The Telephonic CaseManager RN in Medical Oncology provides remote nursing support by coordinating patient care, educating members, and ensuring adherence to treatment plans. This role involves assessing patient health, identifying barriers, and connecting patients with necessary resources to improve health outcomes. Working primarily via telephone, the position requires strong clinical expertise, communication skills, and proficiency in healthcare technology systems.
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 CaseManager 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 CaseManager RN Medical/Oncology will identify, coordinate, and provide appropriate levels of care. The Telephonic CaseManager 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 casemanagement, 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 CaseManager (CCM)
1+ years of experience within Medical/Oncology
Casemanagement 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.
Keywords:
telephonic casemanagement, oncology nurse, patient education, care coordination, medical management, healthcare advocacy, remote nursing, chronic disease management, UnitedHealth Group, RN license
$45k-52k yearly est. 1d ago
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Remote Travel NP/PA Clinical Educator in Physiatry
Iconic Care Support Services
Remote job
A healthcare provider group is seeking a Clinical Educator NP/PA & Travel Nurse to enhance patient outcomes through education and clinical coverage. This role requires a strong background in Physiatry, a passion for teaching, and the ability to travel nationwide. The competitive compensation includes a salary of $155,000-$185,000, full benefits, and comprehensive travel support. Located remotely with necessary metropolitan area constraints, candidates must be residing in specified locales.
#J-18808-Ljbffr
$155k-185k yearly 21h ago
RN Telephone Triage (Work from Home)
Accessnurse
Remote job
Evenings, Weekend Only, Full-time & Part-time opportunities available (20hrs +) Hiring for evenings and weekends (*weekends and holidays are required) Incentives for Bilingual Spanish Telephone Triage RNs! AccessNurse is the premier provider of medical call center solutions, including 24/7 telephone nurse triage, and answering services. In business since 1996, AccessNurse serves more than 20,000 clinicians and practices, along with healthcare systems, health plans and Federally Qualified Health Centers (FQHCs) across the country. AccessNurse is a TeamHealth Company.
The Telephone Triage Nurse role is a great alternative to bedside nursing working 12-hour shifts. This is an opportunity to work remote from home! Training and equipment are provided. Training classes are starting soon.
Overview
The Telephone Triage Nurse will take phone calls and help patients across the lifespan of the call and determine the best way to address their medical issues and concerns.
Essential Duties and Responsibilities
Assesses patient's symptoms utilizing a physician-written algorithms
When appropriate, provide home care instructions using the approved, written guidelines as well as approved reference material provided
Utilize all resources and guidelines to effectively assess, prioritize, advise, schedule classes or physician appointments, or refer calls when necessary to the appropriate medical facility, personnel or specialized community service
Completes all documentation in the appropriate software
Provides guidance recommending a variety of levels of care (e.g. home care, an office visit, emergency room)
Responds to patient's questions
Provides and documents health education to help patients manage their symptoms when indicated
Consults with physicians as needed
Job Requirements:
Qualifications / Experience
Current multi-state RN license with no restrictions; nurses currently holding a single-state RN license must obtain a multi-state license prior to being made a job offer
2+ years of nursing experience
Proficiency using computers and type a minimum of 25 wpm
Excellent listening and comprehension skills to determine key information by patient
Professional, courteous telephone voice
Ability to defuse conversations
Ability to handle confidential information; HIPAA compliance is mandatory
Flexibility with scheduling
Remote Workstation / HIPAA Requirements
Must have a high-speed internet connection
Workstation must be in a room where door can be locked
Desk should be large enough to hold 2 monitors, computer, accessories + hands-free headset
REMOTE: Training Class Dates
100% ATTENDANCE IS REQUIRED
4-week Remote Training over Zoom Video
Week 1: February 16th - February 20th M-F 9:00 am-5:00 pm EST
Week 2: February 23rd - February 27th M-F 9:00 am-5:00 pm EST
Week 3: March 2nd - March 6th M-F 2:00 pm-10:00 pm EST
Week 4: Shift days/times with a preceptor will be discussed with education manager
$43k-64k yearly est. 1d ago
Medical Field Case Manager
Enlyte
Remote job
At Enlyte, we combine innovative technology, clinical expertise, and human compassion to help people recover after workplace injuries or auto accidents. We support their journey back to health and wellness through our industry-leading solutions and services. Whether you're supporting a Fortune 500 client or a local business, developing cutting-edge technology, or providing clinical services you'll work alongside dedicated professionals who share your commitment to excellence and make a meaningful impact. Join us in fueling our mission to protect dreams and restore lives, while building your career in an environment that values collaboration, innovation, and personal growth.
Be part of a team that makes a real difference.
Enjoy the perfect balance of remote work and meaningful field visits in this flexible role. Central Illinois area residency required as you'll travel throughout the region (up to 200 miles/4 hours round trip) to provide personalized care for clients. This position offers professional autonomy while building valuable connections with patients across diverse healthcare settings throughout Central Illinois.
Join our compassionate team and help make a positive difference in an injured person's life. As a Field CaseManager, you will work closely with treating physicians/providers, employers, customers, legal representatives, and the injured/disabled person to create and implement a treatment plan that returns the injured/disabled person back to work appropriately, ensure appropriate and cost-effective healthcare services, achievement of maximum medical recovery and return to an optimal level of work and functioning. In this role, you will:
* Demonstrate knowledge, skills, and competency in the application of casemanagement standards of practice.
* Use advanced knowledge of types of injury, medications, comorbidities, treatment options, treatment alternatives, and knowledge of job duties to advise on a treatment plan.
* Interview disabled persons to assess overall recovery, including whether injuries or conditions are occupational or non-occupational.
* Collaborate with treating physicians/providers and utilize available resources to help create and implement treatment plans tailored to an individual patient.
* Work with employers and physicians to modify job duties where practical to facilitate early return to work.
* Evaluate and modify case goals based on injured/disabled person's improvement and treatment effectiveness.
* Independently manage workload, including prioritizing cases and deciding how best to managecases effectively.
* Complete other duties, such as attend injured worker's appointments when appropriate, prepare status updates for submittal to customers, and other duties as assigned.
Qualifications
* Education: Associates Degree or Bachelor's Degree in Nursing or related field.
* Experience: 2+ years clinical practice preferred. Workers' compensation-related experience preferred.
* Skills: Ability to advocate recommendations effectively with physicians/providers, employers, and customers. Ability to work independently. Knowledge of basic computer skills including Excel, Word, and Outlook Email. Proficient grammar, sentence structure, and written communication skills.
* Certifications, Licenses, Registrations:
* Active Registered Nurse (RN) license required. Must be in good standing.
* URAC-recognized certification in casemanagement (CCM, CDMS, CRC, CRRN or COHN, COHN-S, RN-BC, ACM, CMAC, CMC).
* Travel: Must have reliable transportation and be able to travel to and attend in-person appointments with injured workers in assigned geography.
