Utilization Review Coordinator remote jobs

Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together. The Manager, Utilization Management (UM) Coordination, oversees non-clinical inpatient and pre-service operations under the direction of the Director of Utilization Management. This role provides leadership to UM Supervisors and their coordinator teams to ensure timely, accurate, and compliant processing of authorizations and referrals in accordance with CMS and organizational standards. The Manager drives operational efficiency, staff development, and process improvement while collaborating with internal departments to support continuity of care and overall service quality. Job Responsibilities: Provide operational leadership and direction to two Utilization Management Supervisors overseeing non-clinical coordinator teams supporting both Inpatient and Pre-Service workflows. Lead the teams meet established turnaround times (TATs), quality, and productivity standards for authorization processing, referral routing, and related UM functions. Oversee staffing allocation, scheduling, and workload balancing between inpatient and pre-service units to maintain consistent service levels. Conduct regular one-on-one meetings with supervisors to review performance metrics, workflow barriers, and staff development needs. Own the daily operations to ensure timely and accurate completion of authorizations, correspondence, and documentation in compliance with CMS, NCQA, and organizational standards. Identify process inefficiencies and implement corrective actions to improve turnaround, accuracy, and staff productivity. Lead root-cause analyses for escalated operational issues and coordinate corrective action plans. Responsible for all the accuracy of all UM workflows, systems, and reporting dashboards to support data-driven decision making. Oversee the development and delivery of training materials, competency assessments, and reference guides to promote consistent and compliant practices. Mentor Supervisors to build leadership capacity, coaching them on staff management, delegation, and performance improvement techniques. Drive onboarding, cross-training, and refresher sessions are regularly conducted to support staff versatility across inpatient and pre-service functions. Manage all team activities adhere to CMS and organizational policies related to Utilization Management, confidentiality, and member communication standards. Oversee internal audit reviews and collaborate with the Quality and Compliance teams to address findings and implement improvement plans. Direct that all letters and communications use approved templates and standardized language for UM determinations and continuity-of-care requirements. Participate in internal and external audits, Medical Services Committee meetings, and other regulatory reviews as required. Review and analyze key performance indicators (KPIs), including volume, turnaround time, accuracy, and productivity reports; present trends and improvement strategies to leadership. Support the preparation and submission of monthly UM reports, dashboard summaries, and Medical Services Committee deliverables. Leverage data to identify training needs, process gaps, and operational trends impacting service delivery or compliance. Serve as a liaison between UM, Case Management, Provider Relations, and Claims departments to streamline interdepartmental communication and issue resolution. Collaborate with network providers and internal teams to clarify authorization processes and ensure alignment with benefit and policy criteria. Participate in internal workgroups or initiatives to improve system functionality, workflow automation, and reporting enhancements. Assist with the development, implementation, and monitoring of UM-related initiatives and special projects (e.g., claims review process, continuity-of-care tracking, or performance optimization programs). Evaluate and revise UM policies and procedures to align with evolving regulatory standards and organizational goals. Support readiness activities for CMS audits and other accreditation requirements. Perform other related functions and special assignments as directed by senior leadership. Core Competencies: Leadership & Talent Development - Demonstrates the ability to lead through others by developing and empowering supervisors and staff. Fosters a culture of accountability, engagement, and continuous improvement within the UM department. Operational Management - Applies strong organizational and analytical skills to oversee workflow execution, resource allocation, and performance metrics across inpatient and pre-service teams. Regulatory & Compliance Expertise - Maintains in-depth knowledge of CMS regulatory standards, confidentiality requirements, and UM protocols to ensure full compliance and audit readiness. Analytical Thinking & Decision-Making - Uses data to identify trends, evaluate outcomes, and implement process improvements that enhance accuracy, turnaround times, and service quality. Communication & Collaboration - Communicates clearly across all organizational levels; partners effectively with Clinical Operations, Provider Relations, Case Management, and Claims to resolve issues and align priorities. Process Improvement & Innovation - Continuously evaluates operational workflows and implements efficiency strategies that support organizational goals and member satisfaction. Member & Service Orientation - Demonstrates commitment to delivering high-quality service, ensuring that UM processes support positive member experiences and continuity of care. Change Management - Adapts to evolving regulatory, system, and organizational needs while leading teams through process transitions and new initiatives effectively. Supervisory Responsibilities: Oversees assigned staff. Responsibilities include: recruiting, selecting, orienting, and training employees; assigning workload; planning, monitoring, and appraising job results; and coaching, counseling, and performance management. Job Requirements: Experience Required: Minimum (4) years of related experience in a managed care setting and a minimum (3) years of recent and related supervisory experience Education Required: Highschool Diploma or GED Required Preferred: Bachelor's Degree or higher Other: Strong knowledge of Medicare Managed Care Plans Proficient in Microsoft Word, Excel, and Outlook; advanced Excel skills preferred (pivot tables, formulas, data visualization, and reporting functions for performance tracking and analysis). Experience leading and sustaining process improvement initiatives within healthcare operations to enhance efficiency, compliance, and service quality. Communication and Interpersonal Skills - Excellent written and verbal communication skills; able to build and maintain collaborative relationships with diverse teams, including leadership, staff, and external partners. Analytical and Reasoning Skills - Strong analytical thinking with the ability to define problems, collect and interpret data, establish facts, draw valid conclusions, and develop actionable solutions. Problem-Solving and Organizational Skills - Demonstrated ability to prioritize multiple tasks, manage time effectively, and maintain accuracy in a fast-paced, dynamic environment. Data and Report Analysis - Ability to interpret, analyze, and present statistical and operational reports to support decision-making and performance monitoring. Essential Physical Functions: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 1. While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms. 2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus. Pay Range: $70,823.00 - $106,234.00 Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc. Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation. *DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at ******************************* If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health's talent acquisition team, please email ******************.

The Utilization Review Coordinator ensures efficient and effective management of utilization review processes, including denials and appeals activities. This role collaborates with payers, hospital staff, and clinical specialists to secure timely authorizations for hospital admissions and extended stays. The Utilization Review Coordinator monitors and documents all authorization activities, assists with process improvement initiatives, and serves as a key liaison to reduce denials and optimize patient outcomes. Essential Functions Submits initial assessments, continued stay reviews, and payer-requested documentation, ensuring compliance with policies, regulations, and payer requirements to establish medical necessity. Communicates with commercial payers to provide concise and accurate information to secure timely authorizations and reduce potential denials, utilizing input from the Utilization Review Clinical Specialist. Monitors and updates case management software with documentation of escalations, avoidable days, authorization numbers, denials, and payer interactions to ensure accurate records. Coordinates Peer-to-Peer discussions for unresolved concurrent denials, ensuring the process aligns with hospital, corporate, and payer requirements. Documents outcomes in case management systems. Reviews and closes out cases after patient discharge, ensuring all required documentation is complete and understandable for billing and future audits. Places cases on hold as necessary to resolve pending authorizations or reviews. Maintains performance metrics aligned with Key Performance Indicators (KPIs) for the Utilization Review Service Line. Serves as a key contact for facility and payer representatives, fostering effective communication and collaboration to resolve issues promptly. Participates in training initiatives within the department, supporting onboarding and skill development for team members. Responds promptly to phone calls, faxes, and insurance portal requests, providing high standards of customer service and satisfaction. Escalates issues to the manager as appropriate and provides recommendations for improving operational efficiency and outcomes. Ensures accurate and timely communication of hospital stay authorizations, denials, and delays to all relevant stakeholders. Performs other duties as assigned. Maintains regular and reliable attendance. Complies with all policies and standards. Qualifications H.S. Diploma or GED required Bachelor's Degree preferred 0-2 years of work experience in utilization review, hospital admissions or registration required 1-3 years of work experience in an office, processing center, or similar environment preferred Knowledge, Skills and Abilities Strong knowledge of utilization management principles, payer requirements, and healthcare regulations. Proficiency in case management systems and technology resources for authorization tracking and documentation. Excellent communication and interpersonal skills to interact effectively with payers, clinicians, and administrative staff. Critical thinking and problem-solving skills to analyze and resolve authorization and denial issues. Strong organizational skills to manage multiple priorities and meet deadlines. Attention to detail for accurate documentation and process adherence. Ability to train and support team members, fostering a collaborative and productive environment.

