support associate well-being and work/life balance and offer the following schedules, based on role: In-office: onsite 5 days per week Hybrid: onsite 2-4 days per week Remote: onsite 0-1 days per week. Permitted to reside in the following states, pending approval from the Human Resources Department: Arizona, Connecticut, Florida, Georgia, Louisiana, Massachusetts, North Carolina, Oklahoma, Rhode Island, South Carolina, Texas, Virginia Our culture of belonging at Blue Cross & Blue Shield of Rhode Island (BCBSRI) is at the core of all we do, and it strengthens our ability to meet the challenges of today's healthcare industry. BCBSRI is an equal opportunity employer. The law requires an employer to post notices describing the Federal laws. Please visit ************************************************************** to view the "Know Your Rights" poster.

AMERISAFE is seeking a detail-oriented, productivity driven professional to add to our Florida based Workers Compensation Claims Team. In this position, you will conduct on-site and in-person investigations, determine compensability, establish reserves, document decision making, issue benefit payments, and make notifications to the State administrative authority. You will work with injured workers, employers, medical and legal professionals to ensure the appropriate benefits are provided to injured workers under the appropriate Workers' Compensation Laws. In addition to the benefits listed on our careers page, other benefits of this position include: Salaried position based on location and experience ($50,000 to $95,000) Auto reimbursement program Reimbursement for cell phone and internet Target Case Load of 60 claims Upon an offer and acceptance of employment with AMERISAFE, you will be required to complete our pre-employment screening, which includes a criminal background check, a 10-panel drug test and, if applicable, a review of your motor vehicle report. A 10-panel drug test includes amphetamine/methamphetamine, barbiturates, benzodiazepines, cocaine metabolite (BZE), marijuana metabolite (THCA), methadone, methaqualone, codeine/morphine, phencyclidine, propoxyphene. Note - All positions that require driving for the company are considered safety-sensitive positions. Qualifications Workers Compensation Claims experience highly preferred. Bachelor's degree or related professional business experience acceptable. State license to handle Workers' Compensation claims if required. Professional written and verbal communication skills required. World class customer service attitude required. Ability to learn and use proprietary software and Microsoft Office products is necessary. The ability to be self-directed. This is a remote position. Valid driver's license, acceptable driving record and acceptable vehicle required. Frequent travel within a designated territory required, but rarely is overnight travel required.

Company Details Berkley Medical Management Solutions (BMMS) provides a different kind of managed-care service for W.R. Berkley Corporation. We believe focusing on an injured worker's successful and speedy return to work is good for people and good for Berkley's insurance operating units. BMMS was first started in 2014 by reimagining the relationship between medical need and technology to deliver the best outcome for injured workers and Berkley's operating units. Our goal was clear: combine solid clinical practices, proven return-to-work strategies and robust software into one system for seamless management of workers' compensation cases. To get it right, we started with a flexible technology platform that allowed for impressive customization without sacrificing the ability for expansion and continued innovation. We deploy integrated systems to give W.R. Berkley Companies recommendations and professional services for managing each individual case in an efficient and appropriate manner. The power of our technology takes medical bill-review services and clinical advisory services to a new level. Our unique marriage of technology, software platforms, data analytics and professional services ensures we provide Berkley's operating units with reliable results, and reduced time and expenses associated with case management. Responsibilities As a Telephonic Nurse Case Manager, you will assess, plan, coordinate, monitor, evaluate and implement options and services to facilitate timely medical care and return to work outcomes of injured workers. * Coordinate and implement medical case management to facilitate case closure * Timely and comprehensive communication with with employers, adjusters and the injured workers. * Assess appropriate utilization of medical treatment and services available through contact with physicians and other specialist to ensure cost effective quality care * Review and analyze medical records and assess data to ensure appropriate case management process occurs while providing recommendations to achieve case progress and movement to closure * Responsible for assigned caseloads, which may vary in numbers, territory and/or by state jurisdiction * Acquire and maintain nursing licensure for all jurisdictions as business needs require * Coordinate services to include home services, durable medical equipment, IMEs, admissions, discharges, and vocational services when appropriate and evaluate cost effectiveness and quality of services * Document activities and case progress using appropriate methods and tools following best practices for quality improvement * Reviewing job analysis/ with all providers to coordinate and implement disability case management. This includes coordinating job analysis with employer to facilitate return to work. * Engage and participate in special projects as assigned by case management leadership team * Occasionally attend on site meetings and professional programs * Foster a teamwork environment * Maintaining and updating evidence based medical guidelines (such as Official Disability Guidelines, MD Guidelines and all required state regulated guidelines) in reference to the injured worker treatment plan and work status. * Obtain and maintain applicable state certifications and/or licensures in the state where job duties are performed. * Obtain case management professional certification (CCM) within 2 years of hire Qualifications * Minimum 2 years of experience in workers compensation insurance and medical case management preferred * Minimum of 4 years medical/surgical clinical experience required * Exhibit strong communication skills, professionalism, flexibility and adaptability * Possess working knowledge of medical and vocational resources available to the Workers' Compensation industry * Demonstrate evidence of self-motivation and the ability to perform case management duties independently * Demonstrate evidence of computer and technology skills * Oral and written fluency in both Spanish and English a plus Education * Graduate of an accredited school of nursing and possess a current RN license. * RN compact license preferred, CCM preferred, Bachelor of Nursing preferred Additional Company Details ****************** The Company is an equal employment opportunity employer We do not accept any unsolicited resumes from external recruiting agencies or firms. The company offers a competitive compensation plan and robust benefits package for full time regular employees • Base Salary Range: $80,000 - $88,000 • Benefits: Health, Dental, Vision, Life, Disability, Wellness, Paid Time Off, 401(k) and Profit-Sharing plans. The actual salary