* Internet: Must have reliable internet.
Benefits
We're committed to supporting your ultimate well-being through our total compensation package offerings that support your health, wealth and self. These offerings include Medical, Dental, Vision, Health Savings Accounts / Flexible Spending Accounts, Life and AD&D Insurance, 401(k), Tuition Reimbursement, and an array of resources that encourage a lifetime of healthier living. Benefits eligibility may differ depending on full-time or part-time status. Compensation depends on the applicable US geographic market. The expected base pay for this position ranges from $70,000 - $83,000 annually. In addition to the base salary, you will be eligible to participate in our productivity-based bonus program. Your total compensation, including base pay and potential bonus, will be based on a number of factors including skills, experience, education, and performance metrics.
The Company is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability.
Don't meet every single requirement? Studies have shown that women and underrepresented minorities are less likely to apply to jobs unless they meet every single qualification. We are dedicated to building a diverse, inclusive, and authentic workplace, so if you're excited about this role but your past experience doesn't align perfectly with every qualification in the job description, we encourage you to apply anyway. You may be just the right candidate for this or other roles.
#LI-MC1
Registered Nurse (RN), Nursing, Home Care Registered Nurse, Emergency Room Registered Nurse, Clinical Nurse, NurseCaseManager, Field CaseManager, Medical NurseCaseManager, Workers' Compensation NurseCaseManager, Critical Care Registered Nurse, Advanced Practice Registered Nurse (APRN), Nurse Practitioner, CaseManagement, CaseManager, Home Healthcare, Clinical CaseManagement, Hospital CaseManagement, Occupational Health, Patient Care, Utilization Management, Acute Care, Orthopedics, Rehabilitation, Rehab, CCM, Certified CaseManager, CDMS, Certified Disability Management Specialist, CRC, Certified Rehab Certificate, CRRN, Certified Rehab Registered Nurse, COHN, Certified Occupational Health Nurse, CMC, Cardiac Medicine Certification, CMAC, CaseManagement Administrator Certification, ACM, Accredited CaseManager, MSW, Masters in Social Work, URAC, Vocational CaseManager
$70k-83k yearly 8d ago
Medical Case Management Manager
Allied Benefit Systems 4.2
Remote job
The Medical CaseManagementManager (Manager, Enhanced CaseManagement (ECM)) leads the development, delivery, and continuous improvement of the ECM program, ensuring high quality care coordination and advocacy for member with complex health needs. This role provides direct leadership and mentorship to the ECM team, evaluates and enhances departmental workflows, and fosters strong internal and external partnerships through exceptional communication and relationship building skills. The Manager maintains expertise in self funded benefits administration and government programs such as Medicare and Medicaid to guide members in understanding and optimizing their available coverage options. In addition to managing a limited caseload, the position addresses client inquiries, resolves member escalations, and collaborates with organizational leadership to strengthen program strategy, performance, and impact.
ESSENTIAL FUNCTIONS
Develops and directly manages Enhanced CaseManagement Advocates and Supervisors, while providing indirect oversight to the CaseManagers through supervisory staff. Monitors department dashboards and conducts case audits to ensure teams consistently meet or exceed quality standards and KPIs.
Fosters a collaborative, continuous improvement environment and supports staff in resolving challenges and enhancing performance through constructive, supportive feedback.
Engage with the Client Management and Value Team to offer insight related to high-dollar claimants and provide a clear explanation of ECM strategies, efforts, and impact.
Identify members from our ASO Self-Funded and Co-Sourcing Partially Self-Funded Clients based on current medical condition(s), future claim costs, and current financial assessment for Enhanced CaseManagement evaluation and identify strategic solutions.
Maintain continuous knowledge of Medicare, Medicaid, and other government programs, including application processes, eligibility criteria, dual eligibility, and coordination of benefits (COB).
Identify trends and opportunities to collaborate with Medical Management leadership to enhance processes and strategies to improve quality, efficiency, and outcomes.
Manage a case load of high-complexity members to support their needs, evaluate coverages and offer resources.
Promotes an environment of continuous improvement and collaboration and assists in troubleshooting and resolving escalated challenges quickly by utilizing an empathetic approach.
Coordinate with Client Management and other internal departments to answer questions and resolve client challenges.
Assist in selecting and building the right teams to meet long-term talent planning needs and achieve business goals.
Lead, coach, motivate and develop. Responsible for one-on-one meetings, performance appraisals, growth opportunities and attracting new talent.
Clearly communicate expectations, provide employees with the training, resources, and information needed to succeed.
Actively engage, coach, counsel and provide timely, and constructive performance feedback.
Performs other related duties as assigned.
EDUCATION
Bachelor's degree or equivalent work experience required.
EXPERIENCE AND SKILLS
At least 5 years of CaseManagement experience, preferably from a third-party administrator, carrier, or within the healthcare industry required.
At least 3 years at a supervisor level and successfully demonstrated leadership competencies required.
Demonstrated expertise in Medicaid, Medicare, eligibility processes, and coordination of benefits.
Experience managing teams of employees with a variety of backgrounds and tenure.
Ability to monitor and prioritize multiple deadlines and projects simultaneously.
Experience reading, analyzing, and reviewing organizational metrics and data, preferred.
Comfortable managing competing priorities and guiding others in a fast-paced environment.
Excellent written and verbal communication skills with the ability to influence cross-functionally and present to clients/leadership
Proven experience building training programs, conducting audits, and providing structured feedback.
POSITION COMPETENCIES
Accountability
Communication
Action Oriented
Timely Decision Making
Building Relationships/Shaping Culture
Customer Focus
PHYSICAL DEMAND
This is a standard desk role long periods of sitting and working on a computer are required.
WORK ENVIRONMENT
Remote
Here at Allied, we believe that great talent can thrive from anywhere. Our remote friendly culture offers flexibility and the comfort of working from home, while also ensuring you are set up for success. To support a smooth and efficient remote work experience, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 100Mbps download/25Mbps upload. Reliable internet service is essential for staying connected and productive.
The company has reviewed this job description to ensure that essential functions and basic duties have been included. It is not intended to be construed as an exhaustive list of all functions, responsibilities, skills, and abilities. Additional functions and requirements may be assigned by supervisors as deemed appropriate.
Compensation is not limited to base salary. Allied values our Total Rewards, and offers a competitive Benefit Package including, but not limited to, Medical, Dental, Vision, Life & Disability Insurance, Generous Paid Time Off, Tuition Reimbursement, EAP, and a Technology Stipend.
Allied reserves the right to amend, change, alter, and revise, pay ranges and benefits offerings at any time. All applicants acknowledge that by applying to the position you understand that the specific pay range is contingent upon meeting the qualification and requirements of the role, and for the successful completion of the interview selection and process. It is at the Company's discretion to determine what pay is provided to a candidate within the range associated with the role.
Protect Yourself from Hiring Scams
Important Notice About Our Hiring Process
To keep your experience safe and transparent, please note:
All interviews are conducted via video.
