Nurse Manager jobs at Humana

Become a part of our caring community and help us put health first Humana Healthy Horizons in Virginia is looking for RN, Field Care Managers (Field Care Manager Nurse 2) who performs primarily face to face and telephonic assessments to adult and pediatric members. The RN, Field Care Manager (Field Care Manager Nurse 2) will evaluate member's needs to achieve and/or maintain optimal wellness. This position employs a variety of strategies, approaches, and techniques to manage a member's health issues and identifies and resolves barriers that hinder effective care. They ensure members are progressing towards desired outcomes by continuously monitoring care through use of assessment, data, conversations with member, and active care planning. The RN, Field Care Manager (Field Care Manager, Nurse 2) understands professional concepts, regulations, strategies, and operating standards. They make decisions regarding work approach/priorities and follows direction. Responsible for managing a case load and completing assessments with members in their home or community-based setting, as well as telephonically. Provides clinical support and guidance, particularly for members with medical complexity. Develops and coordinates care plans ensuring that patients receive appropriate services to manage their health needs effectively. Addresses barriers to health care and advocating for optimal member outcomes. Reviews, assesses, and completes medical complexity attestations and clinical oversights. Ensures members are receiving services in the least restrictive setting to achieve and/or maintain optimal well-being by assessing their care needs. Develops and modifies Individual Care Plan and involve applicable members of the care team in care planning (Informal caregiver, coach, PCP, etc.). Focuses on supporting members and/or caregivers utilizing an interdisciplinary approach in accessing social, housing, educational and other services, regardless of funding sources to meet their needs. Collaborates with Community Health Workers (CHW), Housing Specialist and other internal and external agencies for HRSN needs. Primary point of contact for the ICT and shall be responsible for coordinating with the member, ICT participants, and outside resources to ensure the member's needs are met. Use your skills to make an impact Required Qualifications Must reside in the Commonwealth of Northern Virginia Active Registered Nurse (RN) license in the Commonwealth of Virginia without disciplinary action. Two (2) years of prior experience in health care and/or case management. One (1) year of experience working directly with individuals who meet the Cardinal Care Priority Population criteria (adults, pediatrics populations at risk for chronic medical conditions and high social needs). Strong advocate and respect for members at all levels of care. Intermediate to advanced computer skills and experience with Microsoft Word, Excel, and Outlook. Ability to use a variety of electronic information applications/software programs including electronic medical records. Exceptional oral and written communication and interpersonal skills with the ability to build rapport with internal and external customers and stakeholders. Ability to work with minimal supervision within the role and scope. Ability to work a full-time schedule. Preferred Qualifications Prior experience with Medicare, Medicaid and dual eligible populations. Bachelor's Degree Nursing (BSN). Case Management Certification (CCM). Experience with health promotion, coaching and wellness. Knowledge of community health and social service agencies and additional community resources. Bilingual or Multilingual: English/Spanish, Arabic, Vietnamese, Amharic, Urdu or other - Must be able to speak, read and write in both languages without limitations and assistance. See “Additional Information” section for more information. Additional Information Workstyle: Field - This is a field position where employees perform their core duties at non-company locations, such as providing services at business partner facilities or prospects' and members' homes. Travel: 50 - 75% field interactions with members, and their families and providers. May need to attend onsite meetings occasionally in Humana Healthy Horizons office in Glen Allen, VA. Workdays and Hours: Monday - Friday; 8:00am - 5:00pm Eastern Standard Time (EST). Language Assessment Statement: Any Humana associate who speaks with a member in a language other than English must take a language proficiency assessment, provided by an outside vendor, to ensure competency. Applicants will be required to take the Interagency Language Rating (ILR) test as provided by the Federal Government. WAH Internet Statement To ensure Home or Hybrid Home/Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. Satellite, cellular and microwave connection can be used only if approved by leadership. Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information. SSN Alert Statement Humana values personal identity protection. Please be aware that applicants may be asked to provide their Social Security Number, if it is not already on file. When required, an email will be sent from ******************** with instructions on how to add the information into your official application on Humana's secure website. TB Screening This role is considered patient facing and is part of Humana's Tuberculosis (TB) screening program. If selected for this role, you will be required to be screened for TB. Driving Statement This role is part of Humana's driver safety program and therefore requires an individual to have a valid state driver's license and are expected to maintain personal vehicle liability insurance. Individual must carry vehicle insurance in accordance with their residing state minimum required limits, or $25,000 bodily injury per person/$25,000 bodily injury per event /$10,000 for property damage or whichever is higher. Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. Scheduled Weekly Hours 40 Pay Range The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc. $71,100 - $97,800 per year This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance. Description of Benefits Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities. About us Humana Inc. (NYSE: HUM) is committed to putting health first - for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health - delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large. Equal Opportunity Employer It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.

Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service. **Positions available in NE Ohio: Cuyahoga, Geauga, Lake, Lorain, Medina and Cleveland** **KNOWLEDGE/SKILLS/ABILITIES** + Completes face-to-face comprehensive assessments of members per regulated timelines. + Facilitates comprehensive waiver enrollment and disenrollment processes. + Develops and implements a case management plan, including a waiver service plan, in collaboration with the member, caregiver, physician and/or other appropriate healthcare professionals and member's support network to address the member needs and goals. + Performs ongoing monitoring of the care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly. + Promotes integration of services for members including behavioral health care and long term services and supports, home and community to enhance the continuity of care for Molina members. + Assesses for medical necessity and authorize all appropriate waiver services. + Evaluates covered benefits and advise appropriately regarding funding source. + Conducts face-to-face or home visits as required. + Facilitates interdisciplinary care team meetings for approval or denial of services and informal ICT collaboration. + Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts. + Assesses for barriers to care, provides care coordination and assistance to member to address psycho/social, financial, and medical obstacles concerns. + Identifies critical incidents and develops prevention plans to assure member's health and welfare. + Provides consultation, recommendations and education as appropriate to non-RN case managers + Works cases with members who have complex medical conditions and medication regimens + Conducts medication reconciliation when needed. + 50-75% travel required. **JOB QUALIFICATIONS** **Required Education** Graduate from an Accredited School of Nursing **Required Experience** + At least 1 year of experience working with persons with disabilities/chronic conditions and Long Term Services & Supports. + 1-3 years in case management, disease management, managed care or medical or behavioral health settings. + Required License, Certification, Association + Active, unrestricted State Registered Nursing license (RN) in good standing + If field work is required, Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation. **Preferred Education** Bachelor's Degree in Nursing **Preferred Experience** + 3-5 years in case management, disease management, managed care or medical or behavioral health settings. + 1 year experience working with population who receive waiver services. **Preferred License, Certification, Association** Active and unrestricted Certified Case Manager (CCM) To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. \#PJHS3 Pay Range: $26.41 - $51.49 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service. Positions available in NE Ohio: Cuyahoga, Geauga, Lake, Lorain, Medina and Cleveland KNOWLEDGE/SKILLS/ABILITIES * Completes face-to-face comprehensive assessments of members per regulated timelines. * Facilitates comprehensive waiver enrollment and disenrollment processes. * Develops and implements a case management plan, including a waiver service plan, in collaboration with the member, caregiver, physician and/or other appropriate healthcare professionals and member's support network to address the member needs and goals. * Performs ongoing monitoring of the care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly. * Promotes integration of services for members including behavioral health care and long term services and supports, home and community to enhance the continuity of care for Molina members. * Assesses for medical necessity and authorize all appropriate waiver services. * Evaluates covered benefits and advise appropriately regarding funding source. * Conducts face-to-face or home visits as required. * Facilitates interdisciplinary care team meetings for approval or denial of services and informal ICT collaboration. * Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts. * Assesses for barriers to care, provides care coordination and assistance to member to address psycho/social, financial, and medical obstacles concerns. * Identifies critical incidents and develops prevention plans to assure member's health and welfare. * Provides consultation, recommendations and education as appropriate to non-RN case managers * Works cases with members who have complex medical conditions and medication regimens * Conducts medication reconciliation when needed. * 50-75% travel required. JOB QUALIFICATIONS Required Education Graduate from an Accredited School of Nursing Required Experience * At least 1 year of experience working with persons with disabilities/chronic conditions and Long Term Services & Supports. * 1-3 years in case management, disease management, managed care or medical or behavioral health settings. * Required License, Certification, Association * Active, unrestricted State Registered Nursing license (RN) in good standing * If field work is required, Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation. Preferred Education Bachelor's Degree in Nursing Preferred Experience * 3-5 years in case management, disease management, managed care or medical or behavioral health settings. * 1 year experience working with population who receive waiver services. Preferred License, Certification, Association Active and unrestricted Certified Case Manager (CCM) To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. #PJHS3 Pay Range: $26.41 - $51.49 / HOURLY * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. About Us Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Provides support for care management/care coordination long-term services and supports specific activities and collaborates with multidisciplinary team coordinating integrated delivery of member care across the continuum for members with high-need potential. Strives to ensure member progress toward desired outcomes and contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties * Completes comprehensive member assessments within regulated timelines, including in-person home visits as required. * Facilitates comprehensive waiver enrollment and disenrollment processes. * Develops and implements care plans, including a waiver service plan in collaboration with members, caregivers, physicians and/or other appropriate health care professionals and member support network to address the member needs and goals. * Performs ongoing monitoring of care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly. * Promotes integration of services for members including behavioral health care and long-term services and supports (LTSS) and home and community resources to enhance continuity of care. * Assesses for medical necessity and authorizes all appropriate waiver services. * Evaluates covered benefits and advises appropriately regarding funding sources. * Facilitates interdisciplinary