for this position will be determined by a number of factors, including the scope, complexity and location of the role; the skills, education, training, credentials and experience of the candidate; and other conditions of employment. Responsibilities As a Telephonic Nurse Case Manager, you will assess, plan, coordinate, monitor, evaluate and implement options and services to facilitate timely medical care and return to work outcomes of injured workers. - Coordinate and implement medical case management to facilitate case closure - Timely and comprehensive communication with with employers, adjusters and the injured workers. - Assess appropriate utilization of medical treatment and services available through contact with physicians and other specialist to ensure cost effective quality care - Review and analyze medical records and assess data to ensure appropriate case management process occurs while providing recommendations to achieve case progress and movement to closure - Responsible for assigned caseloads, which may vary in numbers, territory and/or by state jurisdiction - Acquire and maintain nursing licensure for all jurisdictions as business needs require - Coordinate services to include home services, durable medical equipment, IMEs, admissions, discharges, and vocational services when appropriate and evaluate cost effectiveness and quality of services - Document activities and case progress using appropriate methods and tools following best practices for quality improvement - Reviewing job analysis/job description with all providers to coordinate and implement disability case management. This includes coordinating job analysis with employer to facilitate return to work. - Engage and participate in special projects as assigned by case management leadership team - Occasionally attend on site meetings and professional programs - Foster a teamwork environment - Maintaining and updating evidence based medical guidelines (such as Official Disability Guidelines, MD Guidelines and all required state regulated guidelines) in reference to the injured worker treatment plan and work status. - Obtain and maintain applicable state certifications and/or licensures in the state where job duties are performed. - Obtain case management professional certification (CCM) within 2 years of hire

Company Details Berkley Medical Management Solutions (BMMS) provides a different kind of managed-care service for W.R. Berkley Corporation. We believe focusing on an injured worker's successful and speedy return to work is good for people and good for Berkley's insurance operating units. BMMS was first started in 2014 by reimagining the relationship between medical need and technology to deliver the best outcome for injured workers and Berkley's operating units. Our goal was clear: combine solid clinical practices, proven return-to-work strategies and robust software into one system for seamless management of workers' compensation cases. To get it right, we started with a flexible technology platform that allowed for impressive customization without sacrificing the ability for expansion and continued innovation. We deploy integrated systems to give W.R. Berkley Companies recommendations and professional services for managing each individual case in an efficient and appropriate manner. The power of our technology takes medical bill-review services and clinical advisory services to a new level. Our unique marriage of technology, software platforms, data analytics and professional services ensures we provide Berkley's operating units with reliable results, and reduced time and expenses associated with case management. Responsibilities As a Telephonic Nurse Case Manager, you will assess, plan, coordinate, monitor, evaluate and implement options and services to facilitate timely medical care and return to work outcomes of injured workers. * Coordinate and implement medical case management to facilitate case closure * Timely and comprehensive communication with with employers, adjusters and the injured workers. * Assess appropriate utilization of medical treatment and services available through contact with physicians and other specialist to ensure cost effective quality care * Review and analyze medical records and assess data to ensure appropriate case management process occurs while providing recommendations to achieve case progress and movement to closure * Responsible for assigned caseloads, which may vary in numbers, territory and/or by state jurisdiction * Acquire and maintain nursing licensure for all jurisdictions as business needs require * Coordinate services to include home services, durable medical equipment, IMEs, admissions, discharges, and vocational services when appropriate and evaluate cost effectiveness and quality of services * Document activities and case progress using appropriate methods and tools following best practices for quality improvement * Reviewing job analysis/ with all providers to coordinate and implement disability case management. This includes coordinating job analysis with employer to facilitate return to work. * Engage and participate in special projects as assigned by case management leadership team * Occasionally attend on site meetings and professional programs * Foster a teamwork environment * Maintaining and updating evidence based medical guidelines (such as Official Disability Guidelines, MD Guidelines and all required state regulated guidelines) in reference to the injured worker treatment plan and work status. * Obtain and maintain applicable state certifications and/or licensures in the state where job duties are performed. * Obtain case management professional certification (CCM) within 2 years of hire Qualifications * Minimum 2 years of experience in workers compensation insurance and medical case management preferred * Minimum of 4 years medical/surgical clinical experience required * Ability to work standard business hours in the either Central Standard Time, Mountain Standard Time or Pacific Time Zone (Monday through Friday, 8:00 AM to 5:00 PM CST/MST/PST). * Exhibit strong communication skills, professionalism, flexibility and adaptability * Possess working knowledge of medical and vocational resources available to the Workers' Compensation industry * Demonstrate evidence of self-motivation and the ability to perform case management duties independently * Demonstrate evidence of computer and technology skills * Oral and written fluency in both Spanish and English a plus Education * Graduate of an accredited school of nursing and possess a current RN license. * A Compact Nursing License is strongly preferred. A California license is ideal but not mandatory. Candidates must be willing and able to obtain a California license within 90 days of their start date. Additional Company Details ****************** The Company is an equal employment opportunity employer We do not accept any unsolicited resumes from external recruiting agencies or firms. The company offers a competitive compensation plan and robust benefits package for full time regular employees • Base Salary Range: $80,000 - $88,000 • Benefits: Health, Dental, Vision, Life, Disability, Wellness, Paid Time Off, 401(k) and Profit-Sharing plans. The actual salary for this position will be determined by a number of factors, including the scope, complexity and location of the role; the skills, education, training, credentials and experience of the candidate; and other conditions of employment. Additional Requirements * Domestic U.S. travel