No job offer will ever be made without a video interview with Human Resources and/or the Hiring Manager.
If someone contacts you claiming to represent us and offers a position without a video interview, it is not legitimate. We never ask for payment or personal financial information during the hiring process.
For your security, please verify all job opportunities through our official careers page: Current Career Opportunities at Allied Benefit Systems
Your security matters to us-thank you for helping us maintain a fair and trustworthy process!
$42k-61k yearly est. 11d ago
Director - Utilization Management & Case Management (remote) RN
Healthcare Strategies, Inc. 4.5
Remote job
We are a nationally recognized healthcare management organization with over 40 years of experience delivering innovative, high-quality clinical solutions. Our mission is to improve member health outcomes by identifying risk, promoting treatment compliance, and delivering personalized care.
Position Summary
The Director of Utilization Management & CaseManagement provides strategic and operational leadership for UM and LCM programs. This role is responsible for driving clinical excellence, regulatory compliance, process improvement, and team performance while partnering with senior leadership, clients, and sales to support continued growth.
Key Responsibilities
Lead and manage UM and LCM teams, fostering high performance and professional development
Ensure compliance with URAC standards and applicable state regulations
Drive process improvement, efficiency, and automation initiatives
Serve as clinical and operational SME for business development and new product launches
Collaborate cross-functionally with Sales, Client Services, Clinical, and IT teams
Support client relationships, reporting reviews, and strategic planning
Participate in sales presentations and client meetings as needed
Qualifications
Bachelor's degree in healthcare, business, or related field
Clinical background with healthcare leadership experience
Progressive management experience in healthcare operations
Experience working with senior leadership and external clients
Experience in utilization management and casemanagement
Experience with self-funded groups and InterQual criteria preferred
Strong communication, analytical, and leadership skills
Ability to travel as needed (approximately 10%)
Compensation & Benefits
Competitive salary based on experience
Comprehensive benefits package including medical, dental, vision, 401(k), PTO, and more
Join Our Team
If you are a strategic, results-driven healthcare leader ready to make an impact, we invite you to apply.
$58k-83k yearly est. Auto-Apply 6d ago
Telephonic Nurse Case Manager (RN) - REMOTE - Compact License - Mon-Fri 8:30 -5:30 local time
Ek Health Services 3.7
Remote job
Telephonic CaseManager - Rare Opportunity!
EK Health is now hiring for a Telephonic NurseCaseManager (RN) for our CaseManagement Team! This role includes assessing, planning, implementing, coordinating, and evaluation of service options. The goal of the CaseManager is to assist the injured worker in receiving appropriate, cost-effective medical care for their injury in a timely manner, and to expedite their return to work.
Position Logistics: Monday - Friday, 8:30am -5:30pm local time, Full-time Remote.
NOTE: Requires a Compact RN license in good standing. Workers Compensation experience is preferred but not required.
Wage is based on experience, education, certifications and location (may be either hourly or salary based on individual state requirements).
Benefits & Perks:
Base pay $35-42/hr ($72,800 - $87,360 annually). Wage is based on experience, education, certifications and location (may be either hourly or salary based on individual state requirements).
Medical, Dental and Vision Insurance
401K
Paid Time Off
Paid holidays
Equipment is provided
Monthly internet stipend
Here's a snapshot of what you'll be doing (not all-inclusive):
Communicate with medical providers, employers and with injured workers
Perform a complete nursing evaluation to determine needs of patient
Review and evaluate all medical correspondence, provider reports, & treatment plan history
Evaluate clinical status of claimant and research for alternative options to treatment as warranted
Communicate with the claims examiners regarding directives, and provide updates on file status
Arranging transportation services when necessary and authorized
Evaluating therapy facilities and their progress on specific cases
Prepare comprehensive notes following any discussions had with injured worker, medical providers, claims examiners, and employers in the case file
Discuss the analyzed data and the comprehensive plan of care with the insurance representative prior to implementation
Upon authorization, implement this plan of care with patient, physician and health care providers
Arrange for care/services as needed (home care, procedures, medication, equipment or supplies)
Monitor the plan of care with modifications or changes suggested to the patient and physician as the need arises
Coordinate information between all parties (injured worker, physicians, employer, other providers, such as therapists, and attorney, if any is involved)
Requirements
Graduate of an accredited school of nursing
3-5 years clinical experience as an RN outside of school
Valid Compact RN license in good standing with no restrictions
Valid state-appropriate RN license in good standing with no restrictions
Possesses and can demonstrate the professional and technical skills of a Registered Nurse
Experience in CaseManagement, Workers' Compensation experience preferred, but not required
Experience in Home Health Care, Occupational Health considered a plus
Excellent Written and Oral Communication Skills
Excellent Interpersonal & Organizational Skills
High comfort level with computers and computer programs (MS Word, MS Excel, Email)
$72.8k-87.4k yearly 10d ago
Workers Compensation Telephonic Nurse Case Manager (Remote)
Berkley 4.3
Remote job
Company Details
Berkley Medical Management Solutions (BMMS) provides a different kind of managed-care service for W.R. Berkley Corporation. We believe focusing on an injured worker's successful and speedy return to work is good for people and good for Berkley's insurance operating units. BMMS was first started in 2014 by reimagining the relationship between medical need and technology to deliver the best outcome for injured workers and Berkley's operating units. Our goal was clear: combine solid clinical practices, proven return-to-work strategies and robust software into one system for seamless management of workers' compensation cases.
To get it right, we started with a flexible technology platform that allowed for impressive customization without sacrificing the ability for expansion and continued innovation. We deploy integrated systems to give W.R. Berkley Companies recommendations and professional services for managing each individual case in an efficient and appropriate manner. The power of our technology takes medical bill-review services and clinical advisory services to a new level. Our unique marriage of technology, software platforms, data analytics and professional services ensures we provide Berkley's operating units with reliable results, and reduced time and expenses associated with casemanagement.
Responsibilities
As a Telephonic NurseCaseManager, you will assess, plan, coordinate, monitor, evaluate and implement options and services to facilitate timely medical care and return to work outcomes of injured workers.
Coordinate and implement medical casemanagement to facilitate case closure
Timely and comprehensive communication with with employers, adjusters and the injured workers.
Assess appropriate utilization of medical treatment and services available through contact with physicians and other specialist to ensure cost effective quality care
Review and analyze medical records and assess data to ensure appropriate casemanagement process occurs while providing recommendations to achieve case progress and movement to closure
Responsible for assigned caseloads, which may vary in numbers, territory and/or by state jurisdiction
Acquire and maintain nursing licensure for all jurisdictions as business needs require
Coordinate services to include home services, durable medical equipment, IMEs, admissions, discharges, and vocational services when appropriate and evaluate cost effectiveness and quality of services
Document activities and case progress using appropriate methods and tools following best practices for quality improvement
Reviewing job analysis/job description with all providers to coordinate and implement disability casemanagement. This includes coordinating job analysis with employer to facilitate return to work.