care team (ICT) meetings for approval or denial of services and informal ICT collaboration. * Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts. * Assesses for barriers to care and provides care coordination and assistance to members to address psycho/social, financial, and medical obstacles concerns. * Identifies critical incidents and develops prevention plans to assure member health and welfare. * May provide consultation, resources and recommendations to peers as needed. * Care manager RNs may be assigned complex member cases and medication regimens. * Care manager RNs may conduct medication reconciliation as needed. * 25-40% estimated local travel may be required (based upon state/contractual requirements). Required Qualifications * At least 2 years experience in health care, including at least 1 year experience in care management, managed care, and/or experience in a medical or behavioral health setting, and at least 1 year of experience working with persons with disabilities, chronic conditions, substance abuse disorders, and long-term services and supports (LTSS), or equivalent combination of relevant education and experience. * Registered Nurse (RN). License must be active and unrestricted in state of practice. * Valid and unrestricted driver's license, reliable transportation, and adequate auto insurance for job related travel requirements, unless otherwise required by law. * Ability to operate proactively and demonstrate detail-oriented work. * Demonstrated knowledge of community resources. * Ability to work within a variety of settings and adjust style as needed - working with diverse populations and various personalities and personal situations. * Ability to work independently, with minimal supervision and demonstrate self-motivation. * Responsiveness in all forms of communication, and ability to remain calm in high-pressure situations. * Ability to develop and maintain professional relationships. * Excellent time-management and prioritization skills, and ability to focus on multiple projects simultaneously and adapt to change. * Excellent problem-solving and critical-thinking skills. * Strong verbal and written communication skills. * Microsoft Office suite/applicable software program(s) proficiency. * In some states, must have at least one year of experience working directly with individuals with substance use disorders. Preferred Qualifications * Certified Case Manager (CCM). * Experience working with populations that receive waiver services. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $23.76 - $51.49 / HOURLY * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. About Us Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

The Revenue Cycle Clinician for the Appellate Solution is responsible for: * Recovering revenue associated with disputed/denied clinical claims or those eligible for clinical review * Preparing and documenting appeal based on industry accepted criteria. ESSENTIAL DUTIES AND RESPONSIBILITIES Include the following. Others may be assigned. 1. Performs retrospective (post -discharge/ post-service) medical necessity reviews to determine appellate potential of clinical disputes/denials or those eligible for clinical review. 2. Demonstrates proficiency in use of medical necessity criteria sets, currently InterQual or other key factors or systems as evidenced by Inter-rater reliability studies and other QA audits. Constructs and documents a succinct and fact based clinical case to support appeal utilizing appropriate module of InterQual criteria (Acute, Procedures, etc). If clinical review does not meet IQ criteria, other pertinent clinical facts are utilized to support the appeal. Pertinent clinical facts include, but are not limited to, documentation preventing a safe transfer/discharge or documentation of medical necessary services denied for no authorization. 3. Demonstrates ability to critically think and follow documented processes for supporting the clinical appellate process. 4. Adhers to the department standards for productivity and quality goals. Ensuring accounts assigned are worked in a timely manner based on the payor guidelines. 5. Demonstrates proficiency in utilization of electronic tools including but not limited to ACE, nThrive, eCARE, Authorization log, InterQual, VI, HPF, as well as competency in Microsoft Office. 6.Demonstrates basic patient accounting knowledge i.e. UB92/UB04 and EOB components, adjustments, credits, debits, balance due, patient liability, denials management, etc. 7. Additional responsibilities: a) Serves as a resource to non-clinical personnel. b) Provides CRC leadership with sound solutions related to process improvement c) Assist in development of policy and procedures as business needs dictate. d) Assists Law Department with any medical necessity reviews as capacity allows up to and including attending mediation hearings, other litigation forums, etc. KNOWLEDGE, SKILLS, ABILITIES To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. * Demonstrates proficiency in the application of medical necessity criteria, currently InterQual * Possesses excellent written, verbal and professional letter writing skills * Critical thinker, able to make decisions regarding medical necessity independently * Ability to interact intelligently and professionally with other clinical and non-clinical partners * Demonstrates knowledge of managed care contracts including reimbursement matrixes and terms * Ability to multi-task * Ability to conduct research regarding State/Federal appellate guidelines and applicable regulatory processes related to the appellate process. * Ability to conduct research regarding off-label use of medications Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment. This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings. EDUCATION / EXPERIENCE Include minimum education, technical training, and/or experience required to perform the job. * Must possess a valid nursing license (Registered) * Minimum of 3 yearsacute care experience in a facility environment * Medical-surgical/critical care experience preferred * Appeals writing experience preffered * Minimum of 2 years UR/Case Management experience preferred * Managed care payor experience a plus either in Utilization Review, Case Management or Appeals * * Previous classroom led instruction on InterQual or MCG products (Acute Adult, Peds, Outpatient and Behavioral Health) preferred CERTIFICATES, LICENSES, REGISTRATIONS * Current, valid RN/ licensure * Certified Case Manager (CCM) or Certified Professional in Utilization Review/Utilization Management/Healthcare Management (CPUR , CPUM, or CPHM) preferred PHYSICAL DEMANDS The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. * Ability to lift 15-20lbs * Ability to travel approximately 10% of the time; either to facility sites, National Insurance Center (NIC) sites, Headquarters or other designated sites * Ability to sit and work at a computer for