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

This position is a responsible administrative and clinical role focused on organizing and tracking utilization review (UR) data for Alabama's Region IV mental health centers. Region IV includes the service areas of AltaPointe Health (Mobile, Baldwin and Washington counties), CarePath Behavioral Health (formerly Southwest Alabama Mental Health Center), South Central Alabama Mental Health Center and SpectraCare Health Systems. The employee reports directly to the AltaPointe Chief Quality Officer for the provision of UR services and collaborates closely with Region IV community mental health centers (CMHCs) and the Alabama Department of Mental Health (ADMH) regarding UR activities. This role requires advanced clinical expertise and a comprehensive understanding of utilization review principles as they apply to community mental health residential programs. Responsibilities Coordinates with ADMH on issues related to housing/residential/crisis slots in Region IV area. Responsible for collecting, tracking, and reporting UR data provided by Region IV CMHCs via the UR tracking protocol spreadsheets/documents specified by ADMH in a timely and accurate manner (i.e. census, readmissions, discharges, etc). Assists ADMH in maintaining a complete and accurate database for all certified housing/residential programs, as well as Crisis Residential Units (CRUs) and Designated Mental Health Facility (DMHF) Hospitals, in the Mental Illness Community Residential Services (MICRS) reporting system. Monitor lengths of stay in residential programs in Region IV. Conduct Discharge Planning Conference call at least once per month with all Region IV providers to staff service recipients currently under Civil Commitment or at risk of Civil Commitment who are at Bryce Hospital, DMHF CRU, and/or DMHF Hospital.as well as staff service recipients in housing/residential who need outplacement and barriers complicate such discharge. Attends/participates in the monthly staffing of Bryce service recipients held by ADMH and be prepared to discuss housing/residential vacancies throughout Region IV. Attends training related to UR function as provided and/or coordinated by ADMH. Participates in trainings and meetings to assist ADMH and the Regional Board of Supervisors (BOS). Actively participates in the utilization review and management of continuum and Region II resources. Acts as residential placement liaison for service recipients in Region IV and their assigned community mental health centers: Develops a thorough understanding of all community mental health center-operated or contracted housing and residential services in the area, with a focus on admission criteria. Maintains a working knowledge of all CMHC residential and housing services in Region IV, state hospitals, DMHFs, and inpatient community resources serving the Region. Makes regular contact with appropriate staff involved in service recipients' care coordination, case review, and discharge planning at various facilities and programs. Coordinates discharges into residential services across catchment areas as needed or requested by community mental health centers, state hospitals, or ADMH. This coordination is intended to complement, not replace, the essential responsibilities of the CMHC. Assists ADMH and community mental health centers in locating options for service recipients who have special needs that cannot be met in their home area. Help facilitate movement to out-of-state facilities, CRUs, and/or housing/residential by assisting with difficult placements. Supervision and consultation. Seeks supervision and consultation as needed. Adheres to professional code of ethics. Accepts and employs suggestions for improvement. Courteous and respectful attitude Treats service recipients with care, dignity and compassion. Respects service recipients' privacy and confidentiality. Is pleasant and cooperative with others, including service recipients and families. Personal values do not inhibit ability to relate and care for others. Is sensitive to the service recipients' needs, expectations and individual differences. Administrative and other related duties as assigned. Attends all meetings of the UR coordinators as called by ADMH. Travels to various state and local hospitals and community programs as needed Completes assigned tasks in a timely manner. Ability to apply programmatic knowledge to the operations of programs for the seriously mentally ill (SMI). Maintains current license and requirements for renewals and certifications, if applicable. Qualifications Master's degree from an accredited college or university in social work, psychology, or related field. Minimum of three years post master's clinical experience. Experience providing clinical services in a residential or inpatient clinical setting is preferred. Must possess a valid Alabama driver's license and maintain a driving record acceptable to the organization's automobile insurance provider. Although this position requires frequent travel, employees will not be expected to transport service recipients. A reliable vehicle is required for work-related travel. Proof of current automobile insurance that meets or exceeds Alabama's minimum coverage requirements must be provided and maintained.Proficiency in using a personal computer and Microsoft Office Suite-including Word, Excel, PowerPoint, Outlook, and cloud-based tools such as Microsoft Teams and OneDrive-for efficient word processing, data management, presentations, communication, and file sharing.Strong verbal and written communication skills to support and enhance the Utilization Review (UR) Coordinator's efforts across the entire Service Area. Ability to compile, analyze, and present data in clear, concise, and well-organized reports. Must be proficient in creating charts, graphs, and data tables that effectively communicate Utilization Review (UR) indicators in a way that is easily understood by the public during brief presentations. Additionally, must be capable of presenting UR data in formats that support direct evaluation of program effectiveness. Knowledge, outlined below, to be attained within (6) six months of employment: Thorough working knowledge of the principles of utilization review and quality improvement as applied in mental health settings Knowledge of psychiatric disorders in adults with SMI Knowledge of available region and community resources Knowledge of co-occurring psychiatric and substance abuse disorders Knowledge and training in mental illness program operations, structure, and development

Hello, Thank you for your interest in career opportunities with the University of Mississippi Medical Center. Please review the following instructions prior to submitting your job application: * Provide all of your employment history, education, and licenses/certifications/registrations. You will be unable to modify your application after you have submitted it. * You must meet all of the job requirements at the time of submitting the application. * You can only apply one time to a job requisition. * Once you start the application process you cannot save your work. Please ensure you have all required attachment(s) available to complete your application before you begin the process. * Applications must be submitted prior to the close of the recruitment. Once recruitment has closed, applications will no longer be accepted. After you apply, we will review your qualifications and contact you if your application is among the most highly qualified. Due to the large volume of applications, we are unable to individually respond to all applicants. You may check the status of your application via your Candidate Profile. Thank you, Human Resources Important Applications Instructions: Please complete this application in entirety by providing all of your work experience, education and certifications/ license. You will be unable to edit/add/change your application once it is submitted. Job Requisition ID: R00046700 Job Category: Nursing Organization: Utilization Review Location/s: Main Campus Jackson Job Title: RN - Utilization Reviewer - Coordinated Care Job Summary: Accountable to perform utilization management services for designated patient case load, including prospective, concurrent, retrospective, and denial management reviews by applying clinical protocols and review medical necessity criteria. Reports quality of care issues identified during the um process to the appropriate manager. To perform job duties in accordance with the medical center's purpose. Education & Experience Four (4) years RN experience, one (1) year of which must have been in performance improvement, utilization review, or case management. CERTIFICATIONS, LICENSES OR REGISTRATION REQUIRED: Valid RN license. CPUM (certified professional in utilization management), ACM (accredited case manager), or CCM (certified case manager) preferred. Knowledge, Skills & Abilities Knowledge of the aspects of utilization review. Excellent interpersonal verbal and written communication and negotiation skills. Skills in the use of personal computers and related software applications. Ability to gather data, compile information, and prepare reports. Ability to identify process improvements. Good working knowledge of and understanding of medical procedures and diagnoses, procedure codes, including ICD-10, CPT, and DSM-IV codes. Current working knowledge of discharge planning, utilization management, case management, performance improvement and managed care reimbursement. Ability to work independently and exercise sound judgement in interactions with physicians, payers, and patients and their families. Demonstrate commitment to the organ Ization's mission and the behavioral expectations in all interactions and in performing all job duties. Performs duties in a manner to promote quality patient care and customer service/satisfaction, while promoting safety, cost efficiency, and commitment to continuous quality improvement (CQI) process. Independent, focused and follow written instructions. Ability to use medical necessity guidelines with minimal supervision. Equipped to work remotely to include hardware with high speed internet via cable and Windows 10 RESPONSIBILITIES: * Performs all aspects of prospective, concurrent, retrospective and denials review for individual cases to include benefit coverage issues, medical necessity appropriate level of care (setting) and mandated services. * Assists in the collection and reporting of financial indicators including case mix, los, cost per case, excess days, resource utilization, readmission rates, denials and appeals. Uses data to drive decisions and plan/implement performance improvement strategies related to case management for assigned patients, including fiscal, clinical and patient satisfaction. Collects, analyzes and addresses variances from the plan of care path with physician and/or other members of the healthcare team. Uses concurrent variance data to drive practice changes and positively impact outcomes. Collects delay and other data for specific performance and/or outcome indicators as determined by administrator - resource management. Documents key clinical path variances and outcomes which relate to areas of direct responsibility (e.g., discharge planning, care transitions and care coordination). Uses pathway data in collaboration with other disciplines to ensure effective patient management concurrently. * Applies approved clinical appropriateness criteria to monitor appropriateness of admissions, and continued stays, and documents findings based on department standards. Identifies at-risk populations using approved screening tool and follows established reporting procedures. Refers cases and issues to care management physician advisor in compliance with department procedures and follows up as indicated. Communicates with third party payers to facilitate covered day reimbursement certification for assigned patients. Discusses payor criteria and issues on a case-by-case basis with clinical staff and follows up to resolve problems with payers as needed. Uses quality screens to identify potential issues and forwards information to clinical quality review department. Completes utilization management and quality screening for assigned patients. * Works collaboratively and maintains active communication with physicians, nursing, and other members of the inter-disciplinary care team to effect timely, appropriate patient management and eliminate barriers to efficient delivery of care in the appropriate setting. Addresses/resolves system problems impeding diagnostic or treatment progress. Proactively identifies and resolves delays and obstacles to discharge. Utilizes conflict resolution skills as necessary to ensure timely resolution of issues. Collaborates with physicians and all members of the multidisciplinary team to facilitate care for designated case load; monitors the patient's progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective; facilitates the following on a timely basis: completion and reporting diagnostic testing; completion of treatment plan and discharge plan; modification of plan of care, as necessary, to meet the ongoing needs of the patient; communication to third party payers and other relevant information to the care team; assignment of appropriate levels of care; completion of all required documentation in epic screens and patient records. * Ensures safe care to patients adhering to policies, procedures, and standards, within budgetary specifications, including time management, supply management, productivity, and accuracy of practice. * Promotes individual professional growth and development by meeting requirements for mandatory/ continuing education, skills competency, supports department- based goals which contribute to the success of the organization; serves as preceptor, mentor, and resource to less experienced staff. * Actively participates in clinical performance improvement activities * The duties listed are general in nature and are examples of the duties and responsibilities performed and are not meant to be construed as exclusive or all-inclusive. Management retains the right to add or change duties at any time. Environmental and Physical Demands: Requires occasional exposure to unpleasant or disagreeable physical environment such as high noise level and exposure to heat and cold, no handling or working with potentially dangerous equipment, occasional working hours beyond regularly scheduled hours, occasional travelling to offsite locations, occasional activities subject to significant volume changes of a seasonal/clinical nature, occasional work produced is subject to precise measures of quantity and quality, occasional bending, occasional lifting/carrying up to 10 pounds, occasional lifting/carrying up to 25 pounds, no lifting/carrying up to 50 pounds, no lifting/carrying up to 75 pounds, no lifting/carrying up to100 pounds, no lifting/carrying 100 pounds or more, no climbing, no crawling, occasional crouching/stooping, no driving, occasional kneeling,occasional pushing/pulling, occasional reaching, frequent sitting,occasional standing,occasional twisting, and frequent walking. (Occasional-up to 20%, frequent-from 21% to 50%, constant-51% or more) Time Type: Part time FLSA Designation/Job Exempt: No Pay Class: Hourly FTE %: 100 Work Shift: Benefits Eligibility: Grant Funded: Job Posting Date: 11/5/2025 Job Closing Date (open until filled if no date specified):

