Emergency Department Registered Nurse jobs at Presbyterian

You may be eligible for a sign-on bonus of up to $20,000. You may also be eligible for relocation assistance. Join our team as a day or night shift, full-time, Intensive Care Unit (ICU) Registered Nurse in Albuquerque, NM. Why Join Us? Thrive in a People-First Environment and Make Healthcare Better Thrive: We empower our team with career growth opportunities, tuition assistance, and resources that support your wellness, education, and financial well-being. People-First: We prioritize your well-being with paid time off, comprehensive health benefits, and a supportive, inclusive culture where you are valued and cared for. Make Healthcare Better: We use advanced technology to support our team and enhance patient care. Get to Know Your Team: Lovelace Medical Center is an acute care hospital with 263 licensed beds, providing comprehensive care, including around-the-clock emergency care, surgical services, non-invasive robotic spine surgery, stroke care, radiology and oncology services. Responsibilities The Registered Nurse is responsible and accountable for the practice of Professional Nursing, including patient care and staff management assigned to the RN in his/her charge. May serve in the role of Charge Nurse and is accountable for professional practice. Adheres to policies and procedures and regulations to ensure compliance and patient safety. Qualifications Job Requirements: Associate's Degree or Diploma of Nursing Valid NM Nursing license or NM compact license (within 90 days of hire) BLS certification must be obtained within 14 days of hire or transfer into the role and prior to providing direct patient care. DEPARTMENT MAY ALSO REQUIRE ACLS and or PALS Preferred Job Requirements: Bachelor's Degree in Nursing. 2 years of experience in a specialty 2 years of general nursing experience. #LI-KM1

You may be eligible for a sign-on bonus of up to $20,000. You may also be eligible for relocation assistance. Join our team as a day or night shift, full-time, Intensive Care Unit (ICU) Registered Nurse in Albuquerque, NM. Why Join Us? Thrive in a People-First Environment and Make Healthcare Better Thrive: We empower our team with career growth opportunities, tuition assistance, and resources that support your wellness, education, and financial well-being. People-First: We prioritize your well-being with paid time off, comprehensive health benefits, and a supportive, inclusive culture where you are valued and cared for. Make Healthcare Better: We use advanced technology to support our team and enhance patient care. Get to Know Your Team: Lovelace Medical Center is an acute care hospital with 263 licensed beds, providing comprehensive care, including around-the-clock emergency care, surgical services, non-invasive robotic spine surgery, stroke care, radiology and oncology services. Responsibilities The Registered Nurse is responsible and accountable for the practice of Professional Nursing, including patient care and staff management assigned to the RN in his/her charge. May serve in the role of Charge Nurse and is accountable for professional practice. Adheres to policies and procedures and regulations to ensure compliance and patient safety. Qualifications Job Requirements: Associate's Degree or Diploma of Nursing Valid NM Nursing license or NM compact license (within 90 days of hire) BLS certification must be obtained within 14 days of hire or transfer into the role and prior to providing direct patient care. DEPARTMENT MAY ALSO REQUIRE ACLS and or PALS Preferred Job Requirements: Bachelor's Degree in Nursing. 2 years of experience in a specialty 2 years of general nursing experience. #LI-KM1

