Utilization review nurse jobs in Guaynabo, PR - 14 jobs

The Infusion Admitting / Evaluating Nurse is responsible for providing specialized infusion therapy care in the patient's home, performing clinical evaluations to determine eligibility and continuity of treatment. Administers intravenous therapies, educates the patient and their family, and documents in accordance with clinical, regulatory, and accreditation standards (ACHC, CMS, and Puerto Rico Department of Health). The admitting nurse must foster Alivia's values, support the vision of the infusion department, and actively contribute towards the unit's success. Responsibilities include, but are not limited to the following: Conduct initial clinical assessments at home to determine the feasibility and safety of infusion treatment. Admit patients within 24 hours of receiving the referral. In accordance with regulatory and accreditation standards. Coordinate medication reconciliation and develop the initial care plan in conjunction with the prescribing physician and multidisciplinary team. Monitor the patient's response to treatment and document clinical findings in the electronic system. Educate the patient and family about treatment, devices, infection control, warning signs, and patient rights and responsibilities. Obtain and document the patient's informed consent in the medical record. Identify and report adverse events, incidents, complaints, deviations, or clinical risks to the quality and compliance committee in a timely manner. Required: Bachelor's degree in nursing from an accredited university. Current nursing license in Puerto Rico. Participation in continuing education and documented annual clinical competencies. Valid driver's license in Puerto Rico and availability of a motor vehicle. Minimum of 2 years of experience in home health, infusion, or acute care services. Preferably in a home setting. Knowledge of infusion pumps, central and peripheral catheters. ***Equal Opportunity Employer M/F/V/D***

By joining Sedgwick, you'll be part of something truly meaningful. It's what our 33,000 colleagues do every day for people around the world who are facing the unexpected. We invite you to grow your career with us, experience our caring culture, and enjoy work-life balance. Here, there's no limit to what you can achieve. Newsweek Recognizes Sedgwick as America's Greatest Workplaces National Top Companies Certified as a Great Place to Work Fortune Best Workplaces in Financial Services & Insurance Utilization Review Coordinator **PRIMARY PURPOSE** : To assign utilization review requests; to verify and enter data in appropriate system(s); and to provide general support to clinical staff in a team environment. **ARE YOU AN IDEAL CANDIDATE?** We are looking for enthusiastic candidates who thrive in a collaborative environment, who are driven to deliver great work. **ESSENTIAL FUNCTIONS and RESPONSIBILITIES** + Accesses, triages and assigns cases for utilization review (UR). + Responds to telephone inquiries proving accurate information and triage as necessary. + Enters demographics and UR information into claims or clinical management system; maintains data integrity. + Obtains all necessary information required for UR processing from internal and external sources per policies and procedures. + Distributes incoming and outgoing correspondence, faxes and mail; uploads review documents into paperless system as necessary. + Supports other units as needed. **ADDITIONAL FUNCTIONS and RESPONSIBILITIES** + Performs other duties as assigned. + Supports the organization's quality program(s). **QUALIFICATIONS** **Education & Licensing** High School diploma or GED required. **Experience** Two (2) years of administrative experience or equivalent combination of experience and education required. Customer service in medical field preferred. Workers compensation, disability and/or liability claims processing experience preferred. **Skills & Knowledge** + Knowledge of medical and insurance terminology + Knowledge of ICD9 and CPT coding + Excellent oral and written communication, including presentation skills + PC literate, including Microsoft Office products + Analytical and interpretive skills + Strong organizational skills + Detail Oriented + Good interpersonal skills + Ability to work in a team environment + Ability to meet or exceed Performance Competencies **WORK ENVIRONMENT** When applicable and appropriate, consideration will be given to reasonable accommodations. **TAKING CARE OF YOU BY** + We offer a diverse and comprehensive benefits package including: + Three Medical, and two dental plans to choose from. + Tuition reimbursement eligible. + 401K plan that matches 50% on every $ you put in up to the first 6% you save. + 4 weeks PTO your first full year. **NEXT STEPS** If your application is selected to advance to the next round, a recruiter will be in touch. _As required by law, Sedgwick provides a reasonable range of compensation for roles that may be hired in jurisdictions requiring pay transparency in job postings. Actual compensation is influenced by a wide range of factors including but not limited to skill set, level of experience, and cost of specific location. For the jurisdiction noted in this job posting only, the range of starting pay for this role is $18-20.00/hr. A comprehensive benefits package is offered including but not limited to, medical, dental, vision, 401k and matching, PTO, disability and life insurance, employee assistance, flexible spending or health savings account, and other additional voluntary benefits._ The statements contained in this document are intended to describe the general nature and level of work being performed by a colleague assigned to this description. They are not intended to constitute a comprehensive list of functions, duties, or local variances. Management retains the discretion to add or to change the duties of the position at any time. Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace. **If you're excited about this role but your experience doesn't align perfectly with every qualification in the job description, consider applying for it anyway! Sedgwick is building a diverse, equitable, and inclusive workplace and recognizes that each person possesses a unique combination of skills, knowledge, and experience. You may be just the right candidate for this or other roles.** **Sedgwick is the world's leading risk and claims administration partner, which helps clients thrive by navigating the unexpected. The company's expertise, combined with the most advanced AI-enabled technology available, sets the standard for solutions in claims administration, loss adjusting, benefits administration, and product recall. With over 33,000 colleagues and 10,000 clients across 80 countries, Sedgwick provides unmatched perspective, caring that counts, and solutions for the rapidly changing and complex risk landscape. For more, see** **sedgwick.com**

Job Description A Nursing Success Coordinator who uses Assessment Technologies Institute (ATI) and the simulations of Nursing, resources serves as a dedicated academic support professional within a nursing program, focused on improving student performance, retention, and NCLEX success rates. This role involves acting as a liaison between students, faculty, and ATI, Evolve, Sherpath, vSim and others simulators programs. Essential Duties and Responsibilities: Student Remediation and Support: Establishes plans of action for students who fail exams or struggle academically, providing one-on-one or group tutoring, workshops, and study habit coaching. They guide students through online modules and tutorials, such as the Launch academic readiness program, to build foundational knowledge and essential nursing skills. ATI Integration and Management: Ensures the smooth operation and full integration of ATI, Evolve, Sherpath, vSim and others simulators programs resources across all program levels. This includes scheduling and setting up testing, managing student accounts, and assisting faculty in using ATI, Evolve, Sherpath, vSim and others simulators programs materials in both classroom and clinical settings. Data Analysis and Intervention: Analyzes data from proctored assessments, practice exams, and student time in tutorials to identify individual and cohort weaknesses and trends. This data-driven approach allows for personalized study plans and early intervention strategies. Faculty Liaison and Training: Serves as a campus "ATI champion," Evolve, Sherpath, vSim and others simulators programs. Ensuring faculty training is completed and best practices for using all products are reinforced throughout the program. They also serve as the main point of contact with ATI, Evolve, Sherpath, vSim and others simulators programs. company representatives. NCLEX Preparation: Utilizes ATI's, Evolve, Sherpath, vSim and others simulators programs comprehensive predictor exams and other resources to track student progress and predict NCLEX success, providing targeted support to ensure students are practice-ready upon graduation. Supervisory Responsibilities: This role does not involve supervision of other employees but may provide guidance and support to students and faculty as needed. Qualifications/Education: Master's degree in Nursing (MSN) with Role in Education highly desirable. Current specialist nurse license. Relevant nursing experience, typically several years, is expected. Familiarity and expertise with the ATI, Evolve, Sherpath, vSim and others simulators programs and learning platforms are essential skills for this role. Strong interpersonal, communication, and data management skills are necessary to collaborate with faculty, advise students, and manage program data effectively Proficiency and familiarity with educational platforms and simulation programs such as ATI, Evolve, Sherpath, vSim, and other learning management or simulation tools are essential. Strong interpersonal, communication, and data management skills are required to effectively collaborate with faculty, advice and support students, and manage academic and program-related data. Competencies: Technical Competencies Proficiency in Learning Management Systems (LMS) such as Canvas and their integration with ATI, Evolve, Sherpath, vSim, and other learning management or simulation tools are essential. Competence in digital tools such as Microsoft Teams, Words, Excel, among others. Ability to analyze student performance data and apply findings to continuous improvement initiatives. Knowledge of simulation-based learning methodologies and assessment tools. Core Competencies Strong analytical, organizational, and problem-solving skills. Excellent written and verbal communication abilities. Leadership and teamwork skills with a focus on collaboration and faculty support. Ability to train and mentor faculty and students in the effective use of technological platforms. Commitment to academic excellence, innovation, and quality improvement. High attention to detail, confidentiality, and data integrity. Capacity to manage multiple priorities in a fast-paced academic environment. Language Skills: Ability to express him or herself correctly, precisely, and effectively, orally and in writing. Command of English and Spanish. Mathematical Skills: Ability to make mathematical and deductive reasoning problem solving.+ Technological Skills: Computer skills including practical experience in Microsoft Word, Power Point, Outlook with advance skills in Microsoft Excel. Reasoning Ability: Can identify problems and present solutions. Physical Demands: While performing the duties of the position, physical effort is required (hands and feet). Work Environment: The work environment is dynamic and active. Work will be in an office with different tasks.