At Luminare Health , our employees are the cornerstone of our business and the foundation to our success. We empower employees with curated development plans that foster growth and promote rewarding, fulfilling careers. Join HCSC and be part of a purpose-driven company that will invest in your professional development. Job SummaryThe Physician Review Coordinator is primarily responsible for initiation and oversight of the Healthcare Management Division's physician-level review process with Independent Review Organizations. Additionally, when business needs warrant, the individual conducts medical necessity reviews utilizing evidence-based medical criteria.Required Job Qualifications: Active RN License required Minimum three years of experience in a clinical setting Active MCG UM/CM Certification or obtain MCG UM/CM Certification within 6 months of hire Possess strong time management and organizational skills Ability to work independently and complete tasks in a timely manner, reprioritizing workload to meet customer and business needs Willingness to adjust and adapt to meet the business needs in an atmosphere that sometimes requires rapid change Comfort with telephonic and written communications with all levels of leadership within the organization, providers, IROs and business contacts in an efficient, professional manner Excellent customer service and interpersonal skills Comfort with using electronic applications including electronic documentation system and the ability to accurately document electronically while engaging callers or reviewing medical documents Excellent verbal and written communication skills Ability to use commonsense understanding to carry out instructions furnished in written, oral or diagram form Demonstration of excellent critical thinking skills to deal with problems in varying situations and reach reasonable solutions Proficient in MS Word, Excel and Outlook with the willingness to expand knowledge of the MS Suite of tools Preferred Job Qualifications: Utilization Management, Case Management, or Claims experience with a TPA or insurer highly preferred Bachelor of Science in Nursing Must reside in one of the following States: Illinois Montana New Mexico Oklahoma Texas Indiana Missouri Wisconsin Iowa Kansas North Carolina Pennsylvania Are you being referred to one of our roles? If so, ask your connection at HCSC about our Employee Referral process! EEO Statement: We are an Equal Opportunity Employment employer dedicated to providing a welcoming environment where the unique differences of our employees are respected and valued. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other legally protected characteristics. Pay Transparency Statement: At Luminare, you will be part of an organization committed to offering meaningful benefits to our employees to support their life outside of work. From health and wellness benefits, 401(k) savings plan, pension plan, paid time off, paid parental leave, disability insurance, supplemental life insurance, employee assistance program, paid holidays, tuition reimbursement, plus other incentives, we offer a robust total rewards package for associates. The compensation offered will vary depending on your job-related skills, education, knowledge, and experience. This role aligns with an annual incentive bonus plan subject to the terms and the conditions of the plan. Min to Max Range: $56,700.00 - $106,400.00 Exact compensation may vary based on skills, experience, and location.

It's an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances. Job Summary: The Behavioral Health Utilization Manager plays a critical role in ensuring the appropriate and effective delivery of mental health and substance use disorder services. This role serves as a key clinical decision-maker, exercising independent judgment and critical thinking in the evaluation of behavioral health service requests. This position is responsible for managing complex outpatient and non-24-hour diversionary cases, applying clinical expertise to ensure appropriate, timely, and effective care. The role requires a proactive and analytical approach to service delivery, with a focus on clinical quality and compliance. Our Investment in You: · Full-time remote work · Competitive salaries · Excellent benefits Key Responsibilities: · Use advanced clinical judgment and critical thinking to evaluate outpatient and non-24-hour behavioral health services, determining the appropriateness of care based on individual member needs, clinical presentations, and professional standards. · Collaborate with Medical Directors when clinical complexity requires further review, ensuring decisions align with clinical best practices and organizational values. · Identify members who may benefit from enhanced care coordination or specialized interventions and initiate appropriate referrals to internal programs. · Ensure accurate, timely, and well-reasoned documentation of clinical decisions in accordance with operational standards and regulatory expectations. · Provide clear, thoughtful communication to internal and external stakeholders, helping resolve questions or concerns with clinical insight in a timely manner. · Participate in clinical rounds and interdisciplinary case discussions to support collaborative care planning and cross-functional learning. · Represent the organization with external partners, including providers and state agencies, conveying clinical insight and ensuring organizational compliance. · Monitor clinical trends for potential indicators of Fraud, Waste, and Abuse (FWA), and take appropriate action when concerns are identified. · Partner with leadership and the BH Medical Director to evaluate existing processes and support initiatives aimed at improving quality and operational efficiency. · Provide crisis intervention support using clinical judgment to de-escalate situations and assist members in stabilizing their conditions. · Uphold all organizational policies, professional standards, and compliance requirements. · Contribute to special projects and organizational initiatives as assigned by senior leadership, offering insight and subject matter expertise. · In rotation with other BH UM clinicians, provide on-call weekend and holiday support for members that are ED boarding and manage urgent authorization needs. Potential Additional Responsibilities · Providing Network Management in collaboration with other MCEs within Massachusetts for CBHI Providers (may require some travel within Massachusetts) Qualifications: Educational Requirements: · Master's degree in Social Work, Psychology, Counseling, or a related Behavioral Health field. Experience: · 5-7years of experience in a health insurance environment with a focus on behavioral health. · Demonstrated expertise in utilization management and medical necessity determinations. Preferred Qualifications: · Experience working with Child and Adolescent Behavioral Health Services and/or Substance Use Disorder Services. · Familiarity with managed care principles and regulatory compliance requirements. Licensure and Certification: · Active, unrestricted independent licensure in Massachusetts and/or New Hampshire in one of the following: LICSW, LMHC, or LMFT. · For ABA UM Position Only: Must hold an active Board Certified Behavior Analyst (BCBA) credential. Additional independent licensure (LICSW, LMHC, LMFT) is preferred. Core Competencies: · Exceptional verbal and written communication skills, with the ability to collaborate effectively across all organizational levels and with external partners. · Strong organizational and time management abilities, with a focus on meeting deadlines and managing competing priorities. · Capacity to thrive in a fast-paced environment, balancing multiple responsibilities while maintaining accuracy and efficiency. · Proficiency in Microsoft Office applications, particularly Outlook, Word, and Excel, along with experience in data management systems. · Superior analytical and problem-solving skills with a keen attention to detail. Work Environment and Physical Demands: · Primarily remote role with periodic travel to the Charlestown, MA office for team meetings and training sessions. · Additional travel within Massachusetts may be required for individuals with CBHI Network Management expectations. · Dynamic and fast-paced work setting requiring adaptability and resilience. · Minimal physical exertion required; standard office tasks such as typing and phone use. · Consistent and reliable attendance is an essential job requirement. Compensation Range $69,500 - $100,500 This range offers an estimate based on the minimum job qualifications. However, our approach to determining base pay is comprehensive, and a broad range of factors is considered when making an offer. This includes education, experience, skills, and certifications/licensure as they directly relate to position requirements; as well as business/organizational needs, internal equity, and market-competitiveness. In addition, WellSense offers generous total compensation that includes, but is not limited to, benefits (medical, dental, vision, pharmacy), merit increases, Flexible Spending Accounts, 403(b) savings matches, paid time off, career advancement opportunities, and resources to support employee and family wellbeing. Note: This range is based on Boston-area data, and is subject to modification based on geographic location. About WellSense WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members. Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees

The once in a century transition to autonomous and electric vehicles is underway and will require a multi-trillion-dollar investment in energy and charging infrastructure, and the real estate to site it on. Terawatt is the leader in delivering large scale, turnkey charging solutions for companies rapidly deploying AV and EV fleets. Whether it's an urban mobility hub, or a carefully located multi-fleet hub for semi-trucks, Terawatt brings the talent, capabilities, and capital to create reliable, cost-effective solutions for customers on the leading edge of the transition to the next generation of transport. With a growing portfolio of sites across the US in urban hubs and along key logistics and transportation corridors and logistics hubs, Terawatt is building the permanent transportation and logistics infrastructure of tomorrow through a robust combination of capital, real estate, development, and site operations solutions. The company develops, finances, owns, and operates charging solutions that take the cost and complexity out of electrifying fleets. At Terawatt, we execute humbly and with urgency to provide tailored solutions for fleets that delight our clients and support the transition of transportation. Role Description Terawatt Infrastructure seeks an Energy and Utilities Manager for its Energy & Utility team. The Energy and Utilities Manager is a critical, independent contributor role responsible for developing and executing comprehensive utility engagement strategies throughout the entire development lifecycle of Terawatt Infrastructure projects. This individual will serve as the primary point of contact and subject-matter expert for all utility-related matters, ensuring seamless coordination and alignment among internal teams, including real estate, Development, Design-Construction, and Business Development. During the crucial site evaluation phase, the Energy and Utilities Manager will proactively engage with relevant utility providers to assess infrastructure availability, capacity, costs, and potential risks. This involves conducting thorough due diligence, analyzing utility maps and data, and collaborating with development teams to determine optimal site selection based on utility feasibility and economic considerations. The role extends to project engineering, where the Energy and Utilities Manager will actively contribute to the customer and utility design process, ensuring that utility requirements and specifications are integrated into project plans. This includes collaborating with teams to develop detailed utility layouts, load calculations, and energization designs. Furthermore, this individual will create realistic project schedules incorporating utility timelines for service connections, upgrades, and relocations, effectively mitigating potential delays. Budgeting is another key area of responsibility, requiring the Energy and Utilities Manager to develop and manage comprehensive utility budgets that cover connection fees, infrastructure upgrades, and ongoing service charges. This involves cost estimation, financial forecasting, and proactive identification of cost-saving opportunities. A significant aspect of this role involves skillfully negotiating and executing complex utility agreements and contracts, ensuring favorable terms and conditions for the organization. This includes managing relationships with utility providers, resolving disputes, and staying abreast of utility changes and industry best practices.Core Responsibilities Own key project milestones and deliverables, and manage delivery dates Collaborate closely and guide the Site Acquisition, Project Development, and Construction teams regarding preliminary utility-related engineering, design, and construction timelines. Understand and make critical recommendations regarding timing, cost, and economic trade-offs involved with site energization or interconnection for behind-the-meter generation. Be the owner of the dry utility space: interpret Utility Design Standards and draft dry utility space design via Bluebeam design tools. Be a problem solver when utility bottlenecks or failures are causing project delays. Inform the Company's energy and energization strategy through collaboration with the Real Estate, Project Development, Design & Construction, and Business Development teams. Identify, hire, and manage utility consultants as needed for projects. Preferred Qualifications Experience working with regulated and municipal electrical utilities in major US metro areas. A strong understanding of utility distribution/transmission planning and design, and electrical design standards. Electrical and site design experience Experience with the complete utility coordination process, from application to design to energization. Strategic thinking skills regarding business, operations, and technical challenges, coupled with the technical skills to execute project schedules, contracts, initiatives, and team objectives. Experience in estimating utility service costs. Experience with project development from greenfield or brownfield site acquisition to operational assets. We are building a team that represents a variety of backgrounds, perspectives, and skills. At Terawatt, we continuously strive to foster inclusion, humility, energizing relationships, and belonging, and welcome new ideas. We're growing and want you to grow with us. We encourage people from all backgrounds to apply. If a reasonable accommodation is required to fully participate in the job application or interview process, or to perform the essential functions of the position, please contact ********************************* . Terawatt Infrastructure is an equal-opportunity employer.

At ABB, we help industries outrun - leaner and cleaner. Here, progress is an expectation - for you, your team, and the world. As a global market leader, we'll give you what you need to make it happen. It won't always be easy, growing takes grit. But at ABB, you'll never run alone. Run what runs the world. This Position reports to: Manufacturing Manager - NEMA Your role and responsibilities (Mandatory) In this role, you will have the opportunity to operate process equipment or machinery to convert raw materials or semi-finished parts into components or finished parts for a final product at the right time and with the required quality. Each day, you will execute the assigned tasks according to agreed workflows and in accordance with ABB standard processes and safety guidelines and reports any non-compliance. You will also showcase your expertise by operating machines in accordance with the operating manual, work schedule, and/or production order instructions. The work model for the role is: {onsite/hybrid/remote} {insert Linkedin #} This role is contributing to the {insert product group/business area/division/function} in {insert region}. Main stakeholders are {insert main stakeholder groups if available}. You will be mainly accountable for: Performing routine machinery set-up, adjustments, and repairing and fitting simple replacement parts. Ensuring regular standard maintenance of the equipment, tools set-up, programming activities, and troubleshooting and reporting issues, if any; and maintaining detailed records of machinery set-ups, repairs, and maintenance activities. Keeping track of approved, defective units, and final products. Our team dynamics (Optional) You will join a {insert adjectives - e.g. dynamic, talented, high performing} team, where you will be able to thrive. Qualifications for the role (Mandatory) You are immersed in / engaged in / absorbed in / highly skilled in/ you enjoy working with {relevant tools and methodologies} and the {insert relevant industry/sector} market Ability to demonstrate your experience in / Have established skills / advanced skills / You have {insert number of years} years of experience in {insert relevant field} (OPTIONAL: working as {insert relevant role} with {insert relevant products or technologies}) Possess an enhanced knowledge of / You are qualified in / Highly adept in {insert specialized software/platforms} You are passionate about / you are captivated by / you are innovative around {insert relevant soft skills} and {insert relevant soft skills} Degree in / Have a demonstrated track record in / Extensive knowledge of / Proven experience of {insert specific degree, qualification} in {insert subject} You are at ease communicating in {insert required language skill(s)} You hold current {insert required licenses} valid in {insert job location} and {insert country-specific VISA/work permit} {where required} What's in it for you? (Optional) Benefits (Optional) We also offer our employees the following benefits: Benefit 1 Benefit 2 Benefit 3 Benefit 4 Benefit 5 Local Specific Benefits (Open Field below - Optional) Locally, you can count on {Add local perks and benefits in text format} More about us (Mandatory) {Insert specific business area/division/service function or corporate function paragraph from common source material} {Insert country/location -specific boilerplate (1-2 sentences only)} {optional} {Insert country-specific legal statement e.g.: EEO/data privacy} {where required} {Insert PES (Pre-employment screening) sentence} {when required} {Insert local TP or hiring manager contacts if necessary} Guidelines: Please be aware: All fields in yellow should be populated with relevant information (based on Job description and the Kick-off form). All other text can also be modified if necessary, within the given guidelines. Text in bold is fixed and should not be edited or removed Reporting Manager section is mandatory both internally and externally, to be posted via eRec functionality “Your role and responsibilities” should be plain text followed by maximum 4 additional bullet points The “Qualifications for the role” section should include no less than five and no more than seven bullet points. These bullet points should be listed in order of importance for the success in the role Indicate the required language knowledge in the “Qualifications for the role” section whenever it is mandatory and/or applicable Information about “Licenses and visa/work permit” is optional, use this sentence wherever it is required In the “More about us” section you can add further legal statements/PES indications or Talent Partner contacts, for example Read more about the guidelines in the Guidelines doc available in the SharePoint We value people from different backgrounds. Could this be your story? Apply today or visit *********** to read more about us and learn about the impact of our solutions across the globe.