required (up to 10% of time) Sponsorship Details Sponsorship not Offered for this Role Responsibilities As a Telephonic Nurse Case Manager, you will assess, plan, coordinate, monitor, evaluate and implement options and services to facilitate timely medical care and return to work outcomes of injured workers. - Coordinate and implement medical case management to facilitate case closure - Timely and comprehensive communication with with employers, adjusters and the injured workers. - Assess appropriate utilization of medical treatment and services available through contact with physicians and other specialist to ensure cost effective quality care - Review and analyze medical records and assess data to ensure appropriate case management process occurs while providing recommendations to achieve case progress and movement to closure - Responsible for assigned caseloads, which may vary in numbers, territory and/or by state jurisdiction - Acquire and maintain nursing licensure for all jurisdictions as business needs require - Coordinate services to include home services, durable medical equipment, IMEs, admissions, discharges, and vocational services when appropriate and evaluate cost effectiveness and quality of services - Document activities and case progress using appropriate methods and tools following best practices for quality improvement - Reviewing job analysis/job description with all providers to coordinate and implement disability case management. This includes coordinating job analysis with employer to facilitate return to work. - Engage and participate in special projects as assigned by case management leadership team - Occasionally attend on site meetings and professional programs - Foster a teamwork environment - Maintaining and updating evidence based medical guidelines (such as Official Disability Guidelines, MD Guidelines and all required state regulated guidelines) in reference to the injured worker treatment plan and work status. - Obtain and maintain applicable state certifications and/or licensures in the state where job duties are performed. - Obtain case management professional certification (CCM) within 2 years of hire

AMERISAFE is seeking a detail-oriented, productivity driven professional to add to our Illinois based Workers Compensation Claims Team. In this position, you will conduct on-site and in-person investigations, determine compensability, establish reserves, document decision making, issue benefit payments, and make notifications to the State administrative authority. You will work with injured workers, employers, medical and legal professionals to ensure the appropriate benefits are provided to injured workers under the appropriate Workers' Compensation Laws. In addition to the benefits listed on our careers page, other benefits of this position include: Salaried position based on location and experience ($50,000 to $95,000) Auto reimbursement program Reimbursement for cell phone and internet Target Case Load of 60 claims Upon an offer and acceptance of employment with AMERISAFE, you will be required to complete our pre-employment screening, which includes a criminal background check, a 10-panel drug test and, if applicable, a review of your motor vehicle report. A 10-panel drug test includes amphetamine/methamphetamine, barbiturates, benzodiazepines, cocaine metabolite (BZE), marijuana metabolite (THCA), methadone, methaqualone, codeine/morphine, phencyclidine, propoxyphene. Qualifications Claims experience highly preferred. Bachelor's degree or related professional business experience acceptable. State license to handle Workers' Compensation claims if required. Professional written and verbal communication skills required. World class customer service attitude required. Ability to learn and use proprietary software and Microsoft Office products is necessary. The ability to be self-directed. This is a remote position. Valid driver's license, acceptable driving record and acceptable vehicle required. Frequent travel within a designated territory required, but rarely is overnight travel required.

Full-time Description Case Managers I, II, III, IV PER DIEM OPPORTUNITIES Conifer Park is seeking Per Diem Case Managers to join our clinical team in Glenville, NY. In this role, the employee assumes full charge of patient case management, delivering individual and group mental health and chemical dependency services including assessment, discharge planning, managed care, and relevant communication, formulation and implementation of treatment plans, and performing specified duties. Requirements Case Manager I Requirements: High School Diploma or GED with a minimum of 1 year of Case Management experience or applicable internship and a CASAC-T certification. Chemical dependency and/or mental health experience preferred and group counseling, didactic skills. Case Manager II Requirements: High School Diploma or GED with 1 year of Case Management experience or applicable internship and posses a current CASAC Certification. Case Manager III Requirements: Bachelor's Degree and current CASAC certification OR Master's licensable degree and a minimum of 1 year relevant experience or applicable internship Case Manager VI Requirements: Master's Licensed Degree with LMHC, LMSW or LCSW Experience in Chemical dependency and/or mental health. Experience in Group counseling and Didactic Skills We offer competitive wages, benefits, and a pension plan in a supportive working environment. Background checks, pre-employment & drug screenings required. We are an equal opportunity employer according to standards INDHP Salary Description $19.86 -$37.62

Full-time Description Case Manager I, II, III, IV ** SIGN ON BONUS ELIGIBLE ** Conifer Park is seeking a full-time Case Manager to join our clinical team in Glenville, NY. In this role, the employee assumes full charge of patient case management, delivering individual and group mental health and chemical dependency services including assessment, discharge planning, managed care, and relevant communication, formulation and implementation of treatment plans, and performing specified duties. Schedules: Sundays - Thursdays 8:00am - 4:30pm Tuesdays - Saturdays 8:00am - 4:30pm Mondays - Fridays 8:00am - 4:30pm Tuesdays - Saturdays 10:00am - 6:30pm Requirements Case Manager I Requirements: High School Diploma or GED with a minimum of 1 year of Case Management experience or applicable internship and a CASAC-T certification. Chemical dependency and/or mental health experience preferred and group counseling, didactic skills. Case Manager II Requirements: High School Diploma or GED with 1 year of Case Management experience or applicable internship and posses a current CASAC Certification. Case Manager III Requirements: Bachelor's Degree and current CASAC certification OR Master's licensable degree and a minimum of 1 year relevant experience or applicable internship Case Manager VI Requirements: Master's Licensed Degree with LMHC, LMSW or LCSW Experience in Chemical dependency and/or mental health. Experience in Group counseling and Didactic Skills We offer competitive wages, benefits, and a pension plan in a supportive working environment. Background checks, pre-employment & drug screenings required. Sign on bonus eligible position, payable in three installments for a total of $4000. We are an equal opportunity employer according to standards Schedules: Tuesdays-Saturdays 11:00am-8:00pm INDMP Salary Description $19.86 -$37.62

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.