Corrections professionals who foster a humane and secure environment and ensure public safety by preparing individuals for successful reentry into our communities. Corrections professionals who foster a humane and secure environment and ensure public safety by preparing individuals for successful reentry into our communities. Overview Help Accepting applications Open & closing dates 10/01/2025 to 09/30/2026 Salary $50,241 to - $114,573 per year Pay scale & grade GL 05 - 10 Locations Many vacancies in the following locations: Aliceville, AL Maxwell AFB, AL Talladega, AL Forrest City, AR Show morefewer locations (90) Phoenix, AZ Safford, AZ Tucson, AZ Atwater, CA Herlong Sierra Ordnance Depot, CA Lompoc, CA Los Angeles, CA Mendota, CA San Diego, CA Victorville, CA Florence, CO Littleton, CO Danbury, CT Coleman, FL Marianna, FL Miami, FL Miami-Dade County, FL Tallahassee, FL Atlanta, GA Jesup, GA Honolulu, HI Chicago, IL Greenville, IL Marion, IL Pekin, IL Thomson, IL Terre Haute, IN Leavenworth, KS Ashland, KY Inez, KY Lexington, KY Manchester, KY Pine Knot, KY Oakdale, LA Pollock, LA Fort Devens, MA Cumberland, MD Milan, MI Duluth, MN Rochester, MN Sandstone, MN Waseca, MN Springfield, MO Yazoo City, MS Butner Federal Correctional Complex, NC Berlin, NH Fairton, NJ Fort Dix, NJ Kings, NY Otisville, NY Ray Brook, NY Elkton, OH El Reno, OK Oklahoma City, OK Sheridan, OR Gregg Township, PA Kelly Township, PA Lewis Run, PA Loretto, PA Minersville, PA Philadelphia, PA Waymart, PA Guaynabo, PR Bennettsville, SC Edgefield, SC Estill, SC Salters, SC Yankton, SD Memphis, TN Bastrop, TX Beaumont, TX Big Spring, TX Bryan, TX Federal Medical Center Carswell, TX Fort Worth, TX Houston, TX La Tuna, TX Seagoville, TX Texarkana, TX Three Rivers, TX Jonesville, VA Prince George, VA Seatac, WA Grand Marsh, WI Alderson, WV Beaver, WV Bruceton Mills, WV Glenville, WV Morgantown, WV Welch, WV Remote job No Telework eligible No Travel Required Occasional travel - Travel may be required for training and/or work related issues. Relocation expenses reimbursed No Appointment type Permanent Work schedule Full-time - Registered Nurse Accelerated Promotion Program covers the 0610 series ranging from GL-05 through GL-10 grade levels. If eligible, this enables a Registered Nurse to promote up to twice at an accelerated pace through a training program. Service Competitive Promotion potential 10 - Grade 10 - Registered Nurse Accelerated Promotion Program covers the 0610 series ranging from GL-05 through GL-10 grade levels. If eligible, this enables a Registered Nurse to promote up to twice at an accelerated pace through a training program. Job family (Series) * 0610 Nurse Supervisory status No Security clearance Other Drug test Yes Bargaining unit status No Announcement number DHA-2026-0002 Control number 847130700 This job is open to Help The public U.S. Citizens, Nationals or those who owe allegiance to the U.S. Career transition (CTAP, ICTAP, RPL) Federal employees whose job, agency or department was eliminated and are eligible for priority over other applicants. Clarification from the agency This is a public notice under the Direct Hiring Authority open to all U.S. citizens. Please review instructions in the "

A Nursing Success Coordinator who uses Assessment Technologies Institute (ATI) and the simulations of Nursing, resources serves as a dedicated academic support professional within a nursing program, focused on improving student performance, retention, and NCLEX success rates. This role involves acting as a liaison between students, faculty, and ATI, Evolve, Sherpath, vSim and others simulators programs. Essential Duties and Responsibilities: Student Remediation and Support: Establishes plans of action for students who fail exams or struggle academically, providing one-on-one or group tutoring, workshops, and study habit coaching. They guide students through online modules and tutorials, such as the Launch academic readiness program, to build foundational knowledge and essential nursing skills. ATI