You may be eligible for a sign-on bonus of up to $20,000. You may also be eligible for relocation assistance. Join our team as a day or night shift, full-time, Intensive Care Unit (ICU) Registered Nurse in Albuquerque, NM. Why Join Us? Thrive in a People-First Environment and Make Healthcare Better Thrive: We empower our team with career growth opportunities, tuition assistance, and resources that support your wellness, education, and financial well-being. People-First: We prioritize your well-being with paid time off, comprehensive health benefits, and a supportive, inclusive culture where you are valued and cared for. Make Healthcare Better: We use advanced technology to support our team and enhance patient care. Get to Know Your Team: Lovelace Medical Center is an acute care hospital with 263 licensed beds, providing comprehensive care, including around-the-clock emergency care, surgical services, non-invasive robotic spine surgery, stroke care, radiology and oncology services. Responsibilities The Registered Nurse is responsible and accountable for the practice of Professional Nursing, including patient care and staff management assigned to the RN in his/her charge. May serve in the role of Charge Nurse and is accountable for professional practice. Adheres to policies and procedures and regulations to ensure compliance and patient safety. Qualifications Job Requirements: Associate's Degree or Diploma of Nursing Valid NM Nursing license or NM compact license (within 90 days of hire) BLS certification must be obtained within 14 days of hire or transfer into the role and prior to providing direct patient care. DEPARTMENT MAY ALSO REQUIRE ACLS and or PALS Preferred Job Requirements: Bachelor's Degree in Nursing. 2 years of experience in a specialty 2 years of general nursing experience. #LI-KM1

You may be eligible for a sign-on bonus of up to $20,000! You may also be eligible for relocation assistance. Join our team as a night/day shift, full-time/part-time/PRN, Intermediate Care Unit (IMC) Registered Nurse in Albuquerque, NM. Why Join Us? Thrive in a People-First Environment and Make Healthcare Better Thrive: We empower our team with career growth opportunities, tuition assistance, and resources that support your wellness, education, and financial well-being. People-First: We prioritize your well-being with paid time off, comprehensive health benefits, and a supportive, inclusive culture where you are valued and cared for. Make Healthcare Better: We use advanced technology to support our team and enhance patient care. Get to Know Your Team: Lovelace Medical Center is an acute care hospital with 263 licensed beds, providing comprehensive care, including around-the-clock emergency care, surgical services, non-invasive robotic spine surgery, stroke care, radiology and oncology services. Responsibilities The Registered Nurse is responsible and accountable for the practice of Professional Nursing, to include patient care and staff management assigned to the RN in his/her charge. May serve in the role of Charge Nurse and is accountable for professional practice. Adheres to policies and procedures and regulations to ensure compliance and patient safety. Qualifications Job Requirements: Associate's degree or Diploma of Nursing Valid NM Nursing license or NM compact license (within 90 days of hire) BLS certification must be obtained within 14 days of hire or transfer into the role and prior to providing direct patient care. DEPARTMENT MAY ALSO REQUIRE ACLS and or PALS Preferred Job Requirements: Bachelor's degree in nursing. 2 years' experience in the specialty as well as 2 years of general nursing experience. #LI-KM1

You may be eligible for a sign-on bonus of up to $20,000! You may also be eligible for relocation assistance. Join our team as a night/day shift, full-time/part-time/PRN, Intermediate Care Unit (IMC) Registered Nurse in Albuquerque, NM. Why Join Us? Thrive in a People-First Environment and Make Healthcare Better Thrive: We empower our team with career growth opportunities, tuition assistance, and resources that support your wellness, education, and financial well-being. People-First: We prioritize your well-being with paid time off, comprehensive health benefits, and a supportive, inclusive culture where you are valued and cared for. Make Healthcare Better: We use advanced technology to support our team and enhance patient care. Get to Know Your Team: Heart Hospital of New Mexico at Lovelace Medical Center is New Mexico's only hospital dedicated exclusively to cardiovascular care, including the state's only facility performing left ventricular aortic device (LVAD) implant and a state-of-the-art hybrid operating room. Responsibilities The Registered Nurse is responsible and accountable for the practice of Professional Nursing, to include patient care and staff management assigned to the RN in his/her charge. May serve in the role of Charge Nurse and is accountable for professional practice. Adheres to policies and procedures and regulations to ensure compliance and patient safety. Qualifications Job Requirements: Associate's degree or Diploma of Nursing Valid NM Nursing license or NM compact license (within 90 days of hire) BLS certification must be obtained within 14 days of hire or transfer into the role and prior to providing direct patient care. DEPARTMENT MAY ALSO REQUIRE ACLS and or PALS Preferred Job Requirements: Bachelor's degree in nursing. 2 years of general nursing experience. #LI-KM1 #LI-KM1