At ScionHealth, we empower our caregivers to do what they do best. We value every voice by caring deeply for every patient and each other. We show courage by running toward the challenge and we lean into new ideas by embracing curiosity and question asking. Together, we create our culture by living our values in our day-to-day interactions with our patients and teammates. Job Summary The Utilization Management Manager plays a vital role in ensuring patients have timely access to care by managing both front-end prior authorizations and in-house concurrent review authorizations. This position blends strong relationship-building skills with clinical knowledge to navigate complex payer requirements, streamline the authorization process, and support seamless patient transitions. From start to finish, this role drives the authorization process-reviewing prospective, retrospective, and concurrent medical records; coordinating with referring hospitals to secure prior authorizations; and partnering with case management teams at ScionHealth facilities to complete concurrent review authorizations. Acting as a navigator and liaison between Business Development, facility administration, managed care organizations, and payors, the specialist ensures determinations are communicated promptly and accurately to all relevant stakeholders. By combining attention to detail with proactive collaboration, the Utilization Management Manager safeguards revenue integrity, reduces delays, and supports the organization's mission of delivering exceptional patient care. This role actively contributes to quality improvement, problem-solving, and productivity initiatives within an interdisciplinary model, demonstrating accountability and a commitment to operational excellence. Essential Functions Extrapolates and summarizes essential medical information to obtain authorization for admission and continued stay to/at ScionHealth Level of Care. Prepares recommendations to sumbit timely request for reconsideration of denial determination in attempt to have denied authorization requests overturned. Ensures authorization requests are processed timely to meet regulatory timeframes. Reviews medical necessity assessments completed by case management, evaluating documentation for specific criteria related to severity of illness, and level of care appropriateness. Generates written appeals to medical necessity-based payor denials for denials prior to admission and concurrent review authorizations. Appeal letters may be processed on behalf of the physician, combining clinical and regulatory knowledge in efforts to have consideration of authorization. Documents authorization information in relevant tracking systems. Effectively builds relationships with business development team, admissions team/clinical staff and managed care team, to coordinate the patient admission functions in keeping with the mission and vision of the hospital. Supports review of patient referral for clinical and financial approval and/or escalation to leadership for approval following the Care Considerations grid. Coordinates and facilitates pre-admission Prior Authorizations for patients from the referral sources: Identifies /reviews medical record information needed from referring facility. Applies appropriate clinical guidelines to pre-authorization determination process. Communicates specific patient needs for equipment, supplies, and consult services as related to prior authorization requirements. Acts as a liaison with the Business Development team through every stage of the authorization process through determination. Initiates appeals process as appropriate. Facilitates and coordinates physician-to-physician communication as appropriate to support the denial management process. Communicates to appropriate teams, including business development and facility administration when clinical authorization and financial approval is complete, following standard authorization process. Provides hospital team with needed prior authorization information on pending / new admissions. Coordinate with managed care payor on all coverage issues and supports the LOA process as requested. Coordinates and facilitates Concurrent Review Authorizations for patients actively in-house at a ScionHealth facility Identifies /reviews medical record information needed from facility. Applies appropriate clinical guidelines to concurrent review authorization process. Review medical necessity review information provided by the case management team and communicates any additinoal questions or information requests Acts as a liaison with the Case Management team through every stage of the concurrent review authorization process through determination. Initiates appeals process as appropriate. Communicates with Medical Advisors or case managers of managed care company as necessary; including during Care Coordination / Managed Care calls Maintains a knowledge of areas of responsibility and develops and follows a program of continuing education. Participates in continuing education/ professional development activities. Learns and develops full knowledge of the CAAT Admission Processes and actively seeks to continuously improve them. Knowledge/Skills/Abilities/Expectations Strong relationship building skills and a spirit to serve to ensure effective communication and service excellence. Knowledge of regulatory standards and compliance guidelines. Working knowledge of medical necessity justification through but not limited to non-physician review guidelines (InterQual and Milliman), Medicare and Medicaid rules, regulations, coverage guidelines, NCDs and LCDs. Working knowledge of Medicare, Medicaid and Managed Care payment and methodology. Extensive knowledge of clinical symptomology, related treatments and hospital utilization management. Excellent interpersonal, verbal and written skills to communicate effectively and to obtain cooperation/collaboration from hospital leadership, as well as physicians, payors and other external customers. Critical thinking, problem solving, and decision-making capabilities with the ability to discern, collect, organize, evaluate, and communicate pertinent clinical information with effective verbal and written skills. Technical writing skills for appeal letters and reports. Effective time management and prioritization skills. Computer skills with working knowledge of Microsoft Office (Word, Excel, PowerPoint, and Outlook), word-processing and spreadsheet software. Demonstrates good interpersonal skills when working or interacting with patients, their families and other staff members. Conducts job responsibilities in accordance with the standards set out in the Company's Code of Business Conduct, its policies and procedures, the Corporate Compliance Agreement, applicable federal and state laws, and applicable professional standards. Communicates and demonstrates a professional image/attitude for patients, families, clients, coworkers and others. Adheres to policies and practices of ScionHealth. Must read, write, and speak fluent English Must have good and regular attendance. Approximate percent of time required to travel\: N/A Education Postsecondary non-Degree (Cert/Diploma/Program Grad) of an Accredited School of Nursing required Associate's Degree in healthcare or related field required Bachelor's Degree in healthcare or related field preferred Equivalent combination of Education and/or Experience in lieu of education (3+ years in a related field) may be considered. Licenses/Certifications Healthcare professional licensure preferred. In lieu of licensure, 3+ years of experience in relevant field required. Some states may require licensure or certification. Experience 3+ years of experience in a healthcare strongly preferred. Experience in managed care, case management, utilization review, or discharge planning a plus.