Integration and Management: Ensures the smooth operation and full integration of ATI, Evolve, Sherpath, vSim and others simulators programs resources across all program levels. This includes scheduling and setting up testing, managing student accounts, and assisting faculty in using ATI, Evolve, Sherpath, vSim and others simulators programs materials in both classroom and clinical settings. Data Analysis and Intervention: Analyzes data from proctored assessments, practice exams, and student time in tutorials to identify individual and cohort weaknesses and trends. This data-driven approach allows for personalized study plans and early intervention strategies. Faculty Liaison and Training: Serves as a campus "ATI champion," Evolve, Sherpath, vSim and others simulators programs. Ensuring faculty training is completed and best practices for using all products are reinforced throughout the program. They also serve as the main point of contact with ATI, Evolve, Sherpath, vSim and others simulators programs. company representatives. NCLEX Preparation: Utilizes ATI's, Evolve, Sherpath, vSim and others simulators programs comprehensive predictor exams and other resources to track student progress and predict NCLEX success, providing targeted support to ensure students are practice-ready upon graduation. Supervisory Responsibilities: This role does not involve supervision of other employees but may provide guidance and support to students and faculty as needed. Qualifications/Education: Master's degree in Nursing (MSN) with Role in Education highly desirable. Current specialist nurse license. Relevant nursing experience, typically several years, is expected. Familiarity and expertise with the ATI, Evolve, Sherpath, vSim and others simulators programs and learning platforms are essential skills for this role. Strong interpersonal, communication, and data management skills are necessary to collaborate with faculty, advise students, and manage program data effectively Proficiency and familiarity with educational platforms and simulation programs such as ATI, Evolve, Sherpath, vSim, and other learning management or simulation tools are essential. Strong interpersonal, communication, and data management skills are required to effectively collaborate with faculty, advice and support students, and manage academic and program-related data. Competencies: Technical Competencies Proficiency in Learning Management Systems (LMS) such as Canvas and their integration with ATI, Evolve, Sherpath, vSim, and other learning management or simulation tools are essential. Competence in digital tools such as Microsoft Teams, Words, Excel, among others. Ability to analyze student performance data and apply findings to continuous improvement initiatives. Knowledge of simulation-based learning methodologies and assessment tools. Core Competencies Strong analytical, organizational, and problem-solving skills. Excellent written and verbal communication abilities. Leadership and teamwork skills with a focus on collaboration and faculty support. Ability to train and mentor faculty and students in the effective use of technological platforms. Commitment to academic excellence, innovation, and quality improvement. High attention to detail, confidentiality, and data integrity. Capacity to manage multiple priorities in a fast-paced academic environment. Language Skills: Ability to express him or herself correctly, precisely, and effectively, orally and in writing. Command of English and Spanish. Mathematical Skills: Ability to make mathematical and deductive reasoning problem solving.+ Technological Skills: Computer skills including practical experience in Microsoft Word, Power Point, Outlook with advance skills in Microsoft Excel. Reasoning Ability: Can identify problems and present solutions. Physical Demands: While performing the duties of the position, physical effort is required (hands and feet). Work Environment: The work environment is dynamic and active. Work will be in an office with different tasks.