You may be eligible for a sign-on bonus of up to $20,000! You may also be eligible for relocation assistance. Join our team as a night/day shift, full-time/part-time/PRN, Intermediate Care Unit (IMC) Registered Nurse in Albuquerque, NM. Why Join Us? Thrive in a People-First Environment and Make Healthcare Better Thrive: We empower our team with career growth opportunities, tuition assistance, and resources that support your wellness, education, and financial well-being. People-First: We prioritize your well-being with paid time off, comprehensive health benefits, and a supportive, inclusive culture where you are valued and cared for. Make Healthcare Better: We use advanced technology to support our team and enhance patient care. Get to Know Your Team: Heart Hospital of New Mexico at Lovelace Medical Center is New Mexico's only hospital dedicated exclusively to cardiovascular care, including the state's only facility performing left ventricular aortic device (LVAD) implant and a state-of-the-art hybrid operating room. Responsibilities The Registered Nurse is responsible and accountable for the practice of Professional Nursing, to include patient care and staff management assigned to the RN in his/her charge. May serve in the role of Charge Nurse and is accountable for professional practice. Adheres to policies and procedures and regulations to ensure compliance and patient safety. Qualifications Job Requirements: Associate's degree or Diploma of Nursing Valid NM Nursing license or NM compact license (within 90 days of hire) BLS certification must be obtained within 14 days of hire or transfer into the role and prior to providing direct patient care. DEPARTMENT MAY ALSO REQUIRE ACLS and or PALS Preferred Job Requirements: Bachelor's degree in nursing. 2 years of general nursing experience. #LI-KM1 #LI-KM1

You may be eligible for a sign-on bonus of up to $20,000! You may also be eligible for relocation assistance. Join our team as a night/day shift, full-time/part-time/PRN, Intermediate Care Unit (IMC) Registered Nurse in Albuquerque, NM. Why Join Us? Thrive in a People-First Environment and Make Healthcare Better Thrive: We empower our team with career growth opportunities, tuition assistance, and resources that support your wellness, education, and financial well-being. People-First: We prioritize your well-being with paid time off, comprehensive health benefits, and a supportive, inclusive culture where you are valued and cared for. Make Healthcare Better: We use advanced technology to support our team and enhance patient care. Get to Know Your Team: Lovelace Medical Center is an acute care hospital with 263 licensed beds, providing comprehensive care, including around-the-clock emergency care, surgical services, non-invasive robotic spine surgery, stroke care, radiology and oncology services. Responsibilities The Registered Nurse is responsible and accountable for the practice of Professional Nursing, to include patient care and staff management assigned to the RN in his/her charge. May serve in the role of Charge Nurse and is accountable for professional practice. Adheres to policies and procedures and regulations to ensure compliance and patient safety. Qualifications Job Requirements: Associate's degree or Diploma of Nursing Valid NM Nursing license or NM compact license (within 90 days of hire) BLS certification must be obtained within 14 days of hire or transfer into the role and prior to providing direct patient care. DEPARTMENT MAY ALSO REQUIRE ACLS and or PALS Preferred Job Requirements: Bachelor's degree in nursing. 2 years' experience in the specialty as well as 2 years of general nursing experience. #LI-KM1