Engage and participate in special projects as assigned by casemanagement leadership team
Occasionally attend on site meetings and professional programs
Foster a teamwork environment
Maintaining and updating evidence based medical guidelines (such as Official Disability Guidelines, MD Guidelines and all required state regulated guidelines) in reference to the injured worker treatment plan and work status.
Obtain and maintain applicable state certifications and/or licensures in the state where job duties are performed.
Obtain casemanagement professional certification (CCM) within 2 years of hire
Qualifications
Minimum 2 years of experience in workers compensation insurance and medical casemanagement preferred
Minimum of 4 years medical/surgical clinical experience required
Ability to work standard business hours in the either Central Standard Time, Mountain Standard Time or Pacific Time Zone (Monday through Friday, 8:00 AM to 5:00 PM CST/MST/PST).
Exhibit strong communication skills, professionalism, flexibility and adaptability
Possess working knowledge of medical and vocational resources available to the Workers' Compensation industry
Demonstrate evidence of self-motivation and the ability to perform casemanagement duties independently
Demonstrate evidence of computer and technology skills
Oral and written fluency in both Spanish and English a plus
Education
Graduate of an accredited school of nursing and possess a current RN license.
A Compact Nursing License is strongly preferred. A California license is ideal but not mandatory. Candidates must be willing and able to obtain a California license within 90 days of their start date.
Additional Company Details ******************
The Company is an equal employment opportunity employer
We do not accept any unsolicited resumes from external recruiting agencies or firms.
The company offers a competitive compensation plan and robust benefits package for full time regular employees
• Base Salary Range: $80,000 - $88,000
• Benefits: Health, Dental, Vision, Life, Disability, Wellness, Paid Time Off, 401(k) and Profit-Sharing plans.
The actual salary for this position will be determined by a number of factors, including the scope, complexity and location of the role; the skills, education, training, credentials and experience of the candidate; and other conditions of employment. Additional Requirements • Domestic U.S. travel required (up to 10% of time) Sponsorship Details Sponsorship not Offered for this Role
$80k-88k yearly Auto-Apply 43d ago
Medical & Disability Nurse Case Manager
Liberty Mutual 4.5
Remote job
If you're a registered nurse looking for a new opportunity to work in a fast-paced, professional environment where your talent contributes to our competitive edge, Liberty Mutual Insurance has the opportunity for you. Under general technical direction, responsible for medically managing assigned caseload and by applying clinical expertise ensure individuals receive appropriate healthcare in order to return to work and normal activity in a timely and cost effective manner. Caseload may include catastrophic/complex medical/disability cases, lost time, and/or medical only claims. Also act as a clinical resource for field claim partners.
This is a remote position, however, you will be required to report into the office twice a month per business requirements if you reside within 50 miles of the following offices: Lake Oswego, OR, Chandler, AZ, Hoffman Estates, IL, Suwanee, GA, Indianapolis, IN, Plano, TX, Boston, MA, Westborough, MA, Las Vegas, NV, and Weatogue, CT
.
Please note this policy is subject to change.
Responsibilities:
Follows Liberty Mutual's established standards and protocols to effectively manage assigned caseload of medical/disability cases and by applying clinical expertise assist to achieve optimal outcome and to facilitate claim resolution and disposition.
Effectively communicates with injured employees, medical professionals, field claims staff, attorneys, and others to obtain information, and to negotiate medical treatment and return to work plans using critical thinking skills, clinical expertise and other resources as needed to achieve an optimal case outcome.
Utilizes the Nursing Process (assessment, diagnosis, planning, intervention and evaluation) to facilitate medical management to attain maximum medical improvement and return-to-work (RTW) per state jurisdictional requirements.
Appropriately utilizes internal and external resources and referrals i.e., Utilization Review, Peer Review, Field Claims Specialists, Regional Medical Director Consults, and Vocational Rehabilitation to achieve best possible case outcome.
Follows general technical direction from nursemanager, senior medical and disability casemanager and/or CCMU staff to resolve highly complex medical and/or RTW issues and/or successfully manage catastrophic injuries.
Documents all RN activities accurately, concisely and on a timely basis. This includes documenting the medical and disability casemanagement strategies for claim resolution, based on clinical expertise. Adheres to confidentiality policy.
Appropriately applies clinical expertise to claims and delivers services in an efficient and effective manner.
Accurately and appropriately documents time tracking for work performed. Achieves annual time tracking goal.
Handles special projects as assigned.
Qualifications
Ability to analyze and make sound nursing judgments and to accurately document activities.
Strong communication skills in order to build relationships with injured employees, medical professionals, employers, field claims staff and others.
Good negotiation skills to effectively establish target return to work dates and coordinate medical care.
Knowledge of state, local and federal laws related to health care delivery preferred.
Personal computer knowledge and proficiency in general computer applications such as Internet Explorer and Microsoft Office (including Word, Excel and Outlook).
Degree from an accredited nursing school required (prefer Bachelor of Science in Nursing).
Minimum of 3 to 5 years of clinical nursing experience; prefer previous orthopedic, emergency room, critical care, home care or rehab care experience.
Previous medical casemanagement experience a plus.
Must also have current unrestricted registered nurse (R.N.) license in the state where the position is based and other assigned states as required by law.
Must have additional professional certifications, such as CCM, COHN, CRRN, etc., where required by WC law.
About Us
Pay Philosophy: The typical starting salary range for this role is determined by a number of factors including skills, experience, education, certifications and location. The full salary range for this role reflects the competitive labor market value for all employees in these positions across the national market and provides an opportunity to progress as employees grow and develop within the role. Some roles at Liberty Mutual have a corresponding compensation plan which may include commission and/or bonus earnings at rates that vary based on multiple factors set forth in the compensation plan for the role.
At Liberty Mutual, our goal is to create a workplace where everyone feels valued, supported, and can thrive. We build an environment that welcomes a wide range of perspectives and experiences, with inclusion embedded in
every aspect of our culture and reflected in everyday interactions. This comes to life through comprehensive
benefits, workplace flexibility, professional development opportunities, and a host of opportunities provided through our Employee Resource Groups. Each employee plays a role in creating our inclusive culture, which supports every individual to do their best work. Together, we cultivate a community where everyone can make a meaningful impact for our business, our customers, and the communities we serve.
We value your hard work, integrity and commitment to make things better, and we put people first by offering you benefits that support your life and well-being. To learn more about our benefit offerings please visit: ***********************
Liberty Mutual is an equal opportunity employer. We will not tolerate discrimination on the basis of race, color, national origin, sex, sexual orientation, gender identity, religion, age, disability, veteran's status, pregnancy, genetic information or on any basis prohibited by federal, state or local law.