Optum Home & Community Care, part of the UnitedHealth Group family of businesses, is creating something new in health care. We are uniting industry-leading solutions to build an integrated care model that holistically addresses an individual's physical, mental and social needs - helping patients access and navigate care anytime and anywhere. As a team member of our Optum At Home product, together with an interdisciplinary care team we help patients navigate the health care system, and connect them to key support services. This preventive care can help patients stay well at home. We're connecting care to create a seamless health journey for patients across care settings. Join us to start **Caring. Connecting. Growing together.** Registered Nurses in the Optum at Home program work with patients primarily in their home setting. They perform as part of a care team including a Nurse Practitioner, Behavioral Health Advocate, Care Navigator and other supporting team members. They deliver role appropriate patient care through in-home visits, telephonic outreach and consultations, and interdisciplinary team activities. The Registered Nurse may perform care and counsel of the ill, injured, or infirm, in the promotion and maintenance of health with individuals, groups, or both throughout the life span. They help to manage health problems and coordinate health care for the Optum at Home patients in accordance with State and Federal rules and regulations and the nursing standards of care. This includes (but is not limited to) assessment of health status, development, and implementation of plan of care, and ongoing evaluation of patient status and response to the plan of care. Clinical management is conducted in collaboration with other care team members. If you are located in Tulsa OK area 60 mile radius, you will have the flexibility to work remotely* as you take on some tough challenges. **Primary Responsibilities:** + Assess the health status of members as within the scope of licensure and with the frequency established in the model of care + Establish goals to meet identified health care needs + Plan, implement and evaluate responses to the plan of care + Work collaboratively the multidisciplinary team to engage resources and strategies to address medical, functional, and social barriers to care + Works closely with mental health clinicians to help bridge the gap between mental and physical health + Consult with the patient's PCP, specialists, or other health care professionals as appropriate + Assess patient needs for community resources and make appropriate referrals for service + Facilitate the patient's transition within and between health care settings in collaboration with the primary care physician and other treating physicians + Completely and accurately document in patient's electronic medical record + Provide patients and family members with counseling and education regarding health maintenance, disease prevention, condition trajectory and need for follow up as appropriate during each patient visit + Verify and document patient and/or family understanding of condition, plan of care and follow up recommendations + Actively participate in organizational quality initiatives + Participate in collaborative multidisciplinary team meetings to optimize clinical integration, efficiency, and effectiveness of care delivery + Maintain credentials essential for practice, to include licensure, certification (if applicable) and CEUs + Demonstrate a commitment to the mission, core values and goals of UnitedHealthcare and its healthcare delivery including the ability to integrate values of compassion, integrity, performance, innovation and relationships in the care provided to our members 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 licensure as RN in state of practice + RN licensure in OK + 2+ years of experience as an RN + Experience in assessing the medical needs of patients with complex behavioral, social and/or functional needs + Computer literate and able to navigate the Internet + Proven ability to work with diverse care teams in a variety of settings including non-clinical settings (primarily patient homes) + Ability to travel up to 75% of the time for field based work, valid driver's license **Preferred Qualifications:** + Home health experience + Geriatric experience + Proven computer skills, including us of Electronic Medical Records + Proven effective time management and communication skills + Proven excellent administrative and organizational skills and the ability to effectively communicate with seniors and their families **Physical Requirements:** + Ability to lift a 30-pound bag in and out of car and to navigate stairs and a variety of dwelling conditions and configurations + Ability to spend at least 1 hour with a member in their home, which may be in understaffed or remote areas, in the presence of pets or individuals who are tobacco users *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 salary for this role will range from $58,800 to $105,000 annually 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._ _OptumCare 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._ _OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment._

Optum Home & Community Care, part of the UnitedHealth Group family of businesses, is creating something new in health care. We are uniting industry-leading solutions to build an integrated care model that holistically addresses an individual's physical, mental and social needs - helping patients access and navigate care anytime and anywhere. As a team member of our Optum At Home product, together with an interdisciplinary care team we help patients navigate the health care system, and connect them to key support services. This preventive care can help patients stay well at home. We're connecting care to create a seamless health journey for patients across care settings. Join us to start Caring. Connecting. Growing together. Registered Nurses in the Optum at Home program work with patients primarily in their home setting. They perform as part of a care team including a Nurse Practitioner, Behavioral Health Advocate, Care Navigator and other supporting team members. They deliver role appropriate patient care through in-home visits, telephonic outreach and consultations, and interdisciplinary team activities. The Registered Nurse may perform care and counsel of the ill, injured, or infirm, in the promotion and maintenance of health with individuals, groups, or both throughout the life span. They help to manage health problems and coordinate health care for the Optum at Home patients in accordance with State and Federal rules and regulations and the nursing standards of care. This includes (but is not limited to) assessment of health status, development, and implementation of plan of care, and ongoing evaluation of patient status and response to the plan of care. Clinical management is conducted in collaboration with other care team members. If you are located in Tulsa OK area 60 mile radius, you will have the flexibility to work remotely* as you take on some tough challenges. Primary Responsibilities: * Assess the health status of members as within the scope of licensure and with the frequency established in the model of care * Establish goals to meet identified health care needs * Plan, implement and evaluate responses to the plan of care * Work collaboratively the multidisciplinary team to engage resources and strategies to address medical, functional, and social barriers to care * Works closely with mental health clinicians to help bridge the gap between mental and physical health * Consult with the patient's PCP, specialists, or other health care professionals as appropriate * Assess patient needs for community resources and make appropriate referrals for service * Facilitate