You may be eligible for a sign-on bonus of up to $20,000! You may also be eligible for relocation assistance. Join our team as a night/day shift, full-time/part-time/PRN, Intermediate Care Unit (IMC) Registered Nurse in Albuquerque, NM. Why Join Us? Thrive in a People-First Environment and Make Healthcare Better Thrive: We empower our team with career growth opportunities, tuition assistance, and resources that support your wellness, education, and financial well-being. People-First: We prioritize your well-being with paid time off, comprehensive health benefits, and a supportive, inclusive culture where you are valued and cared for. Make Healthcare Better: We use advanced technology to support our team and enhance patient care. Get to Know Your Team: Heart Hospital of New Mexico at Lovelace Medical Center is New Mexico's only hospital dedicated exclusively to cardiovascular care, including the state's only facility performing left ventricular aortic device (LVAD) implant and a state-of-the-art hybrid operating room. Responsibilities The Registered Nurse is responsible and accountable for the practice of Professional Nursing, to include patient care and staff management assigned to the RN in his/her charge. May serve in the role of Charge Nurse and is accountable for professional practice. Adheres to policies and procedures and regulations to ensure compliance and patient safety. Qualifications Job Requirements: Associate's degree or Diploma of Nursing Valid NM Nursing license or NM compact license (within 90 days of hire) BLS certification must be obtained within 14 days of hire or transfer into the role and prior to providing direct patient care. DEPARTMENT MAY ALSO REQUIRE ACLS and or PALS Preferred Job Requirements: Bachelor's degree in nursing. 2 years of general nursing experience. #LI-KM1 #LI-KM1

You may be eligible for a sign-on bonus of up to $20,000! You may also be eligible for relocation assistance. Join our team as a night/day shift, full-time/part-time/PRN, Intermediate Care Unit (IMC) Registered Nurse in Albuquerque, NM. Why Join Us? Thrive in a People-First Environment and Make Healthcare Better Thrive: We empower our team with career growth opportunities, tuition assistance, and resources that support your wellness, education, and financial well-being. People-First: We prioritize your well-being with paid time off, comprehensive health benefits, and a supportive, inclusive culture where you are valued and cared for. Make Healthcare Better: We use advanced technology to support our team and enhance patient care. Get to Know Your Team: Lovelace Medical Center is an acute care hospital with 263 licensed beds, providing comprehensive care, including around-the-clock emergency care, surgical services, non-invasive robotic spine surgery, stroke care, radiology and oncology services. Responsibilities The Registered Nurse is responsible and accountable for the practice of Professional Nursing, to include patient care and staff management assigned to the RN in his/her charge. May serve in the role of Charge Nurse and is accountable for professional practice. Adheres to policies and procedures and regulations to ensure compliance and patient safety. Qualifications Job Requirements: Associate's degree or Diploma of Nursing Valid NM Nursing license or NM compact license (within 90 days of hire) BLS certification must be obtained within 14 days of hire or transfer into the role and prior to providing direct patient care. DEPARTMENT MAY ALSO REQUIRE ACLS and or PALS Preferred Job Requirements: Bachelor's degree in nursing. 2 years' experience in the specialty as well as 2 years of general nursing experience. #LI-KM1

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.

we are seeking a (RN) Registered Nurse who must hold a compact license. , home office with internet connectivity of high speed required Work Schedule Monday to Friday - operation hours 6 AM to 6 PM (Team will work on set schedule) Looking for a RN with experience with appeals, claims review, and medical coding. JOB DESCRIPTION Job SummaryProvides 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.

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. KNOWLEDGE/SKILLS/ABILITIES Completes comprehensive assessments of members per regulated timelines and determines who may qualify for case management based on clinical judgment, changes in member's health or psychosocial wellness, and triggers identified in the assessment. Develops and implements a case management plan in collaboration with the member, caregiver, physician and/or other appropriate healthcare professionals and member's support network to address the member needs and goals. Conducts face-to-face or home visits as required. Performs ongoing monitoring of the care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly. Maintains ongoing member case load for regular outreach and management. Promotes integration of services for members including behavioral health care and long term services and supports/home and community to enhance the continuity of care for Molina members. Facilitates interdisciplinary care team meetings and informal ICT collaboration. Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts. Assesses for barriers to care, provides care coordination and assistance to member to address concerns. RNs provide consultation, recommendations and education as appropriate to non-RN case managers. RNs are assigned cases with members who have complex medical conditions and medication regimens RNs conduct medication reconciliation when needed. JOB QUALIFICATIONS Required Education Graduate from an Accredited School of Nursing. Bachelor's Degree in Nursing preferred. Required Experience 1-3 years in case management, disease management, managed care or medical or behavioral health settings. Required License, Certification, Association Nevada licensure must be Active, unrestricted State Registered Nursing (RN) license in good standing. **NV is not a compact state 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. Prior experience in Utilization Management and discharge planning. Preferred License, Certification, Association Active, unrestricted Certified Case Manager (CCM) Some experience with Utilization Management processes is desirable (InterQual, MCG guidelines) , discharge planning, as well as Case Management. This position will play a critical role in working with Sr. leadership and reducing readmission rates. Works directly with facility discharge planners to ensure members have appropriate discharge plans in place i.e. home health, DME, PT/OT, etc. 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. Pay Range: $27.73 - $54.06 / 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.