American Health Plans, a division of Franklin, Tennessee-based American Health Partners Inc. owns and operates Institutional Special Needs Plans (I-SNPs) for seniors who reside in long-term care facilities. In partnership with nursing home operators, these Medicare Advantage plans manage medical risk by improving patient care to reduce emergency room visits and avoidable hospitalizations. This division currently operates in Tennessee, Georgia, Missouri, Kansas, Oklahoma, Utah, Texas, Mississippi, Iowa, Idaho, Louisiana, and Indiana with planned expansion into other states in 2025. For more information, visit AmHealthPlans.com. If you would like to be part of a collaborative, supportive and caring team, we look forward to receiving your application! Benefits and Perks include: * Affordable Medical/Dental/Vision insurance options * Generous paid time-off program and paid holidays for full time staff * TeleDoc 24/7/365 access to doctors * Optional short- and long-term disability plans * Employee Assistance Plan (EAP) * 401K retirement accounts with company match * Employee Referral Bonus Program JOB SUMMARY: The Utilization Review Nurse is to assess the medical necessity and quality of healthcare services by conducting pre-service, concurrent, and retrospective utilization management reviews. The primary role of the Utilization Management (UM) Nurse is to provide clinical support to the Clinical Services Department and Medical Director to assure that members receive all appropriate medical services in compliance with medical and regulatory guidelines. ESSENTIAL JOB DUTIES: To perform this job, an individual must accomplish each essential function satisfactorily, with or without a reasonable accommodation. * Assess the medical necessity, quality of care, level of care and appropriateness of health care services for plan members * Identify placement settings that offer the lowest level of restriction and greatest level of autonomy for the members based upon medical necessity * Conduct outreach to requesting providers which can include specialty physicians, ancillary providers and institutions to gather the appropriate/necessary clinical data * Apply clinical review criteria, guidelines, and screens in determining the medical necessity of health care services against the clinical data provided * Certify cases that meet clinical review criteria, guidelines and/or screens * Consult with physician when reviews do not meet clinical review criteria, guidelines, and screens * Refer cases to other professionals internally, including case management and medical consultation when indicated * Adhere to accreditation, contractual and regulatory timeframes in performing all utilization management review processes * Ensure that the Director of Medical Management or designee is made aware of any potential risk management issues in a timely manner * Other duties as assigned JOB REQUIREMENTS: * Maintain privacy and confidentiality of records, conditions, and other information relating to residents, employees and facility * Encourage an atmosphere of optimism, warmth and interest in patients' personal and health care needs * Develop and maintain collaborative relationships with providers and educate on levels of care * Ensure the integrity and high quality of utilization management services * Self-motivated * Ability to work independently and as part of a team * Able to work congenially with a wide variety of individuals * Maintain the highest level of confidentiality and professionalism at all times * Strong oral and written communications skills, including active listening * Proficient in navigating through multiple computer applications * Positive, engaging customer service skills * Critical thinking and decision-making skills * Successful completion of required training * Handle multiple priorities effectively * Independent discretion/decision making * Make decisions under pressure REQUIRED QUALIFICATIONS: * Experience: o At least 1 year experience in utilization management with a health plan or hospital-based UM department with use of Interqual or MCG o Prefer clinical experience o Broad knowledge of Medicare regulations and guidance o Trained in clinical certification, utilization management, URAC and NCQA principles, policies, and procedures o Excellent customer service experience o Strong knowledge of medical terminology and CPT, ICD-10, and HCPCS codes o Proven ability to problem-solve and make solid decisions * License/Certification: o Current Certified Case Manager (CCM) credential is a plus o Current, active and unrestricted Registered Nurse (RN) license EQUAL OPPORTUNITY EMPLOYER This Organization is an equal opportunity employer. We do not discriminate based on race, color, religion, sex, handicap, disability, age, marital status, sexual orientation, national origin, veteran status, or any other characteristic(s) protected by federal, state, and local laws. This Organization will make reasonable accommodations for qualified individuals with disabilities should a request for an accommodation be made. A key part of this policy is to provide equal employment opportunity regarding all terms and conditions of employment and in all aspects of a person's relationship with the Organization including recruitment, hiring, promotions, upgrading positions, conditions of employment, compensation, training, benefits, transfers, discipline, and termination of employment.

, however, candidates must reside in the State of TX or State of IL is a contract for about 9 months. Pay: $41/hour RN working in the insurance or managed care industry using medically accepted criteria to validate the medical necessity and appropriateness of the treatment plan. This Position Is Responsible For Performing Accurate And Timely Medical Review Of Claims Suspended For Medical Necessity, Contract Interpretation, Pricing; And To Initiate And/Or Respond To Correspondence From Providers Or Members Concerning Medical Determinations. Knowledge of accreditation, i.e. URAC, NCQA standards and health insurance legislation. Awareness of claims processes and claims processing systems. PC proficiency to include Microsoft Word and Excel and health insurance databases. Verbal and written communication skills with ability to communicate to physicians, members and providers and compose and explain document findings. Organizational skills and prioritization skills. :Registered Nurse (RN) with unrestricted license in state. 3 years clinical experience. Needs to be able to navigate MCG and Medical policies with the reviews.

The Division of Pulmonary, Critical Care, and Sleep Medicine and the Department of Internal Medicine at the University of South Florida Morsani College of Medicine, is seeking a Pulmonary/Critical Care physician for a full-time position at the Assistant, Associate or Full Professor rank. This is a full-time 12-month salaried faculty appointment at the rank of Assistant Professor and carries with it attending staff privileges at Tampa General Hospital (TGH) and affiliated hospitals. Appointment at the rank of Associate Professor requires a minimum of five years of continuing and productive service as an Assistant Professor, or the equivalent. Appointment at the rank of Full Professor requires a minimum of five years of continuing and productive service as an Associate Professor, or the equivalent. Responsible to a Chair or other appropriate higher-level administrator of a State university. Responsible for teaching, research, service, and related administrative activities. Responsible for academic advising and related activities. May represent the university, college/school, or department. Minimum: Medical degree from an accredited institution or the highest degree appropriate in the field of specialization with a demonstrated record of achievement in teaching, academic research, and service. Must meet university criteria for appointment to the rank of Assistant, Associate, or Full Professor. For Associate/Full Professor - Normally will have produced creative work, professional writing or research in refereed and other professional journals, and be a recognized authority in the field of specialization. Preferred: Must hold or be eligible for a full, unrestricted Florida Medical License or foreign equivalent required. To perform this position, the candidate will need to obtain and maintain a full un-restricted FL Medical License, maintain credentials in the USF Health faculty practice plan, and be a medical staff member in good standing at the hospitals he/she is assigned to perform clinical duties. The candidate will participate in the teaching of residents, fellows, and medical students in clinical medicine. USF is especially interested in candidates who can contribute to the diversity and excellence of the academic community through their research, teaching, and/or service. MUST BE BOARD CERTIFIED/ELIGIBLE IN: Critical Care and Pulmonary Disease Clinical-Provides Pulmonary and Critical Care Services at USF, TGH and/or other affiliated hospitals and clinics. Teaching-Provide instruction and supervision for medical students, residents and fellows at USF and its affiliated institutions in the areas of critical care, clinics, consults and lectures. Responsible to a Chair or other appropriate higher-level administrator of a State university. Responsible for teaching, research, service, and related administrative activities. Responsible for academic advising and related activities. May represent the university, college/school, or department.