Fair Chance Notices
California
Los Angeles Incorporated
Los Angeles Unincorporated
Philadelphia
San Francisco
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$58k-71k yearly est. Auto-Apply 20h ago
Utilization Management Nurse - Remote
Actalent
Remote job
* Review approximately 20 cases a day for medical necessity. * Advocate for and protect members from unnecessary hospital admissions. * Follow established procedures and processes to complete authorizations. * Collaborate with a team of nurses to assist each other and complete cases.
Qualifications:
* 3+ years of utilization management, concurrent review, prior authorization, utilization review, casemanagement, and discharge planning is must
* Active RN Compact License is Must
If you are Interested , Kindly give a call : **************
Job Type & Location
This is a Contract position based out of Fort Worth, TX.
Pay and Benefits
The pay range for this position is $35.00 - $40.00/hr.
Eligibility requirements apply to some benefits and may depend on your job classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits available for this temporary role may include the following: • Medical, dental & vision • Critical Illness, Accident, and Hospital • 401(k) Retirement Plan - Pre-tax and Roth post-tax contributions available • Life Insurance (Voluntary Life & AD&D for the employee and dependents) • Short and long-term disability • Health Spending Account (HSA) • Transportation benefits • Employee Assistance Program • Time Off/Leave (PTO, Vacation or Sick Leave)
Workplace Type
This is a fully remote position.
Application Deadline
This position is anticipated to close on Jan 21, 2026.
About Actalent
Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500.
The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.
If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing due to a disability, please email actalentaccommodation@actalentservices.com for other accommodation options.
Flexible Independent Contractor (1099) Opportunity
Required State Medical License in Florida or Oregon
Founded in 1983,
Medical Review Institute of America (MRIoA)
is a nationally recognized Independent Review Organization (IRO) specializing in technology-driven utilization management and clinical medical review solutions. We're a leader in Peer and Utilization Reviews, known for excellence and continuous improvement.
THE OPPORTUNITY:
We are currently seeking Board-Certified physicians in Rheumatology to conduct independent Utilization Reviews. This is a flexible, fully remote opportunity requiring just 1-2 hours per week-with no minimum commitment.
ADDITIONAL INFORMATION:
Work remotely from anywhere in the US (Per HIPPA Regulations patient records cannot leave the US).
Covered under MRIoA's Errors and Omissions policy.
Independent Contractor (1099) opportunity.
Workers are required to adhere to all applicable HIPAA regulations and company policies and procedures regarding the confidentiality, privacy, and security of sensitive health information.
California Consumer Privacy Act (CCPA) Information (California Residents Only):
Sensitive Personal Info: MRIoA may collect sensitive personal info such as real name, nickname or alias, postal address, telephone number, email address, Social Security number, signature, online identifier, Internet Protocol address, driver's license number, or state identification card number, and passport number.
Data Access and Correction: Applicants can access their data and request corrections. For questions and/or requests to edit, delete, or correct data, please email the Medical Review Institute at ************.
Must have a Medical Degree MD or DO
Must have a current STATE unencumbered medical license in Florida or Oregon
Current Board Certification in Rheumatology
Must have 5 years of clinical experience residency to be included
Daytime availability is required for peer-to-peer conversations
$75k-106k yearly est. Easy Apply 13d ago
Remote Triage Nurse (Full-Time)
Diana Health
Remote job
Diana Health is a network of modern women's health practices working in partnership with hospitals to reimagine the maternity and women's healthcare experience. We are restructuring the traditional approach to care to create an experience that is good for patients and good for providers. We do that by combining a tech-enabled, wellness-focused care program that women love with a clinical system that helps us drive continuous quality improvement and ensure work-life balance for our care team. We work with clients across all life stages to empower and support them to live happier, healthier, more fulfilling lives. With strong collaborative care teams; passionate administrators and a significant investment in operational support, Diana Health providers are well-supported to bring their very best to the work they love.
We are an interdisciplinary team joined together by our shared commitment to transform women's health. Come join us!
Description
We are looking for a full-time LPN passionate about all aspects of women's health to provide direct patient care as part of an interdisciplinary care team and to serve as the first line of communication with patients in our clinical phone and messaging triage during office hours. The ideal candidate thrives in a busy practice, loves women's health and building relationships with patients, is an excellent problem-solver and communicator, and is able to multi-task easily. Bilingual skills preferred with a preference for Spanish language, open to other languages.
What you'll do
Patient Care
Act as the first line of call in clinical communications for patients, within guidelines/protocols
Administer injections and medications
Provide direct clinical care as needed for minor check in visits or lab draws
Provide supporting paperwork and education for patients
Support clinic visits as appropriate and per training when needed
Administrative
Support the everyday flow of clinic acting as back up support for MA
Maintaining logs
Cleaning of rooms as needed and sterilization of instruments
Obtaining and transcribing patient medical records
Additional workflow items as the need arises
Qualifications
Current certification as a Tennessee Licensed Practical Nurse
2+ years of experience in an outpatient preferred
Excellent communication, interpersonal, and organizational skills
Strong computer skills and familiarity with EMRs
Lactation certification (IBCLC, CLC, CLE) preferred, but not required
Bilingual, Spanish skills preferred
Benefits
Competitive compensation
Health; dental & vision, with an HSA/FSA option
401(k) with employer match
Paid time off
Paid parental leave
Diana Health Culture
Having a growth mindset and striving for continuous learning and improvement
Positive, can do / how can I help attitude
Empathy for our team and our clients
Taking ownership and driving to results
Being scrappy and resourceful
RN working in the insurance or managed care industry using medically accepted criteria to validate the medical necessity and appropriateness of the treatment plan.
JOB RESPONSIBILITIES:
This position is responsible for performing initial, concurrent review activities; discharge care coordination for determining efficiency, effectiveness, and quality of medical/surgical services, and serving as liaison between providers and medical and network management divisions.
Collects clinical and non-clinical data.
Verifies eligibility.
Determines benefit levels in accordance to contract guidelines.
Provides information regarding utilization management requirements and operational procedures to members, providers, and facilities.
JOB QUALIFICATIONS (Required):
Registered Nurse (RN) with a valid, current, unrestricted license in the state of operations.
3 years of clinical experience in a Physician's office, Hospital/Surgical setting, or Health Care Insurance Company.
Knowledge of medical terminology and procedures.
Verbal and written communication skills.
JOB QUALIFICATIONS (Preferred):
MCG or InterQual experience
Utilization management experience
LOCATION: REMOTE in Texas (Austin area - Travis/Williamson Counties or Richardson area - Dallas/Collin Counties).