we are seeking a (RN) Registered Nurse who must hold a compact license. , home office with internet connectivity of high speed required Work Schedule Monday to Friday - operation hours 6 AM to 6 PM (Team will work on set schedule) Looking for a RN with experience with appeals, claims review, and medical coding. JOB DESCRIPTION Job SummaryProvides 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.

**New Mexico residency required. Provides support for care transition activities. Facilitates transitional care processes and coordination for member discharge from hospital admission to all other settings. Strives to ensure that best possible services are available to members at time of hospital discharge, and focuses on goal to reduce member readmissions. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Follows member throughout a 30 day program that starts at hospital admission and continues oversight through transitions from acute setting to all other settings, including nursing facility placement/private home, with the goal of reduced readmissions. • Ensures safe and appropriate transitions by collaborating with the hospital discharge planner, as well as collaborating with hospitalists, outpatient providers, facility staff, and family/support network. • Ensures member transitions to setting with adequate caregiving and functional support, as well as medical and medication oversight support. • Works with participating ancillary providers, public agencies or other service providers to make sure necessary services and equipment are in place for safe transition. • Conducts face-to-face visits of all members while in the hospital and, home visits high-risk members post-discharge as needed. • Coordinates care and reassesses member needs using the Coleman Care Transition model post-discharge. • Educates and supports member focusing on seven primary areas (Transition of Care Pillars): medication management, use of personal health record, follow-up care, signs and symptoms of worsening condition, nutrition, functional needs and or home and community-based services, and advance directives. • Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts. • Assesses for barriers to care, provides care coordination and assistance to member to address concerns. • Facilitates interdisciplinary care team meetings (ICT) and collaboration. • Provides consultation, recommendations and education as appropriate to non-behavioral health care managers. • 40-50% local travel may be required (based upon state/contractual requirements). Required Qualifications • At least 2 years experience in health care, with at least 1 year of experience in hospital discharge planning, care management or behavioral health setting, 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. • Knowledge of or experience using the Care Transitions Intervention (CTI) or similar model. • Background in discharge planning and/or home health. • Demonstrated knowledge of community resources. • Proactive and detail-oriented. • Ability to work within a variety of settings and adjust style as needed - working with diverse populations, various personalities and personal situations. • Ability to work independently, with minimal supervision and demonstrate self-motivation. • Responsive 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. • Excellent verbal and written communication skills. • Microsoft Office suite/other applicable software program(s) proficiency. Preferred Qualifications • Transitions of care sub-specialty certification and/or Certified Case Manager (CCM). • Hospital discharge planning or home health 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: $26.41 - $51.49 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Meda Health is looking for an CVOR RN to work a travel assignment in an acute care hospital setting. Must have at least two years of experience, state licensure and BLS/ACLS (at minimum). Competitive and Transparent Pay We value your expertise and respect your dedication - and our goal is to compensate you more than fairly for them. We don't want you to scramble to figure out your coverage, especially when you're already feeling under the weather. At Meda Health, your coverage starts when you do. You're covered, period. Our employees get the following benefits right off the bat: Health Vision Dental Life insurance