the patient's transition within and between health care settings in collaboration with the primary care physician and other treating physicians * Completely and accurately document in patient's electronic medical record * Provide patients and family members with counseling and education regarding health maintenance, disease prevention, condition trajectory and need for follow up as appropriate during each patient visit * Verify and document patient and/or family understanding of condition, plan of care and follow up recommendations * Actively participate in organizational quality initiatives * Participate in collaborative multidisciplinary team meetings to optimize clinical integration, efficiency, and effectiveness of care delivery * Maintain credentials essential for practice, to include licensure, certification (if applicable) and CEUs * Demonstrate a commitment to the mission, core values and goals of UnitedHealthcare and its healthcare delivery including the ability to integrate values of compassion, integrity, performance, innovation and relationships in the care provided to our members 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 licensure as RN in state of practice * RN licensure in OK * 2+ years of experience as an RN * Experience in assessing the medical needs of patients with complex behavioral, social and/or functional needs * Computer literate and able to navigate the Internet * Proven ability to work with diverse care teams in a variety of settings including non-clinical settings (primarily patient homes) * Ability to travel up to 75% of the time for field based work, valid driver's license Preferred Qualifications: * Home health experience * Geriatric experience * Proven computer skills, including us of Electronic Medical Records * Proven effective time management and communication skills * Proven excellent administrative and organizational skills and the ability to effectively communicate with seniors and their families Physical Requirements: * Ability to lift a 30-pound bag in and out of car and to navigate stairs and a variety of dwelling conditions and configurations * Ability to spend at least 1 hour with a member in their home, which may be in understaffed or remote areas, in the presence of pets or individuals who are tobacco users * 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 salary for this role will range from $58,800 to $105,000 annually 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. OptumCare 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. OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

About us: Fallon Health is a company that cares. We prioritize our members-always-making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, Fallon Health delivers equitable, high-quality, coordinated care and is continually rated among the nation's top health plans for member experience, service, and clinical quality. We believe our individual differences, life experiences, knowledge, self-expression, and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status, and other characteristics that make people unique. Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs-including Medicare, Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)- in the region. Learn more at fallonhealth.org or follow us on Facebook, Twitter and LinkedIn. Brief summary of purpose: The Nurse Case Manager (NCM) is an integral part on an interdisciplinary team focused on care coordination, care management and improving access to and quality of care for Fallon members. NCM seeks to establish telephonic and/or face to face relationships with the member/caregiver(s) to better ensure ongoing service provision and care coordination, consistent with the member specific care plan developed by the NCM and Care Team. Responsibilities may include conducting in home face to face visits for member identified as needing face to face visit interaction and assessments with the goal to coordinate and facilitate services to meet member needs according to benefit structures and available community resources. The NCM may conduct assessments and may determine the number of hours' members require for MassHealth programs such as the personal care attendant program, adult foster care, group adult foster care, and other programs per product benefits and guidelines. The NCM may utilize an ACD line to support department and incoming/outgoing calls with the goal of first call resolution with each interaction. Responsibilities Note: Job Responsibilities may vary depending upon the member's Fallon Health Product Member Assessment, Education, and Advocacy o Telephonically assesses and case manages a member panel o May conduct in home face to face visits for onboarding new enrollees and reassessing members, utilizing a variety of interviewing techniques, including motivational interviewing, and employs culturally sensitive strategies to assess a Member's clinical/functional status to identify ongoing special conditions and develops and implements an individualized,coordinated care plan, in collaboration with the member, the Clinical Integration team, and Primary Care Providers, Specialist and other community partners, to ensure a cost effective quality outcome o Performs medication reconciliations o Performs Care Transitions Assessments - per Program and product line processes o Utilizing clinical judgment and nursing assessment skills, may complete NaviCare Program Assessment Tools and Minimum Data Set Home Care (MDS HC) Form when a member's medical/functional status changes that warrants a change in rating category to ensure members are in the correct State defined rating category o Maintains up to date knowledge of Program and product line benefits, Plan Evidence of Coverage details, and department policies and processes and follows policies and processes as outlined to be able to provide education to members and providers; performing a member advocacy and education role including but not limited to member rights o Serves as an advocate for members to ensure they receive Fallon Health benefits as appropriate and if member needs are identified but not covered by Fallon Health, works with community agencies to facilitate access to programs such as community transportation, food programs, and other services available through senior centers and other external partners o Follows department and regulatory standards to authorize and coordinate healthcare services ensuring timeliness in compliance with documented care plan goals and objectives o Assesses the Member's knowledge about the management of current disease processes and medication regimen, provides teaching to increase Member/caregiver knowledge, and works with the members to assist with learning how to self- manage his or her health needs, social needs or behavioral health needs o Collaborates with appropriate team members to ensure health education/disease management information is provided as identified o Collaborates with the interdisciplinary team in identifying and addressing high risk members o Educate members on preventative screenings and other health care procedures such as vaccines, screenings according to established protocols and program processes such initiatives involving Key Metrics outreach o Ensures members/PRAs participate in the development and approval of their care plans in conjunction with the interdisciplinary primary care team o Strictly observes HIPAA regulations and the Fallon Health Policies regarding confidentiality of member information o Supports Quality and Ad-Hoc campaigns Care Coordination and Collaboration o Provides culturally appropriate care coordination, i.e. works with interpreters, provides communication approved documents in the appropriate language, and demonstrates culturally appropriate behavior when working with