a prolonged period of time conducting medical necessity reviews WORK ENVIRONMENT The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. * Characteristic of typical office environment requiring use of desk, chair, and office equipment such as computer, telephone, printer, etc. OTHER * May require travel - approximately 10% * Interaction with facility Case Management, Physician Advisor is a requirement. Compensation and Benefit Information Compensation * Pay: $30.85 - $46.28 per hour. Compensation depends on location, qualifications, and experience. * Position may be eligible for a signing bonus for qualified new hires, subject to employment status. * Conifer observed holidays receive time and a half. Benefits Conifer offers the following benefits, subject to employment status: * Medical, dental, vision, disability, and life insurance * Paid time off (vacation & sick leave) - min of 12 days per year, accrue at a rate of approximately 1.84 hours per 40 hours worked. * 401k with up to 6% employer match * 10 paid holidays per year * Health savings accounts, healthcare & dependent flexible spending accounts * Employee Assistance program, Employee discount program * Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, AD&D, auto & home insurance. * For Colorado employees, Conifer offers paid leave in accordance with Colorado's Healthy Families and Workplaces Act. Employment practices will not be influenced or affected by an applicant's or employee's race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship. Tenet participates in the E-Verify program. Follow the link below for additional information. E-Verify: ***************************** The employment practices of Tenet Healthcare and its companies comply with all applicable laws and regulations. **********

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start **Caring. Connecting. Growing together.** We're making a solid connection between exceptional patient care and outstanding career opportunities. The result is a culture of performance that's driving the health care industry forward. As a Telephone Case Manager RN with UnitedHealth Group, you'll support a diverse member population with education, advocacy and connections to the resources they need to feel better and get well. Instead of seeing a handful of patients each day, your work may affect millions for years to come. Ready for a new path? Apply today! The **Telephonic Case Manager RN Medical/Oncology** will identify, coordinate, and provide appropriate levels of care. The Telephonic Case Manager RN Medical/Oncology is responsible for clinical operations and medical management activities across the continuum of care (assessing, planning, implementing, coordinating, monitoring and evaluating). This includes case management, coordination of care, and medical management consulting. **This is a full-time, Monday - Friday, 8am-5pm position in your time zone.** You'll enjoy the flexibility to work remotely* as you take on some tough challenges. **Primary Responsibilities:** + Make outbound calls and receive inbound calls to assess members current health status + Identify gaps or barriers in treatment plans + Provide patient education to assist with self-management + Make referrals to outside sources + Provide a complete continuum of quality care through close communication with members via in-person or on-phone interaction + Support members with condition education, medication reviews and connections to resources such as Home Health Aides or Meals on Wheels This is high volume, customer service environment. You'll need to be efficient, productive and thorough dealing with our members over the phone. Solid computer and software navigation skills are critical. You should also be solidly patient-focused and adaptable to changes. You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. **Required Qualifications:** + Current, unrestricted RN license in state of residence + Active Compact RN License or ability to obtain upon hire + 3+ years of experience in a hospital, acute care or direct care setting + Proven ability to type and have the ability to navigate a Windows based environment + Have access to high-speed internet (DSL or Cable) + Dedicated work area established that is separated from other living areas and provides information privacy **Preferred Qualifications** + BSN + Certified Case Manager (CCM) + 1+ years of experience within Medical/Oncology + Case management experience + Experience or exposure to discharge planning + Experience in a telephonic role + Background in managed care *All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy. _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._ _Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law._ _UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment._

Provides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines. • Analyzes clinical service requests from members or providers against evidence based clinical guidelines. • Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. • Conducts reviews to determine prior authorization/financial responsibility for Molina and its members. • Processes requests within required timelines. • Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner. • Requests additional information from members or providers as needed. • Makes appropriate referrals to other clinical programs. • Collaborates with multidisciplinary teams to promote the Molina care model. • Adheres to utilization management (UM) policies and procedures. Required Qualifications • At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience. • Registered Nurse (RN). License must be active and unrestricted in state of practice. • Ability to prioritize and manage multiple deadlines. • Excellent organizational, problem-solving and critical-thinking skills. • Strong written and verbal communication skills. • Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications • Certified Professional in Healthcare Management (CPHM). • Recent hospital experience in an intensive care unit (ICU) or emergency room. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $26.41 - $61.79 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