POSITION: 6-month assignment
SALARY: $38 - $40 hourly
HOURS PER WEEK: 40
HOURS PER DAY: 8
$38-40 hourly 60d+ ago
Bilingual Triage Nurse
Firsthand Part Time Nurse Practitioner
Remote job
firsthand supports individuals living with SMI (serious mental illness). Our holistic approach includes a team of peer recovery specialists, benefits specialists and clinicians. Our teams focus on meeting each individual where they are and walking with them side by side as a trusted guide and partner on their journey to better health. firsthand's team members use their lived experience to build trust with these individuals and support them in reconnecting to the healthcare they need, while minimizing inappropriate healthcare utilization. Together with our health plan partners, we are changing the way our society supports those most impacted by SMI. We are cultivating a team of deeply passionate problem-solvers to tackle significant and complex healthcare challenges with us. This is more than a job-it's a calling. Every day, you will engage in work that resonates with purpose, gain wisdom from motivated colleagues, and thrive in an environment that celebrates continuous learning, creativity, and fun.
The Triage Nurse is a remote Registered Nurse who provides telephone and electronic triage support to firsthand individuals and staff, while also supporting outpatient care coordination. This is primarily a day-shift role (8 hours/day, 8:30-4:30 PST or 8:30-4:30 PST), with occasional potential for nights or weekends. When not managing acute issues, Triage Nurses focus on care coordination, training, and related administrative tasks.
Responsibilities of a Triage Nurse include:
Triage and Escalation: Manage inbound clinical issues from firsthand staff and patients via phone; triage appropriately and escalate emergencies immediately.
Collaboration: Work closely with peer mental health workers, social workers, and APPs to address acute issues comprehensively.
Coordination: Coordinate care with patients' other providers to ensure seamless health management.
Training: Develop and deliver training on basic medical topics for peer mental health workers and social workers
Triage Nurses should have:
Strong triage and prioritization skills, with the ability to rapidly assess and determine the appropriate level of care.
Problem-solving expertise with a creative, patient-centered approach.
Ability to provide condition-specific patient education and self-management guidance.
Adaptability to varying team cultures and processes.
Empathy, compassion, and approachability in patient and team interactions.
Required experience includes:
Active RN license through a Nurse Licensure Compact (NLC) state and willingness to obtain licensure in non-compact states.
Bachelor of Science in Nursing (BSN).
At least 3 (three) years of clinical care experience in an Emergency Department.
Experience working with populations facing challenges such as behavioral health and/or substance use disorders.
Care management and coordination experience.
Bilingual in Spanish
Bonus Points for:
Certification in Psychiatric-Mental Health Nursing (PMH-BC)
Washington state RN license
Base salary range:$75,000-$75,000 USD
We firmly believe that great candidates for this role may not meet 100% of the criteria listed in this posting. We encourage you to apply anyway - we look forward to begin getting to know you.
Benefits
For full-time employees, our compensation package includes base, equity (or a special incentive program for clinical roles) and performance bonus potential. Our benefits include physical and mental health, dental, vision, 401(k) with a match, 16 weeks parental leave for either parent, 15 days/year vacation in your first year (this increases to 20 days/year in your second year and beyond), and a supportive and inclusive culture.
Vaccination Policy Employment with firsthand is contingent upon attesting to medical clearance requirements, which include, but may not be limited to: evidence of vaccination for/immunity to COVID-19, Hepatitis B, Influenza, MMR, Chickenpox, Tetanus and Diphtheria. All employees of firsthand are required to receive these vaccinations on a cadence/frequency as advised by the CDC, whereas not otherwise prohibited by state law. New hires may submit for consideration a request to be exempted from these requirements (based on a valid religious or medical reason) via forms provided by firsthand. Such requests will be subject to review and approval by the Company, and exemptions will be granted only if the Company can provide a reasonable accommodation in relation to the requested exemption. Note that approvals for reasonable accommodations are reviewed and approved on a case-by-case basis and availability of a reasonable accommodation is not guaranteed.
Unfortunately, we are not able to offer sponsorship at this time.
$75k-75k yearly Auto-Apply 16d ago
Utilization Review Registered Nurse, Case Management, FT, 08A-4:30P Local Remote
Baptist Health South Florida 4.5
Remote job
The purpose of this position is to conduct initial, concurrent, retrospective chart review for clinical financial resource utilization. Coordinates with healthcare team for optimal/efficient patient outcomes, while decreasing length of stay (LOS) and avoid delays and denied days. They are accountable for a designated patient caseload and provides intervention, coordination to decrease avoidable delays, denial of reimbursement. Specific functions within this role include: Screens pre-admission, admission process using established criteria for all points of entry. Facilitates communication between payers, review agencies, healthcare team. Identify delays in treatment or inappropriate utilization and serves as a resource. Coordinates communication with physicians. Identify opportunities for expedited appeals and collaborates to resolve payer issues. Ensures/Maintains effective communication with Revenue Cycle Departments. Estimated salary range for this position is $73860.80 - $96019.04 / year depending on experience.
Degrees:
* Associates.
Licenses & Certifications:
* MCG Care Guidelines Specialist.
* Registered Nurse.
Additional Qualifications:
* RNs hired prior to 2-2012 (10/1/2017 at Bethesda or 7/1/2019 at BRRH) with an Associates Degree in Nursing are not required to have a BSN to continue their non-leadership role as an RN.
however, they are required to complete the BSN within 3 years of job entry date.
* MCG Specialist Certification ISC/HRC required within 12 months of job entry date.
* 3 years of Nursing experience preferred.
* Excellent written, interpersonal communication and negotiation skills.
* Strong critical thinking skills and the ability to perform clinical/chart review abstract information efficiently.
* Strong analytical, data management and computer skills.
* Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components.
* Current working knowledge of payer and managed care reimbursement preferred.
* Ability to work independently and exercise sound judgment in interactions with the health care team and patients/families.
* Knowledgeable in local, state, and federal legislation and regulations.
* Ability to tolerate high volume production standards.
Minimum Required Experience:
3 Years of Utilization Review in an acute care setting required
$73.9k-96k yearly 13d ago
Utilization Review Nurse-Remote-Contract
Hireops Staffing, LLC
Remote job
$40/hour - Contract for 6 months Must reside in TX
Full time remote Candidates must be based in TX. RN working in the insurance or managed care industry using medically accepted criteria to validate the medical necessity and appropriateness of the treatment plan.
pay rate is $40/hour
This position is responsible for performing initial, concurrent review activities; discharge care coordination for determining efficiency, effectiveness and quality of medical/surgical services and serving as liaison between providers and medical and network management divisions. Collects clinical and non-clinical data. Verifies eligibility. Determines benefit levels in accordance to contract guidelines. Provides information regarding utilization management requirements and operational procedures to members, providers and facilities.
Registered Nurse (RN) with valid, current, unrestricted license in the state of operations.
* 3 years of clinical experience in a physician office, hospital/surgical setting or health care insurance company.
* Knowledge of medical terminology and procedures.
* Verbal and written communication skills.
PREFERRED JOB REQUIREMENTS:
* Utilization management experience
* MCG or InterQual experience
$40 hourly 60d+ ago
Nurse Liaison - Remote
Gateway Rehabilitation Center 3.6
Remote job
Gateway Rehab Center (GRC) has an outstanding opportunity for a Nurse Liaison Gateway Rehab who will be responsible for the pre-admission casemanagement, ASAM level of care assessment, and coordination of admission to care for substance use disordered patients referred from a hospital setting. To be considered for the position, you must live within the Pittsburgh, PA area or surrounding counties.