member, family, caregivers, and/or authorized representatives o With member/authorized representative(s) collaboration develops member centered care plans by identifying member care needs while completing program assessments and working with the Navigator to ensure the member approves their care plan o Manages NaviCare members in conjunction with the Navigator, Behavioral Health Case Manager, Aging Service Access Point Geriatric Support Service Coordinator, contracted Primary Care Providers and others involved/authorized in the member's care o Manages ACO members in conjunction with the Navigator, Social Care Managers, ACO Partners, Community Partners, Behavioral Health Partners and others involved/authorized in the member's care o Monitors progression of member goals and care plan goals, provides feedback and works collaboratively with care team members and work effectively in a team model approach to coordinate a continuum of care consistent with the Member's health care goals and needs o Works collaboratively with Fallon Health Pharmacist, referring members in need of medication review based upon Program process o Develops and fosters relationships with members, family, caregivers, PRAs, vendors and providers to ensure good collaboration and coordination by streamlining the focus of the Member's healthcare needs utilizing the most optimal treatment approach, promoting timely provision of care, enhancing quality of life, and promoting cost-effectiveness of care o Actively participates in clinical rounds Provider Partnerships and Collaboration o May attend in person care plan meetings with providers and office staff and may lead care plan review with providers and care team as applicable. o Demonstrates positive customer service actions and takes responsibility to ensure member and provider requests and needs are met Regulatory Requirements - Actions and Oversight o Completes Program Assessments, Notes, Screenings, and Care Plans in the Centralized Enrollee Record according to product regulatory requirements and Program policies and processes o Knowledge of and compliance with HEDIS and Medicare 5 Star measure processes, performing member education, outreach, and actions in conjunction with the Navigator and other members of the Clinical Integration and Partner Teams o Performs other responsibilities as assigned by the Manager/designee o Supports department colleagues, covering and assuming changes in assignment as assigned by Manager/designee Qualifications Education: Graduate from an accredited school of nursing mandatory and a Bachelors (or advanced) degree in nursing or a health care related field preferred. License: Active, unrestricted license as a Registered Nurse in Massachusetts Certification: Certification in Case Management strongly desired Other: Satisfactory Criminal Offender Record Information (CORI) results and reliable transportation Experience: • 1+ years of clinical experience as a Registered Nurse managing chronically ill members or experience in a coordinated care program required • Understanding of Hospitalization experiences and the impacts and needs after facility discharge required • Experience working face to face with members and providers preferred • Experience with telephonic interviewing skills and working with a diverse population, that may also be Non-English speaking, required • Home Health Care experience preferred • Effective case management and care coordination skills and the ability to assess a member's activities of daily function and independent activities of daily function and the ability to develop and implement a care plan that meets the member's need working in partnership with a care team preferred • Familiarity with NCQA case management requirements preferred Performance Requirements including but not limited to: • Excellent communication and interpersonal skills with members and providers via telephone and in person • Exceptional customer service skills and willingness to assist ensuring timely resolution • Excellent organizational skills and ability to multi-task • Appreciation and adherence to policy and process requirements • Independent learning skills and success with various learning methodologies including but not limited to: self-study, mentoring, classroom, and group education • Working with an interdisciplinary care team as a partner demonstrating respect and value for all roles and is a positive contributor within job role scope and duties • Willingness to learn insurance regulatory and accreditation requirements • Knowledgeable about software systems including but not limited to Microsoft Office Products - Excel, Outlook, and Word • Familiar with Excel spreadsheets to manage work and exposure and familiarity with pivot tables • Accurate and timely data entry • Effective case management and care coordination skills and the ability to assess a member's activities of daily function and independent activities of daily function and the ability to develop and implement a care plan that meets the member's need • Knowledge about community resources, levels of care, criteria for levels of care and the ability to appropriately develop and implement a care plan following regulatory guidelines and level of care criteria • Ability to effectively respond and adapt to changing business needs and be an innovative and creative problem solver Competencies: • Demonstrates commitment to the Fallon Health Mission, Values, and Vision • Specific competencies essential to this position: Problem Solving Asks good questions Critical thinking skills; looks beyond the obvious Adaptability Handles day to day work challenges confidently Willing and able to adjust to multiple demands, shifing priorities, ambiguity, and rapid change Demonstrates flexibility Written Communication Is able to write clearly and succinctly in a variety of communication settings and styles. Pay Range Disclosure: In accordance with the Massachusetts Wage Transparency Act, the pay range for this position is $88,000 - $95,000 per year, which reflects what we reasonably and in good faith expect to pay at the time of posting. Final compensation will depend on the candidate's experience, skills, and fit with the role's responsibilities. Fallon Health 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. #P01 Not Ready to Apply? Join our Talent Community now!

Overview Part-Time Utilization Review Nurse - Remote (Nevada License Required) Schedule: Monday-Friday, 8:00 AM-12:00 PM PST Compensation: $40,000-$45,000 annually (part-time, 20 hours/week) Travel: Once per year to Carson City, NV Reports To: Utilization Review Nurse Supervisor Bring Your Nursing Expertise to a Flexible, Part-Time Role at CCMSI At CCMSI, we don't just process claims-we support people. As one of the largest employee-owned Third Party Administrators in the nation and a certified Great Place to Work , we offer meaningful work, manageable caseloads, and a culture where your expertise matters. As an employee-owner, you'll directly contribute to our success and share in it too. Job Summary We're seeking a Part-Time Utilization Review Nurse to conduct medical necessity reviews for treatment requests related to workers' compensation claims. This role is fully remote (Nevada-based) and ideal for a nurse who thrives in a structured, detail-driven environment and enjoys applying clinical judgment to ensure quality, appropriate care. You will review provider-submitted treatment requests, apply evidence-based guidelines, and issue determinations in accordance with Nevada's utilization review standards. Responsibilities Utilization Review concerns the quality of care provided to injured employees, including whether the service is appropriate and effective and the quality of treatment. Appropriate service is health care service that is medically necessary and reasonable, and based on