The Medical Review Nurse provides support for medical claim and internal appeals review activities - ensuring alignment with applicable state and federal regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Contributes to overarching strategy to provide quality and cost-effective member care. This position will be supporting our Appeals and Grievances department. We are seeking a Registered Nurse with previous Appeals experience. The candidate must have strong organizational skills, proficient knowledge of MS Excel, able to work on multiple screens simultaneously and be computer literate to keep up with the work. The team works in a very fast and productive environment. Further details to be discussed during our interview process. Remote position with location preference in MI, IL or WI Work hours: Monday- Friday: 8:30am -5:00pm EST. There is Saturday on call and holiday rotation. Michigan RN license is required. Job Duties Facilitates clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases in which an appeal has been made, or is likely to be made, to ensure medical necessity and appropriate/accurate billing and claims processing. Reevaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of relevant and applicable state and federal regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of services provided, length of stay, level of care, and inpatient readmissions. Validates member medical records and claims submitted/correct coding, to ensure appropriate reimbursement to providers. Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) issues. Identifies and reports quality of care issues. Assists with complex claim review including diagnosis-related group (DRG) validation, itemized bill review, appropriate level of care, inpatient readmission, and any opportunities identified by the payment integrity analytical team; makes decisions and recommendations pertinent to clinical experience. Prepares and presents cases representing Molina, along with the chief medical officer (CMO), for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings. Reviews medically appropriate clinical guidelines and other appropriate criteria with medical directors on denial decisions. Supplies criteria supporting all recommendations for denial or modification of payment decisions. Serves as a clinical resource for utilization management, CMOs, physicians and member/provider inquiries/appeals. Provides training and support to clinical peers. Identifies and refers members with special needs to the appropriate Molina program per applicable policies/protocols. Job Qualifications REQUIRED QUALIFICATIONS: At least 2 years clinical nursing experience, including at least 1 year of utilization review, medical claims review, long-term services and supports (LTSS), claims auditing, medical necessity review and/or coding experience, or equivalent combination of relevant education and experience. Registered Nurse (RN). License must be active and unrestricted in state of practice. Experience demonstrating knowledge of ICD-10, Current Procedural Technology (CPT) coding and Healthcare Common Procedure Coding (HCPC). Experience working within applicable state, federal, and third-party regulations. Analytic, problem-solving, and decision-making skills. Organizational and time-management skills. Attention to detail. Critical-thinking and active listening skills. Common look proficiency. Effective verbal and written communication skills. Microsoft Office suite and applicable software program(s) proficiency. PREFERRED QUALIFICATIONS: Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ), or other health care certifications. Nursing experience in critical care, emergency medicine, medical/surgical or pediatrics. Billing and coding experience. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $29.05 - $67.97 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

The Medical Review Nurse provides support for medical claim and internal appeals review activities - ensuring alignment with applicable state and federal regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Contributes to overarching strategy to provide quality and cost-effective member care. This position will be supporting our Appeals and Grievances department. We are seeking a Registered Nurse with previous Appeals experience. The candidate must have strong organizational skills, proficient knowledge of MS Excel, able to work on multiple screens simultaneously and be computer literate to keep up with the work. The team works in a very fast and productive environment. Further details to be discussed during our interview process. Remote position with location preference in MI, IL or WI Work hours: Monday- Friday: 8:30am -5:00pm EST. There is Saturday on call and holiday rotation. Michigan RN license is required. Job Duties Facilitates clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases in which an appeal has been made, or is likely to be made, to ensure medical necessity and appropriate/accurate billing and claims processing. Reevaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of relevant and applicable state and federal regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of services provided, length of stay, level of care, and inpatient readmissions. Validates member medical records and claims submitted/correct coding, to ensure appropriate reimbursement to providers. Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) issues. Identifies and reports quality of care issues. Assists with complex claim review including diagnosis-related group (DRG) validation, itemized bill review, appropriate level of care, inpatient readmission, and any opportunities identified by the payment integrity analytical team; makes decisions and recommendations pertinent to clinical experience. Prepares and presents cases representing Molina, along with the chief medical officer (CMO), for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings. Reviews medically appropriate clinical guidelines and other appropriate criteria with medical directors on denial decisions. Supplies criteria supporting all recommendations for denial or modification of payment decisions. Serves as a clinical resource for utilization management, CMOs, physicians and member/provider inquiries/appeals. Provides training and support to clinical peers. Identifies and refers members with special needs to the appropriate Molina program per applicable policies/protocols. Job Qualifications REQUIRED QUALIFICATIONS: At least 2 years clinical nursing experience, including at least 1 year of utilization review, medical claims review, long-term services and supports (LTSS), claims auditing, medical necessity review and/or coding experience, or equivalent combination of relevant education and experience. Registered Nurse (RN). License must be active and unrestricted in state of practice. Experience demonstrating knowledge of ICD-10, Current Procedural Technology (CPT) coding and Healthcare Common Procedure Coding (HCPC). Experience working within applicable state, federal, and third-party regulations. Analytic, problem-solving, and decision-making skills. Organizational and time-management skills. Attention to detail. Critical-thinking and active listening skills. Common look proficiency. Effective verbal and written communication skills. Microsoft Office suite and applicable software program(s) proficiency. PREFERRED QUALIFICATIONS: Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ), or other health care certifications. Nursing experience in critical care, emergency medicine, medical/surgical or pediatrics. Billing and coding experience. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $29.05 - $67.97 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start **Caring. Connecting. Growing together.** We're making a solid connection between exceptional patient care and outstanding career opportunities. The result is a culture of performance that's driving the health care industry forward. As a Telephone Case Manager RN with UnitedHealth Group, you'll support a diverse member population with education, advocacy and connections to the resources they need to feel better and get well. Instead of seeing a handful of patients each day, your work may affect millions for years to come. Ready for a new path? Apply today! The **Telephonic Case Manager RN Medical/Oncology** will identify, coordinate, and provide appropriate levels of care. The Telephonic Case Manager RN Medical/Oncology is responsible for clinical operations and medical management activities across the continuum of care (assessing, planning, implementing, coordinating, monitoring and evaluating). This includes case management, coordination of care, and medical management consulting. **This is a full-time, Monday - Friday, 8am-5pm position in your time zone.** You'll enjoy the flexibility to work remotely* as you take on some tough challenges. **Primary Responsibilities:** + Make outbound calls and receive inbound calls to assess members current health status + Identify gaps or barriers in treatment plans + Provide patient education to assist with self-management + Make referrals to outside sources + Provide a complete continuum of quality care through close communication with members via in-person or on-phone interaction + Support members with condition education, medication reviews and connections to resources such as Home Health Aides or Meals on Wheels This is high volume, customer service environment. You'll need to be efficient, productive and thorough dealing with our members over the phone. Solid computer and software navigation skills are critical. You should also be solidly patient-focused and adaptable to changes. You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. **Required Qualifications:** + Current, unrestricted RN license in state of residence + Active Compact RN License or ability to obtain upon hire + 3+ years of experience in a hospital, acute care or direct care setting + Proven ability to type and have the ability to navigate a Windows based environment + Have access to high-speed internet (DSL or Cable) + Dedicated work area established that is separated from other living areas and provides information privacy **Preferred Qualifications** + BSN + Certified Case Manager (CCM) + 1+ years of experience within Medical/Oncology + Case management experience + Experience or exposure to discharge planning + Experience in a telephonic role + Background in managed care *All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy. _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._ _Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law._ _UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment._

The Medical Review Nurse provides support for medical claim and internal appeals review activities - ensuring alignment with applicable state and federal regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Contributes to overarching strategy to provide quality and cost-effective member care. This position will be supporting our Appeals and Grievances department. We are seeking a Registered Nurse with previous Appeals experience. The candidate must have strong organizational skills, proficient knowledge of MS Excel, able to work on multiple screens simultaneously and be computer literate to keep up with the work. The team works in a very fast and productive environment. Further details to be discussed during our interview process. Remote position with location preference in MI, IL or WI Work hours: Monday- Friday: 8:30am -5:00pm EST. There is Saturday on call and holiday rotation. Michigan RN license is required. Job Duties Facilitates clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases in which an appeal has been made, or is likely to be made, to ensure medical necessity and appropriate/accurate billing and claims processing. Reevaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of relevant and applicable state and federal regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of services provided, length of stay, level of care, and inpatient readmissions. Validates member medical records and claims submitted/correct coding, to ensure appropriate reimbursement to providers. Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) issues. Identifies and reports quality of care issues. Assists with complex claim review including diagnosis-related group (DRG) validation, itemized bill review, appropriate level of care, inpatient readmission, and any opportunities identified by the payment integrity analytical team; makes decisions and recommendations pertinent to clinical experience. Prepares and presents cases representing Molina, along with the chief medical officer (CMO), for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings. Reviews medically appropriate clinical guidelines and other appropriate criteria with medical directors on denial decisions. Supplies criteria supporting all recommendations for denial or modification of payment decisions. Serves as a clinical resource for utilization management, CMOs, physicians and member/provider inquiries/appeals. Provides training and support to clinical peers. Identifies and refers members with special needs to the appropriate Molina program per applicable policies/protocols. Job Qualifications REQUIRED QUALIFICATIONS: At least 2 years clinical nursing experience, including at least 1 year of utilization review, medical claims review, long-term services and supports (LTSS), claims auditing, medical necessity review and/or coding experience, or equivalent combination of relevant education and experience. Registered Nurse (RN). License must be active and unrestricted in state of practice. Experience demonstrating knowledge of ICD-10, Current Procedural Technology (CPT) coding and Healthcare Common Procedure Coding (HCPC). Experience working within applicable state, federal, and third-party regulations. Analytic, problem-solving, and decision-making skills. Organizational and time-management skills. Attention to detail. Critical-thinking and active listening skills. Common look proficiency. Effective verbal and written communication skills. Microsoft Office suite and applicable software program(s) proficiency. PREFERRED QUALIFICATIONS: Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ), or other health care certifications. Nursing experience in critical care, emergency medicine, medical/surgical or pediatrics. Billing and coding experience. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $29.05 - $67.97 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

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.