Responsibilities
Assesses admission candidates' medical and psychiatric appropriateness for treatment.
Determines level of care placement based on ASAM criteria.
Pre-certifies admissions as required.
Discusses treatment options with referral sources.
Acts as liaison between Gateway and outside referral sources.
Coordinates patient transfers from other facilities to Gateway Aliquippa/Westmoreland.
Responds to needs of referral sources and managed care representatives.
Interacts with the physician through coordination of patient assessments. Attends GRC mandatory training and in-services.
Other duties as required.
Knowledge, Skills, and Abilities
Strong communication skills required.
Able to work independently with minimal oversight.
Knowledge of skilled nursing
Requirements
Pennsylvania RN or LPN licensure
3+ years nursing experience preferred.
Experience identifying/treating drug and alcohol addictions.
Experience in conducting assessments and evaluations.
Additional Requirements
Pass PA Criminal Background Check
Obtain PA Child Abuse and FBI Fingerprinting Clearances.
Pass Drug Screen
TB Test
Access to reliable and dependable internet connection.
Work Conditions
Favorable working conditions.
Minimal physical demands
Significant mental demands include those associated with working with patients with addictive disorders and managing multiple tasks.
GRC is an Equal Opportunity Employer committed to diversity, equity, inclusion, and belonging. We value diverse voices and lived experiences that strengthen our mission and impact.
$60k-75k yearly est. 6d ago
Remote Triage Nurse
Medcor 4.7
Remote job
Medcor is looking to hire a full-time Registered Nurse for our remote 24/7 Occupational Health triage call center! The hours for this position include 8-hour or 10-hour shifts between the hours of 12pm and 2am CST.
Job Type: Full-time - 40 hours per week
Salary: $28 per hour with additional shift differential pay available for evenings, nights & weekends.
By joining our nursing team, you will be helping thousands of employers better manage their workplace injuries and improve the quality of healthcare for their employees. Nurses who are successful in this position must be able to talk on the phone for long periods while typing and navigating through various software applications simultaneously. Our nurses must be able to visualize an injury while on the phone and clarify details about the injury while following our propriety algorithms to guide the triage of the injured worker.
Training:
Training for this role will last 5-6 weeks, with 2.5 weeks of classroom instruction and 2.5 weeks of precepting. These first 5-6 weeks of training are held Monday through Friday, from 8a-4p CST. The training schedule is non-negotiable, and all training must be successfully completed within the 6-week time frame. Following training, you will transition to your permanent schedule between the hours of 12p and 2a CST with an every-other-weekend requirement and holiday rotation. Changes to the permanent schedule are not allowed within the first 12 months of employment.
A typical day in the life of a Medcor Triage RN:
Manage a rapid flow of incoming telephone calls from Medcor customers in a call center environment
Document each call efficiently and accurately
Monitor and track individual as well as call center goals, productivity metrics, and statistics
Reflect all shift activities using the phone system and be responsible for personal schedule adherence
Provide superior customer service to Medcor s clients and employees
Complete accurate assessment of symptoms and/or concerns utilizing Medcor s Triage Algorithms
Follow HIPAA Compliance Policies
You Must
Be bilingual, fluent in both the English and Spanish language
Have a valid RN license and current BLS (CPR) certification
Be able to handle a high volume of consecutive calls
Have strong technological skills as well as a typing speed of at least 30 WPM
Work a major U.S. holiday rotation
Work every other weekend
Have effective written, verbal, and interpersonal communication skills. Ability to read, analyze, and interpret triage tools and information along with care instructions to injured employees and their managers.
Be able to talk and/or hear. You are required to sit and use your hands. Specific vision abilities required by this job include close vision for computers and written work with the ability to adjust focus
Be able to work on a computer for long periods
Have a private space in your home with 4 walls and a door for patient privacy
Have access to high-speed internet (no satellite) within your primary residence
Be able to receive and apply feedback
It's a Plus If
You have call center experience
You have occupational health experience
At Medcor, we re passionate about caring for our advocates as much as you are passionate about caring for your patients! Join our team and receive the support you need to be successful in your practice and to focus on your patients. In addition to a collaborative work environment, we offer great pay and benefits and emphasize your wellness.
Here s why people love working for Medcor:
Stability! We ve been around since 1984.
Potential for retention and performance incentives
Opportunities galore! Medcor has a lot more to offer than just this job. There are opportunities to move vertically, horizontally, and geographically. Annually, 20% of our openings are filled by internal employees. The fact is, opportunity exists here!
Training! We believe in it and we ll train and support you to be the best you can be. We feel we offer more training than most other companies.
We have an open-door policy. Do you have something to say? Speak your mind! We encourage it and we look forward to how you can help our organization.
Benefits
We don t just advocate for our clients and our patients; we also advocate for ourselves. Our benefits include paid time off, health and dental insurance, 401K with match, education reimbursement, and more.
To learn more about Medcor s Culture click
here
.
Medcor Philosophy
Medcor embraces a set of simple, interconnected practices that everyone can tailor to their own life and work. To preserve our pioneering, entrepreneurial spirit, we impart our values through the ongoing Better@Medcor campaign: encouraging our advocates to make a conscious choice to practice our values, to celebrate and recognize each other via our peer recognition program, and to support one another during tough times.
Medcor is a tobacco-free and smoke-free workplace!
EOE/M/F/Vet/Disability
We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity or expression, pregnancy, age, national origin, disability status, genetic information, protected veteran status, or any other characteristic protected by law.
$28 hourly 42d ago
Utilization Review Registered Nurse, Case Management, FT, 08A-4:30P Local Remote
Baptisthlth
Remote job
Utilization Review Registered Nurse, CaseManagement, FT, 08A-4:30P Local Remote-155662Description
The purpose of this position is to conduct initial, concurrent, retrospective chart review for clinical financial resource utilization. Coordinates with healthcare team for optimal/efficient patient outcomes, while decreasing length of stay (LOS) and avoid delays and denied days. They are accountable for a designated patient caseload and provides intervention, coordination to decrease avoidable delays, denial of reimbursement. Specific functions within this role include: Screens pre-admission, admission process using established criteria for all points of entry. Facilitates communication between payers, review agencies, healthcare team. Identify delays in treatment or inappropriate utilization and serves as a resource. Coordinates communication with physicians. Identify opportunities for expedited appeals and collaborates to resolve payer issues. Ensures/Maintains effective communication with Revenue Cycle Departments.Qualifications Degrees:Associates.Licenses & Certifications:MCG Care Guidelines Specialist.Registered Nurse.Additional Qualifications:RNs hired prior to 2-2012 (10/1/2017 at Bethesda or 7/1/2019 at BRRH) with an Associates Degree in Nursing are not required to have a BSN to continue their non-leadership role as an RN. however, they are required to complete the BSN within 3 years of job entry date.MCG Specialist Certification ISC/HRC required within 12 months of job entry date.3 years of Nursing experience preferred.Excellent written, interpersonal communication and negotiation skills.Strong critical thinking skills and the ability to perform clinical/chart review abstract information efficiently.Strong analytical, data management and computer skills.Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components.Current working knowledge of payer and managed care reimbursement preferred.Ability to work independently and exercise sound judgment in interactions with the health care team and patients/families.Knowledgeable in local, state, and federal legislation and regulations.Ability to tolerate high volume production standards.Minimum Required Experience: 3 YearsJob CaseManagement/Home HealthPrimary Location Boca RatonOrganization Boca Raton Regional HospitalSchedule Full-time Job Posting Jan 7, 2026, 5:00:00 AMUnposting Date Ongoing Pay Grade R21EOE, including disability/vets
$48k-65k yearly est. Auto-Apply 14d ago
Utilization Review Nurse - Remote
Martin's Point Health Care 3.8
Remote job
Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015.