Care management interventions focus on improving care coordination and reducing the fragmentation of the services the recipients of care often experience, especially when multiple health care providers and different care settings are involved. Taken collectively, care management interventions are intended to enhance client safety, well-being, and quality of life. These interventions carefully consider health care costs through the professional care manager's recommendations of cost-effective and efficient alternatives for care. Thus, effective care management directly and positively impacts the health care delivery system, especially in realizing the goals of the "Triple Aim," which include improving the health outcomes of individuals and populations, enhancing the experience of health care, and reducing the cost of care. The professional care manager performs the primary functions of assessment, planning, facilitation, coordination, monitoring, evaluation, and advocacy. Integral to these functions is collaboration and ongoing communication with the client, client's family or family caregiver, and other health care professionals involved in the client's care. Description Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but we've been part of the national landscape for more than seven decades, with our roots firmly embedded in the South Carolina community. We are the largest insurance company in South Carolina … and much more. We are one of the nation's leading administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies, allowing us to build on various business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team! Position Purpose: Care management interventions focus on improving care coordination and reducing the fragmentation of the services the recipients of care often experience, especially when multiple health care providers and different care settings are involved. Taken collectively, care management interventions are intended to enhance client safety, well-being, and quality of life. These interventions carefully consider health care costs through the professional care manager's recommendations of cost-effective and efficient alternatives for care. Thus, effective care management directly and positively impacts the health care delivery system, especially in realizing the goals of the "Triple Aim," which include improving the health outcomes of individuals and populations, enhancing the experience of health care, and reducing the cost of care. The professional care manager performs the primary functions of assessment, planning, facilitation, coordination, monitoring, evaluation, and advocacy. Integral to these functions is collaboration and ongoing communication with the client, client's family or family caregiver, and other health care professionals involved in the client's care. Location: This is a remote position from 8am - 5pm Monday through Friday. What You'll Do: Provides active care management, assesses service needs, develops and coordinates action plans in cooperation with members, monitors services and implements plans, to include member goals. Evaluates outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions. Ensures accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits. Provides telephonic support for members with chronic conditions, high-risk pregnancy or other at-risk conditions that consist of: intensive assessment/evaluation of condition, at-risk education based on members' identified needs, provides member-centered coaching utilizing motivational interviewing techniques in combination with reflective listening and readiness to change assessment to elicit behavior change and increase member program engagement. Participates in direct intervention/patient education with members and providers regarding health care delivery system, utilization on networks and benefit plans. May identify, initiate, and participate in on-site reviews. Serves as member advocate through continued communication and education. Promotes enrollment in care management programs and/or health and disease management programs. Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members. Performs medical or behavioral review/authorization process. Ensures coverage for appropriate services within benefit and medical necessity guidelines. Utilizes allocated resources to back up review determinations. Identifies and makes referrals to appropriate staff (Medical Director, Case Manager, Preventive Services, Subrogation, Quality of care Referrals, etc.). Participates in data collection/input into system for clinical information flow and proper claims adjudication. Demonstrates compliance with all applicable legislation and guidelines for all regulatory bodies, which may include but isnot limited to ERISA, NCQA, URAC, DOI (State), and DOL (Federal). Maintains current knowledge of contracts and network status of all service providers and applies appropriately. Assists with claims information, discussion, and/or resolution and refers to appropriate internal support areas to ensure proper processing of authorized or unauthorized services. To Qualify For This Position, You'll Need The Following: Required Education: Associate's in a job related field. Degree Equivalency: Graduate of Accredited School of Nursing or 2 years job related work experience. Required Experience: 4 years recent clinical in defined specialty area. Specialty areas include: oncology, cardiology, neonatology, maternity, rehabilitation services, mental health/chemical dependency, orthopedic, general medicine/surgery. Or, 4 years utilization review/case management/clinical/or combination; 2 of the 4 years must be clinical. Required Skills and Abilities: Working knowledge of word processing software. Knowledge of quality improvement processes and demonstrated ability with these activities. Knowledge of contract language and application. Ability to work independently, prioritize effectively, and make sound decisions. Good judgment skills. Demonstrated customer service, organizational, and presentation skills. Demonstrated proficiency in spelling, punctuation, and grammar skills. Demonstrated oral and written communication skills. Ability to persuade, negotiate, or influence others. Analytical or critical thinking skills. Ability to handle confidential or sensitive information with discretion. Required Software and Tools: Microsoft Office. Required License/Certificate: An active, unrestricted RN license from the United States and in the state of hire OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC) OR, active, unrestricted licensure as social worker from the United States and in the state of hire (in Div. 6B) OR, active, unrestricted licensure as counselor, or psychologist from the United States and in the state of hire (in Div. 75 only). For Div. 75 and Div. 6B, except for CC 426: URAC recognized Case Management Certification must be obtained within 4 years of hire as a Case Manager. We Prefer That You Have The Following: Preferred Education: Bachelor's degree- Nursing Preferred Work Experience: 3+ years Oncology experience is preferred. Preferred Skills and Abilities: Working knowledge of spreadsheet, database software. Thorough knowledge/understanding of claims/coding analysis, requirements, and processes. Preferred Licenses and Certificates: Case Manager certification, clinical certification in specialty area. Our Comprehensive Benefits Package Includes The Following: We offer our employees great benefits and rewards. You will be eligible to participate in the benefits the first of the month following 28 days of employment. Subsidized health plans, dental and vision coverage 401k retirement savings plan with company match Life Insurance Paid Time Off (PTO) On-site cafeterias and fitness centers in major locations Education Assistance Service Recognition National discounts to movies, theaters, zoos, theme parks and more What We Can Do for You: We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company. What To Expect Next: After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with our recruiter to verify resume specifics and salary requirements. Equal Employment Opportunity Statement BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations. We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company. If you need special assistance or an accommodation while seeking employment, please email ************************ or call ************, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis. We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Here's more information. Some states have required notifications. Here's more information.

This position is a critical part of utilization management within the emergency department setting. The role ensures that patient admissions meet medical necessity standards and that healthcare resources are used appropriately and efficiently. It combines clinical expertise, analytical skills, and communication abilities to support both patient care and organizational compliance.Responsibilities Review and evaluate electronic medical records of emergency department admissions and screen for medical necessity using InterQual or MCG criteria Apply evidence-based clinical guidelines and criteria to assess and ensure proper utilization of healthcare resources Participate in telephonic discussions with emergency department physicians relative to documentation and admission status Enter clinical review information into system for transmission to insurance companies for authorization Review, analyze, and identify utilization patterns and trends, problems, or inappropriate utilization of resources Qualifications Required Current and unrestricted RN license At least 3 years clinical experience in acute care setting in emergency room, critical care and/or medical/surgical nursing At least 2 years utilization management experience in acute admission and concurrent reviews Intermediate level experience with InterQual and/or MCG criteria within the last two years Proficiency in medical record review in an electronic medical record (EMR) Experience in Microsoft Suite including Office and basic Excel Ability to thrive in a fast-paced, dynamic environment and adapt to frequent changing business needs Passing score(s) on job-related pre-employment assessment(s) Preferred At least 5 years clinical experience in acute care setting in emergency room, critical care and/or medical/surgical nursing At least 3 years utilization management experience within the hospital setting Bachelor's of Science in Nursing (BSN) Case Management Certifications such as Certified Case Manager (CCM), Accredited Case Manager (ACM), Certified Managed Care Nurse (CMCN), Case Management, Board Certified (CMGT-BC) Expectations Comfortable with remote work arrangements and virtual collaboration tools Physical demands include extended periods of sitting, computer use, and telephone communication Shift Needs & Work Requirements: Must work 4 holidays per year, each for a 4-hour shift. 16 hours of the required 48 hours per month must be worked on the weekend. Work schedules and shift assignments are subject to change based on evolving client needs and operational demands. While we strive to provide consistent scheduling, associates may be required to adjust their availability or work different shifts. Flexibility and adaptability are essential for success in this role. Netsmart is proud to be an equal opportunity workplace and is an affirmative action employer, providing equal employment and advancement opportunities to all individuals. We celebrate diversity and are committed to creating an inclusive environment for all associates. All employment decisions at Netsmart, including but not limited to recruiting, hiring, promotion and transfer, are based on performance, qualifications, abilities, education and experience. Netsmart does not discriminate in employment opportunities or practices based on race, color, religion, sex (including pregnancy), sexual orientation, gender identity or expression, national origin, age, physical or mental disability, past or present military service, or any other status protected by the laws or regulations in the locations where we operate. Netsmart desires to provide a healthy and safe workplace and, as a government contractor, Netsmart is committed to maintaining a drug-free workplace in accordance with applicable federal law. Pursuant to Netsmart policy, all post-offer candidates are required to successfully complete a pre-employment background check, including a drug screen, which is provided at Netsmart's sole expense. In the event a candidate tests positive for a controlled substance, Netsmart will rescind the offer of employment unless the individual can provide proof of valid prescription to Netsmart's third party screening provider. If you are located in a state which grants you the right to receive information on salary range, pay scale, description of benefits or other compensation for this position, please use this form to request details which you may be legally entitled. All applicants for employment must be legally authorized to work in the United States. Netsmart does not provide work visa sponsorship for this position. Netsmart's Job Applicant Privacy Notice may be found here.

Our vision aims to empower our clients by actively leveraging our broad range of services. With our global presence, we have career opportunities all across the world which can lead to a unique, exciting and fulfilling career path. Pick your path today! To see what career opportunities we have available, explore below to find your next career! Please be aware of employment scams where hackers pose as legitimate companies and recruiters to obtain personal information from job seekers. Please be vigilant and verify the authenticity of any job offers or communications. We will never request sensitive information such as Social Security numbers or bank details during the initial stages of the recruitment process. If you suspect fraudulent activity, contact us directly through our official channels. Stay safe and protect your personal information. Job Summary: Under general supervision of the Program Manager (PM) and reporting to the PM, the Medical Review Nurse (MRN) is responsible for the initial chart review and chart case management for medical exam/screening programs to verify that all medical information and exam components are accurate. The RN works directly with Physicians and Examinees to ensure all medical information is gathered and performs medical Quality Assurance on all charts in various process stages leading to a final determination. Salary is $66,560-$70,000. Duties and Responsibilities: • Performs medical review of incoming charts to determine if additional medical information is needed. • Collaborates with Physician(s) and other internal nursing staff members for chart review. • Performs medical Quality Assurance (QA) on all charts in various process stages. • Interfaces with Client's Medical Department as well as the on-site provider. • Contacts Examinee via telephone or email to clarify information necessary to complete the chart. • Develops a very good understanding of the specific contract's guidelines and addendums as required. • Masters the various software programs specific to the functioning of the exam program. • Implements and follows up on requests for further evaluation from the Examinee when required. • Works closely with other departments to provide accurate and quality outcomes. • Thoroughly cognizant of metrics and organizes workload to meet them. • Consistently learns and applies codified state and federal regulations specific to particular contract(s). • Serve as backup to other nurses for daily duties and assists with follow-up calls to facilities and Examinees as needed as well as other duties as assigned. • Opportunity to travel and assist on medical mobile events as either a site lead and/or RN as work or personal schedule permit. • May participate in interdepartmental project groups or task forces to integrate activities, communicate issues, obtain approvals, resolve problems, and maintain a specific level of knowledge pertaining to new developments, new task efforts, contract awards, and new policy requirements. • Supports marketing and sales objectives and efforts as requested. • Performs duties in a safe manner. Follows the corporate safety policy. Participates and supports safety meetings, training, and goals. Ensures safe operating conditions within an area of responsibility. Encourages co-workers to work safely. Identifies “close calls” and/or safety concerns to supervisory personnel. Maintains a clean and orderly work area. • Assists in the active implementation of company initiatives to ensure compliance with OSHA VPP, ISO, JCAHO, AAAHC, and other mandated regulations/standards. • May serve on the OSHA VPP, Safety, and Wellness Committees. Qualifications: • 5-7 years of relevant experience. • Fully unencumbered nursing license required. • Proficiency with computer and common office equipment, as well as with MS Office products. • Must be able to multitask, be flexible, be organized, and have excellent oral and written communication skills as well as exceptional attention to detail. Preferred Qualifications: • COHN-S and/or CAOHC certifications • Bachelor's Degree with 5 years of relevant experience • Flexibility and availability to travel and assist to support medical mobile events as either site lead and/or RN Physical Requirements and Work Conditions: • Work is normally performed in a typical interior/office work environment. • Work involves sitting and standing for prolonged periods of time. • May require bending and lifting up to 15 lbs. • Constant use of computer and common office equipment required. Acuity International is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration without regard to race, color, sex, national origin, age, protected veteran status, or disability status. For OFCCP compliance, the taxable entity associated with this job posting is: Acuity-CHS, LLC