Provides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines. • Analyzes clinical service requests from members or providers against evidence based clinical guidelines. • Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. • Conducts reviews to determine prior authorization/financial responsibility for Molina and its members. • Processes requests within required timelines. • Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner. • Requests additional information from members or providers as needed. • Makes appropriate referrals to other clinical programs. • Collaborates with multidisciplinary teams to promote the Molina care model. • Adheres to utilization management (UM) policies and procedures. Required Qualifications • At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience. • Registered Nurse (RN). License must be active and unrestricted in state of practice. • Ability to prioritize and manage multiple deadlines. • Excellent organizational, problem-solving and critical-thinking skills. • Strong written and verbal communication skills. • Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications • Certified Professional in Healthcare Management (CPHM). • Recent hospital experience in an intensive care unit (ICU) or emergency room. Preferred Experience Previous experience in managed care Prior Auth, Utilization Review / Utilization Management and knowledge of Interqual / MCG guidelines. MULTI STATE / COMPACT LICENSURE Individual state licensures which are not part of the compact states are required for: CA, NV, IL, NY and MI WORK SCHEDULE: Tues - Sat shift will rotate with some holidays. Training will be held Mon - Fri To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $26.41 - $61.79 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Provides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines. • Analyzes clinical service requests from members or providers against evidence based clinical guidelines. • Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. • Conducts reviews to determine prior authorization/financial responsibility for Molina and its members. • Processes requests within required timelines. • Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner. • Requests additional information from members or providers as needed. • Makes appropriate referrals to other clinical programs. • Collaborates with multidisciplinary teams to promote the Molina care model. • Adheres to utilization management (UM) policies and procedures. Required Qualifications • At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience. • Registered Nurse (RN). License must be active and unrestricted in state of practice. • Ability to prioritize and manage multiple deadlines. • Excellent organizational, problem-solving and critical-thinking skills. • Strong written and verbal communication skills. • Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications • Certified Professional in Healthcare Management (CPHM). • Recent hospital experience in an intensive care unit (ICU) or emergency room. Preferred Experience Previous experience in managed care Prior Auth, Utilization Review / Utilization Management and knowledge of Interqual / MCG guidelines. MULTI STATE / COMPACT LICENSURE Individual state licensures which are not part of the compact states are required for: CA, NV, IL, NY and MI WORK SCHEDULE: Tues - Sat shift will rotate with some holidays. Training will be held Mon - Fri To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $26.41 - $61.79 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

For this position we are seeking a (RN) Registered Nurse who lives in OHIO and must be licensed for the state of OHIO. This position will support our MMP (Medicaid Medicare Population) with members on Waiver program. This position will have a case load and manage members enrolled in this program. We are looking for Registered Nurses who have experience working with manage care population and/or case management role. Excellent computer skills and diligence are especially important to multitask between systems, talk with members on the phone, and enter accurate contact notes. This is a fast-paced position and productivity is important. This position requires field work doing assessments with members face to face in homes. TRAVEL in the field to do member visits in the surrounding areas will be required: Cincinnati OH - (Mileage is reimbursed) Schedule - Monday thru Friday 800 AM to 5 PM EST (No weekends or Holidays JOB DESCRIPTION Job Summary Provides support for care management/care coordination long-term services and supports specific activities and collaborates with multidisciplinary team coordinating integrated delivery of member care across the continuum for members with high-need potential. Strives to ensure member progress toward desired outcomes and contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Completes comprehensive member assessments within regulated timelines, including in-person home visits as required. • Facilitates comprehensive waiver enrollment and disenrollment processes. • Develops and implements care plans, including a waiver service plan in collaboration with members, caregivers, physicians and/or other appropriate health care professionals and member support network to address the member needs and goals. • Performs ongoing monitoring of care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly. • Promotes integration of services for members including behavioral health care and long-term services and supports (LTSS) and home and community resources to enhance continuity of care. • Assesses for medical necessity and authorizes all appropriate waiver services. • Evaluates covered benefits and advises appropriately regarding funding sources. • Facilitates interdisciplinary care team (ICT) meetings for approval or denial of services and informal ICT collaboration. • Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts. • Assesses for barriers to care and provides care coordination and assistance to members to address psycho/social, financial, and medical obstacles concerns. • Identifies critical incidents and develops prevention plans to assure member health and welfare. • May provide consultation, resources and recommendations to peers as needed. • Care manager RNs may be assigned complex member cases and medication regimens. • Care manager RNs may conduct medication reconciliation as needed. • 25-40% estimated local travel may be required (based upon state/contractual requirements). Required Qualifications • At least 2 years experience in health care, including at least 1 year experience in care management, managed care, and/or experience in a medical or behavioral health setting, and at least 1 year of experience working with persons with disabilities, chronic conditions, substance abuse disorders, and long-term services and supports (LTSS), or equivalent combination of relevant education and experience. • Registered Nurse (RN). License must be active and unrestricted in state of practice. • Valid and unrestricted driver's license, reliable transportation, and adequate auto insurance for job related travel requirements, unless otherwise required by law. • Ability to operate proactively and demonstrate detail-oriented work. • Demonstrated knowledge of community resources. • Ability to work within a variety of settings and adjust style as needed - working with diverse populations and various personalities and personal situations. • Ability to work independently, with minimal supervision and demonstrate self-motivation. • Responsiveness in all forms of communication, and ability to remain calm in high-pressure situations. • Ability to develop and maintain professional relationships. • Excellent time-management and prioritization skills, and ability to focus on multiple projects simultaneously and adapt to change. • Excellent problem-solving and critical-thinking skills. • Strong verbal and written communication skills. • Microsoft Office suite/applicable software program(s) proficiency. • In some states, must have at least one year of experience working directly with individuals with substance use disorders. Preferred Qualifications • Certified Case Manager (CCM). • Experience working with populations that receive waiver services. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $26.41 - $51.49 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service. Positions available in NE Ohio: Cuyahoga, Geauga, Lake, Lorain, Medina and Cleveland KNOWLEDGE/SKILLS/ABILITIES Completes face-to-face comprehensive assessments of members per regulated timelines. Facilitates comprehensive waiver enrollment and disenrollment processes. Develops and implements a case management plan, including a waiver service plan, in collaboration with the member, caregiver, physician and/or other appropriate healthcare professionals and member's support network to address the member needs and goals. Performs ongoing monitoring of the care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly. Promotes integration of services for members including behavioral health care and long term services and supports, home and community to enhance the continuity of care for Molina members. Assesses for medical necessity and authorize all appropriate waiver services. Evaluates covered benefits and advise appropriately regarding funding source. Conducts face-to-face or home visits as required. Facilitates interdisciplinary care team meetings for approval or denial of services and informal ICT collaboration. Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts. Assesses for barriers to care, provides care coordination and assistance to member to address psycho/social, financial, and medical obstacles concerns. Identifies critical incidents and develops prevention plans to assure member's health and welfare. Provides consultation, recommendations and education as appropriate to non-RN case managers Works cases with members who have complex medical conditions and medication regimens Conducts medication reconciliation when needed. 50-75% travel required. JOB QUALIFICATIONS Required Education Graduate from an Accredited School of Nursing Required Experience At least 1 year of experience working with persons with disabilities/chronic conditions and Long Term Services & Supports. 1-3 years in case management, disease management, managed care or medical or behavioral health settings. Required License, Certification, Association Active, unrestricted State Registered Nursing license (RN) in good standing If field work is required, Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation. Preferred Education Bachelor's Degree in Nursing Preferred Experience 3-5 years in case management, disease management, managed care or medical or behavioral health settings. 1 year experience working with population who receive waiver services. Preferred License, Certification, Association Active and unrestricted Certified Case Manager (CCM) To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. #PJHS3 Pay Range: $26.41 - $51.49 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

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 Field Case Manager RN 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. **Primary Responsibilities:** + Reports to RN Manager + 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 member 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. Years of post-high school education can be substituted/is equivalent to years of experience. **Required Qualifications:** + Current unrestricted licensure as RN in Ohio + 2+ years of relevant experience + Experience in assessing the medical needs of patients with complex behavioral, social and/or functional needs + Demonstrated ability to work with diverse care teams in a variety of settings including non-clinical settings (primarily patient homes) + Proven solid computer skills, including use of electronic medical records + Ability to travel 100% of the time in the Cuyahoga County, OH area for field-based work within 60 miles of residence + Valid driver's license + Access to reliable transportation that will enable you to travel to client and/or patient sites within a designated area **Preferred Qualification:** + Field based experience + Case management experience + Proven effective time management and communication skills 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. _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 Field Case Manager RN 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. Primary Responsibilities: * Reports to RN Manager * 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 member 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. Years of post-high school education can be substituted/is equivalent to years of experience. Required Qualifications: * Current unrestricted licensure as RN in Ohio * 2+ years of relevant experience * Experience in assessing the medical needs of patients with complex behavioral, social and/or functional needs * Demonstrated ability to work with diverse care teams in a variety of settings including non-clinical settings (primarily patient homes) * Proven solid computer skills, including use of electronic medical records * Ability to travel 100% of the time in the Cuyahoga County, OH area for field-based work within 60 miles of residence * Valid driver's license * Access to reliable transportation that will enable you to travel to client and/or patient sites within a designated area Preferred Qualification: * Field based experience * Case management experience * Proven effective time management and communication skills 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. 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.