Position Summary
The Utilization Review Nurse is responsible for ensuring the receipt of high quality, cost efficient medical outcomes for those enrollees with a need for inpatient/ outpatient authorizations. This position receives and reviews prior authorization requests for specific inpatient and outpatient medical services, notification of emergent hospital admissions, completes inpatient concurrent review, establishes discharge plans, coordinates transitions of care to lower/higher levels of care, makes referrals for care management programs, and performs medical necessity reviews for retrospective authorization requests as well as claims disputes. The Utilization Review Nurse will use appropriate governmental policies as well as specified clinical guidelines/criteria to guide medical necessity reviews and will use effective relationship management, coordination of services, resource management, education, patient advocacy and related interventions to ensure members receive the appropriate level of care, prevent or reduce hospital admissions where appropriate.
Job Description
PRIMARY DUTIES AND RESPONSIBILITIES
Employees are expected to work consistently to demonstrate the mission, vision, and core values of the organization.
Key Outcomes:
* Review prior authorization requests (prior authorization, concurrent review, and retrospective review) for medical necessity referring to Medical Director as needed for additional expertise and review.
* Utilize evidenced-based criteria, governmental policies, and internal guidelines for medical necessity reviews.
* Manage the review of medical claims disputes, records, and authorizations for billing, coding, and other compliance or reimbursement related issues
* Collaborates with other members of the team, the MPHC Medical Directors, healthcare providers, and members to promote effective utilization of resources. This collaboration includes timely communications with in and out of network hospitals, post-acute care facilities, other providers, and internal departments to authorize services, establish discharge plans, assist to coordinate effective, efficient transitions of care.
* Coordinates referrals to Care Management, as appropriate.
* Manages health care within the benefits structures per line of business and performs functions within compliance, contractual and accreditation regulations, e.g. Department of Defense, Centers for Medicaid and Medicare, NCQA, Employer contracts and state insurance regulations, as applicable. Maintains knowledge of applicable regulatory guidelines.
* Completes all documentation of reviews and decisions, in appropriate systems, according to process/ compliance requirements and within timeliness standards.
* Participates as a member of an interdisciplinary team in the Health Management Department
* May be responsible for maintaining a caseload for concurrent cases/ assisting in caseload coverage for the team
* Establishes and maintains strong professional relationships with community providers.
* Acts as a liaison to ensure the member is receiving the appropriate level of care at the appropriate place and time
* Mentors new staff as assigned.
* Meets or exceeds department quality audit scores.
* Meets or exceeds department productivity standards.
* Assists in creation and updating of department policies and procedures.
* Participates in quality initiatives, committees, work groups, projects, and process improvements that reinforce best practice medical management programming and offerings.
* Participates in the review and analysis of population data and metrics to inform development of programs and improved health outcomes.
* Demonstrates flexibility and agility in working in a fast-paced, team-oriented environment, able to multi-task from one case type to another.
* Assumes extra duties as assigned based on business needs
* Responsible for weekend coverage on a rotating basis.
POSITION QUALIFICATION
Education/Experience
There are additional competencies linked to individual contributor, provider, and leadership roles. Please consult with your leader to discuss additional competencies that are relevant to your position.
Education
* Associate's degree in nursing
* Bachelor's degree in nursing preferred
Licensure/certification
* Compact RN license
Experience
* 3+ years of clinical nursing experience as an RN, preferably in a hospital setting
* 2+ years Utilization Management experience in a health plan UM department
* Certification in managed care nursing or care management (CMCN or CCM) preferred
* Coding/CPC preferred
Knowledge
* Demonstrates an understanding of and alignment with Martin's Point Values.
* Maintains current licensure and practices within scope of license for current state of residence.
* Maintains knowledge of Scope of Nursing Practice in states where licensed.
* Thorough understanding of healthcare policies, insurance guidelines, and regulatory standards (e.g., Medicare, NCQA, TRICARE)
* Familiarity with coding systems like ICD-10 and CPT preferred
Skills
* Proficiency in conducting prospective, concurrent, and retrospective reviews using standardized criteria and guidelines like MCG
* Ability to review and interpret medical records, treatment plans, and clinical documentation, with a keen eye for detail and compliance with healthcare standards
* Technically savvy and can navigate multiple systems and screens while working cases
* Excellent interpersonal, verbal, and written communication skills.
* Critical thinking: can identify root causes and understands coordination of medical and clinical information.
* Computer proficiency in Microsoft Office products including Word, Excel, and Outlook.
Abilities
* Ability to analyze data metrics, outcomes, and trends.
* Ability to prioritize time and tasks efficiently and effectively.
* Ability to manage multiple demands.
* Ability to function independently.
This position is not eligible for immigration sponsorship.
We are an equal opportunity/affirmative action employer.
Martin's Point complies with federal and state disability laws and makes reasonable accommodations for applicants and employees with disabilities. If a reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact *****************************
Do you have a question about careers at Martin's Point Health Care? Contact us at: *****************************
Nowadays, it seems that many people would prefer to work from home over going into the office every day. With remote work becoming a more viable option, especially for nurse case managers, we decided to look into what the best options are based on salary and industry. In addition, we scoured over millions of job listings to find all the best remote jobs for a nurse case manager so that you can skip the commute and stay home with Fido.
We also looked into what type of skills might be useful for you to have in order to get that job offer. We found that nurse case manager remote jobs require these skills:
Care management
Discharge planning
Patients
Home health
Rehabilitation
We didn't just stop at finding the best skills. We also found the best remote employers that you're going to want to apply to. The best remote employers for a nurse case manager include:
Since you're already searching for a remote job, you might as well find jobs that pay well because you should never have to settle. We found the industries that will pay you the most as a nurse case manager:
Government
Health care
Insurance
Top companies hiring nurse case managers for remote work