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 works as 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 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. Maintains quality audit scores within department standards. Maintains productivity within department 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, including weekend rotations Education/Experience: 3+ years of clinical nursing experience as an RN, preferably in a hospital setting Utilization management experience in a health plan UM department Required License(s) and/or Certification(s): Compact RN License Certification in managed care nursing or care management desired (CMCN or CCM) Skills/Knowledge/Competencies (Behaviors): 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. Maintains contemporary knowledge of evidence-based guidelines and applies them consistently and appropriately. Ability to analyze data metrics, outcomes, and trends. Excellent interpersonal, verbal, and written communication skills. Critical thinking: can identify root causes and understands coordination of medical and clinical information. Ability to prioritize time and tasks efficiently and effectively. Ability to manage multiple demands. Ability to function independently. Computer proficiency in Microsoft Office products including Word, Excel, and Outlook. This position is not eligible for immigration sponsorship. We are an equal opportunity/affirmative action employer. Do you have a question about careers at Martin's Point Health Care? Contact us at: *****************************

Job DescriptionCLINICAL REVIEW NURSE - REMOTE ARC Group has multiple positions open for Clinical Review Nurses! These positions are 100% remote. These are direct hire FTE positions with salary, benefits, etc. This is a fantastic opportunity to join a dynamic and well-respected organization offering tremendous career growth potential. At ARC Group, we are committed to fostering a diverse and inclusive workplace where everyone feels valued and respected. We believe that diverse perspectives lead to better innovation and problem-solving. As an organization, we embrace diversity in all its forms and encourage individuals from underrepresented groups to apply. 100% REMOTE! Candidates must currently have PERMANENT US work authorization. Sorry, but we are not considering any candidates from outside companies for this position (no C2C, 3rd party / brokering). SUMMARY STATEMENT The Clinical Review Nurse is responsible for reviewing and making medical determinations as to the validity of health claims and levels of payment in meeting national and local policies as well as accepted medical standards of care. The incumbent applies clinical knowledge to assess the medical necessity, level of services and appropriateness of care which may include cases requiring prior authorization, complex pre-payment medical review or post-payment medical review. ESSENTIAL DUTIES & RESPONSIBILITIES To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This list of essential job functions is not exhaustive and may be supplemented as necessary. 90% of time will be spent on one or more of the following activities depending on assignments: Review and analyze pre and post pay complex health care claims from a medical perspective, inclusive of prior authorization: Perform clinical review work as assigned; may provide guidance to other team members and accurately interpret and apply broad CMS guidelines to specific and highly variable situations. Conduct review of claim data and medical records to make clinical decisions on the coverage, medical necessity, utilization and appropriateness of care per national and local policies, as well as accepted medical standards of care. Review provider practices and identify issues of concern, overpayment and need for corrective action as necessary; includes surfacing potential fraud and abuse or practice concerns. May develop recommendations for further corrective action based on medical review findings. May refer for review, or implement, corrective action related to medical review activities. May process claims and complete project work in the appropriate computer system(s). The remaining 10% of time will be spent on the following activities depending on assignments: Identify providers needing education and individually educate providers who are subject to medical review processes: Initiate or participate in provider teaching activities, creating written teaching material, providing one on one education or education to a group as a result of a medical review (e.g., probe, progressive corrective action, consent, etc.) or appeal. This may involve discussion with CMS leaders and leaders in the provider community. Participate in special projects as assigned. REQUIRED QUALIFICATIONS * Valid nursing degree * 2 years' clinical experience * Excellent written and oral communication skills * Demonstrated experience with evaluating medical and health care delivery issues (e.g., Inpatient Rehab Facility) * Strong computer skills to include Microsoft Office proficiency * Valid unrestricted Registered Nurse (RN) license PREFERRED QUALIFICATIONS * Inpatient Rehabilitation Facility Experience * Bachelor of Science in Nursing (BSN) * Insurance industry experience * Certified Coder ARC Group is a Forbes-ranked a top 20 recruiting and executive search firm working with clients nationwide to recruit the highest quality technical resources. We have achieved this by understanding both our candidate's and client's needs and goals and serving both with integrity and a shared desire to succeed. At ARC Group, we are committed to providing equal employment opportunities and fostering an inclusive work environment. We encourage applications from all qualified individuals regardless of race, ethnicity, religion, gender identity, sexual orientation, age, disability, or any other protected status. If you require accommodations during the recruitment process, please let us know. Position is offered with no fee to candidate.

MOBILE PRIMARY CARE - Remote $23.00hr - $27.00hr About us: Mobile Primary Care is a home-based primary care practice that specializes in geriatric healthcare, serving New York State. About the Opportunity: A healthcare organization seeking a licensed LVN, LPN or RN to join their growing staff as a new Care Management Nurse. This role will be providing telephonic Care Management for patients throughout the health system under the direction of a patient's provider. The nurse utilizes nursing process to evaluate patient needs over the telephone and provide guidance and education to patients, adhering to organizational policies, procedures and guidelines. Provides high risk patients with chronic disease management and liaises between the patient, patient's family or caregiver, provider, provider's office, hospital, home care agency etc. This position is telephonic care coordination as directed by the patients provider. Position Responsibilities: Cooperatively develop and integrate patient centered provider care plan and goals with the client/family and other providers Work collaboratively with team members to provide outreach and engagement with the patient Work closely with in-office providers/staff members to: Provide patient education to assist with self-management Identify gaps or barriers in treatment plans Coordinate care enrolled patients including scheduling appointments Coordinate referrals Coordinate community resources as needed (ie: home health, DME etc) Educate members on disease processes Encourage members to make healthy lifestyle changes Actively maintain assigned caseload of patients Make outbound calls to assess members current health status Receive and respond to telephone calls from patients. Collecting health data and providing medical guidance under the direction of the patients provider Document calls according to established guidelines Connects patient's care team together with updated information as received Participation in education and in-service programs Performs on-call for region that you are assigned Additional duties as assigned Required Qualifications: Unrestricted and current license to practice as LVN/LPN/RN with a New York State license. 3 years of experience within Care Management setting or Case Coordinator either in the homecare, inpatient, physician practice or in-home case management setting Strong working knowledge of chronic disease states including chronic kidney disease, diabetes mellitus, chronic obstructive pulmonary disease and congestive heart failure and basic medical management of these states Must be highly motivated, result-oriented with strong skills in presenting, communicating, organizing and time management skills Strong organizational and interpersonal skills Excellent customer service skills demonstrated by positive feedback from patients/team Ability to identify problems and recommend solutions Demonstrates progressive proficiency with the utilization of available computer technology, including typing skills Demonstrates; leadership, communication, interpersonal and problem-solving skills Experience working with Electronic Health Record (EHR) Ability to sit and work at a computer for extended periods of time 60 words per minute typing Preferred Qualifications: Bilingual in Spanish