objective, clinical findings. Pursuant to the NAC 616C.123 (1), the criteria or guidelines used in the UR Plan, are consistent with the ACOEM Practice guidelines adopted as standards for the provision of accident benefits to employees who have suffered industrial injuries or occupational diseases. Other Medical Criteria utilized include but are not limited to: Official Disability Guidelines The Medical Disability Guidelines NCM/UR shall use the Guidelines as minimum standards for evaluating and ensuring the quality of programs of treatment provided the injured employee who is entitled to accident benefits. Reports the diagnosis, ICD 9 code, medical appropriateness of the service, pertinent physical findings, diagnostic and therapeutic procedures, concurrent problems, follow‑up care and the injured employee's functional limitations. Authorize a determination based on the health care service request reviewed; based on the information provided, meets or does not meet the clinical requirements for medical necessity and reasonableness of said service in accordance with appropriate medical guidelines. The UR reviewer will process requests in accordance with the timelines specified in Nevada Revised Statute and Nevada Administrative Code. Qualifications Qualifications (Required) Active, unrestricted Nevada nursing license (RN). Nursing degree (Associate's or Bachelor's). Prior Utilization Review experience. Strong clinical background; ability to evaluate complex medical information. Excellent written and verbal communication skills. High attention to detail with the ability to shift priorities as needed. Proficiency with Microsoft Office and electronic documentation systems. Nice to Have Experience in trauma, orthopedics, occupational medicine, rehab therapy, med-surg, or workers' compensation. Exceptional organizational skills and the ability to work independently. How We Measure Success Timely and accurate utilization review determinations. Responsiveness to internal and external stakeholders. Quality, clarity, and compliance of documentation. Annual Performance Evaluation. What We Offer • 4 weeks PTO + 10 paid holidays in your first year • Medical, Dental, Vision, Life, and Disability Insurance • 401(k) and Employee Stock Ownership Plan (ESOP) • Internal training and advancement opportunities • A supportive, team-based work environment Compensation & Compliance The posted salary reflects CCMSI's good-faith estimate in accordance with applicable pay transparency laws. Actual compensation will be based on qualifications, experience, geographic location, and internal equity. This role may also qualify for bonuses or additional forms of pay. Visa Sponsorship: CCMSI does not provide visa sponsorship for this position. ADA Accommodations: CCMSI is committed to providing reasonable accommodations throughout the application and hiring process. Equal Opportunity Employer: CCMSI complies with all applicable employment laws, including pay transparency and fair chance hiring regulations. Our Core Values At CCMSI, we believe in doing what's right-for our clients, our coworkers, and ourselves. We look for team members who: • Act with integrity • Deliver service with passion and accountability • Embrace collaboration and change • Seek better ways to serve • Build up others through respect, trust, and communication • Lead by example-no matter their title We don't just work together-we grow together. If that sounds like your kind of workplace, we'd love to meet you. #EmployeeOwned #GreatPlaceToWorkCertified #CCMSICareers #NurseJobs #NursingCareers #RemoteNurse #WorkFromHomeNurse #PartTimeNurse #UtilizationReviewNurse #HealthcareJobs #MedicalReview #WorkersCompensation #NurseLife #NevadaJobs #CarsonCityJobs #ClinicalReview #NurseHiring #NowHiringNurses #HealthcareCareers #RNJobs #NursingCommunity #HiringNow #WorkFromHomeJobs #PartTimeJobs #RemoteJobs #WorkInHealthcare #NursesOfLinkedIn #NursingProfessional #NurseRecruitment #NurseOpportunities #HealthcareAdministration #MedicalCaseManagement #ClinicalNurseSpecialist #NurseSupport #LI-Part Time #LI-Remote We can recommend jobs specifically for you! Click here to get started.

About us: Fallon Health is a company that cares. We prioritize our members-always-making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, Fallon Health delivers equitable, high-quality, coordinated care and is continually rated among the nation's top health plans for member experience, service, and clinical quality. We believe our individual differences, life experiences, knowledge, self-expression, and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status, and other characteristics that make people unique. Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs-including Medicare, Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)- in the region. Learn more at fallonhealth.org or follow us on Facebook, Twitter and LinkedIn. Brief summary of purpose: The Nurse Case Manager (NCM) is an integral part on an interdisciplinary team focused on care coordination, care management and improving access to and quality of care for Fallon members. NCM seeks to establish telephonic and/or face to face relationships with the member/caregiver(s) to better ensure ongoing service provision and care coordination, consistent with the member specific care plan developed by the NCM and Care Team. Responsibilities may include conducting in home face to face visits for member identified as needing face to face visit interaction and assessments with the goal to coordinate and facilitate services to meet member needs according to benefit structures and available community resources. The NCM may conduct assessments and may determine the number of hours' members require for MassHealth programs such as the personal care attendant program, adult foster care, group adult foster care, and other programs per product benefits and guidelines. The NCM may utilize an ACD line to support department and incoming/outgoing calls with the goal of first call resolution with each interaction. Responsibilities Note: Job Responsibilities may vary depending upon the member's Fallon Health Product Member Assessment, Education, and Advocacy Telephonically assesses and case manages a member panel May conduct in home face to face visits for onboarding new enrollees and reassessing members, utilizing a variety of interviewing techniques, including motivational interviewing, and employs culturally sensitive strategies to assess a Member's clinical/functional status to identify ongoing special conditions and develops and implements an individualized,coordinated care plan, in collaboration with the member, the Clinical Integration team, and Primary Care Providers, Specialist and other community partners, to ensure a cost effective quality outcome Performs medication reconciliations Performs Care Transitions Assessments - per Program and product line processes Utilizing clinical judgment and nursing assessment skills, may complete NaviCare Program Assessment Tools and Minimum Data Set Home Care (MDS HC) Form when a member's medical/functional status changes that warrants a change in rating category to ensure members are in the correct State defined rating category Maintains up to date knowledge of Program and product line benefits, Plan Evidence of Coverage details, and department policies and processes and follows policies and processes as outlined to be able to provide education to members and providers; performing a member advocacy and education role including but not limited to member rights Serves as an advocate for members to ensure they receive Fallon Health benefits as appropriate and if member needs are identified but not covered by Fallon Health, works with community agencies to facilitate access to programs such as community transportation, food programs, and other services available through senior centers and other external partners Follows department and regulatory standards to authorize and coordinate healthcare services ensuring timeliness in compliance with documented care plan goals and objectives Assesses the Member's knowledge about the management of current disease processes and medication regimen, provides teaching to increase Member/caregiver knowledge, and works with the members to assist with learning how to self- manage his or her health needs, social needs or behavioral health needs Collaborates with appropriate team members to ensure health education/disease management information is provided as identified Collaborates with the interdisciplinary team in identifying and addressing high risk members Educate members on preventative screenings and other health care procedures such as vaccines, screenings according to established protocols and program processes such initiatives involving Key Metrics outreach Ensures members/PRAs participate in the development and approval of their care plans in conjunction with the interdisciplinary primary care team Strictly observes HIPAA regulations and the Fallon Health Policies regarding confidentiality of member information Supports Quality and Ad-Hoc campaigns Care Coordination and Collaboration Provides culturally appropriate care coordination, i.e. works with interpreters, provides communication approved documents in the appropriate language, and demonstrates culturally appropriate behavior when working with member, family, caregivers, and/or authorized representatives With member/authorized representative(s) collaboration develops member centered care plans by identifying member care needs while completing program assessments and working with the Navigator to ensure the member approves their care plan Manages NaviCare members in conjunction with the Navigator, Behavioral Health Case Manager, Aging Service Access Point Geriatric Support Service Coordinator, contracted Primary Care Providers and others involved/authorized in the member's care Manages ACO members in conjunction with the Navigator, Social Care Managers, ACO Partners, Community Partners, Behavioral Health Partners and others involved/authorized in the member's care Monitors progression of member goals and care plan goals, provides feedback and works collaboratively with care team members and work effectively in a team model approach to coordinate a continuum of care consistent with the Member's health care goals and needs Works collaboratively with Fallon Health Pharmacist, referring members in need of medication review based upon Program process Develops and fosters relationships with members, family, caregivers, PRAs, vendors and providers to ensure good collaboration and coordination by streamlining the focus of the Member's healthcare needs utilizing the most optimal treatment approach, promoting timely provision of care, enhancing quality of life, and promoting cost-effectiveness of care Actively participates in clinical rounds Provider Partnerships and Collaboration May attend in person care plan meetings with providers and office staff and may lead care plan review with providers and care team as applicable. Demonstrates positive customer service actions and takes responsibility to ensure member and provider requests and needs are met Regulatory Requirements - Actions and Oversight Completes Program Assessments, Notes, Screenings, and Care Plans in the Centralized Enrollee Record according to product regulatory requirements and Program policies and processes Knowledge of and compliance with HEDIS and Medicare 5 Star measure processes, performing member education, outreach, and actions in conjunction with the Navigator and other members of the Clinical Integration and Partner Teams Performs other responsibilities as assigned by the Manager/designee Supports department colleagues, covering and assuming changes in assignment as assigned by Manager/designee Qualifications Education: Graduate from an accredited school of nursing mandatory and a Bachelors (or advanced) degree in nursing or a health care related field preferred. License: Active, unrestricted license as a Registered Nurse in Massachusetts Certification: Certification in Case Management strongly desired Other: Satisfactory Criminal Offender Record Information (CORI) results and reliable transportation Experience: • 1+ years of clinical experience as a Registered Nurse managing chronically ill members or experience in a coordinated care program required • Understanding of Hospitalization experiences and the impacts and needs after facility discharge required • Experience working face to face with members and providers preferred • Experience with telephonic interviewing skills and working with a diverse population, that may also be Non-English speaking, required • Home Health Care experience preferred • Effective case management and care coordination skills and the ability to assess a member's activities of daily function and independent activities of daily function and the ability to develop and implement a care plan that meets the member's need working in partnership with a care team preferred • Familiarity with NCQA case management requirements preferred Performance Requirements including but not limited to: • Excellent communication and interpersonal skills with members and providers via telephone and in person • Exceptional customer service skills and willingness to assist ensuring timely resolution • Excellent organizational skills and ability to multi-task • Appreciation and adherence to policy and process requirements • Independent learning skills and success with various learning methodologies including but not limited to: self-study, mentoring, classroom, and group education • Working with an interdisciplinary care team as a partner demonstrating respect and value for all roles and is a positive contributor within job role scope and duties • Willingness to learn insurance regulatory and accreditation requirements • Knowledgeable about software systems including but not limited to Microsoft Office Products - Excel, Outlook, and Word • Familiar with Excel spreadsheets to manage work and exposure and familiarity with pivot tables • Accurate and timely data entry • Effective case management and care coordination skills and the ability to assess a member's activities of daily function and independent activities of daily function and the ability to develop and implement a care plan that meets the member's need • Knowledge about community resources, levels of care, criteria for levels of care and the ability to appropriately develop and implement a care plan following regulatory guidelines and level of care criteria • Ability to effectively respond and adapt to changing business needs and be an innovative and creative problem solver Competencies: • Demonstrates commitment to the Fallon Health Mission, Values, and Vision • Specific competencies essential to this position: Problem Solving Asks good questions Critical thinking skills; looks beyond the obvious Adaptability Handles day to day work challenges confidently Willing and able to adjust to multiple demands, shifing priorities, ambiguity, and rapid change Demonstrates flexibility Written Communication Is able to write clearly and succinctly in a variety of communication settings and styles. Pay Range Disclosure: In accordance with the Massachusetts Wage Transparency Act, the pay range for this position is $88,000 - $95,000 per year, which reflects what we reasonably and in good faith expect to pay at the time of posting. Final compensation will depend on the candidate's experience, skills, and fit with the role's responsibilities. Fallon Health 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. Not Ready to Apply? Join our Talent Community now!