**Your Future Evolves Here** Evolent partners with health plans and providers to achieve better outcomes for people with most complex and costly health conditions. Working across specialties and primary care, we seek to connect the pieces of fragmented health care system and ensure people get the same level of care and compassion we would want for our loved ones. Evolent employees enjoy work/life balance, the flexibility to suit their work to their lives, and autonomy they need to get things done. We believe that people do their best work when they're supported to live their best lives, and when they feel welcome to bring their whole selves to work. That's one reason why diversity and inclusion are core to our business. Join Evolent for the mission. Stay for the culture. **What You'll Be Doing:** The Specialty Appeals Team offers candidates the opportunity to make a meaningful impact as part of a highly trained dedicated team focusing on appeals and post-determination requests. We maintain the principles of utilization management by adhering to Evolent and Client policies and procedures while complying with timeliness guidelines. Our team values collaboration, continuous learning, and a customer-centric approach, ensuring that every team member contributes to providing better health outcomes for the Clients and Members we serve. **Collaboration Opportunities:** The Specialty Appeal nurses work with a group of nurses, providing appeal intake review for one dedicated client. They interact with coordinators who set up the appeal, Physicians and other Clinicians who review the appeal, and managers for direction and leadership. The Appeals teamwork strategies and opportunities for collaboration include all-team and individual team meetings, Teams chats, and monthly communication on team metrics and accomplishments. **What You Will Be Doing:** + Practices and maintains the principles of utilization management and appeals management by adhering to company policies and procedures. + Documents communications with medical office staff and/or MD provider as required. + Interfaces with other departments to satisfactorily resolve issues related to appeals and retrospective reviews. + Provides optimum customer service through professional and accurate communication while maintaining accreditation and health plan's required timeframes. + Refers cases to appropriate internal reviewers according to the business needs of the particular health plan. + Reviews requests for Urgent appeals compared to expedited criteria for downgrade to Standard processing, documenting accordingly. + Works closely with the appeals-dedicated Clinical Reviewers to ensure timely adjudication of processed appeals. + Other duties as assigned. **Qualifications Required and Preferred:** + 1-3 years' experience and as an RN - **Required** + Minimum of 5 years in Utilization Management, health care Appeals, compliance and/or grievances/complaints in a quality improvement environment- **Required** + Able to work in a rotation to work 10:30am to 7pm CST (which includes 30-minute unpaid lunch break) 3 days/week, to meet the business needs of nurses providing coverage until 7:00pm CST. - **Required** + Must be able to exercise independent and sound judgment in clinical decision making. - **Preferred** + Able to navigate through internal and external computer systems. Working knowledge of Microsoft Office Product Suit - **Preferred** + Strong organizational and effective time management skills; demonstrated ability to manage multiple priorities. - **Preferred** + Outstanding interpersonal and negotiation skills to effectively establish positive relationships both internally and externally, including strong written and verbal communication skills. - **Preferred** To ensure a secure hiring process we have implemented several identity verification steps, including submission of a government issued photo ID. We conduct identity verification during interviews, and final interviews may require onsite attendance. All candidates must complete a comprehensive background check, in-person I-9 verification, and may be subject to drug screening prior to employment. The use of artificial intelligence tools during interviews is prohibited and monitored. Misrepresentation will result in immediate disqualification from consideration. **Technical Requirements:** We require that all employees have the following technical capability at their home: High speed internet over 10 Mbps and, specifically for all call center employees, the ability to plug in directly to the home internet router. These at-home technical requirements are subject to change with any scheduled re-opening of our office locations. **Evolent is an equal opportunity employer and considers all qualified applicants equally without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, or disability status.** **If you need reasonable accommodation to access the information provided on this website, please contact** ************************** **for further assistance.** The expected base salary/wage range for this position is $37- $42/hr. This position is also eligible for a bonus component that would be dependent on pre-defined performance factors. As part of our total compensation package, Evolent is proud to offer comprehensive benefits (including health insurance benefits) to qualifying employees. All compensation determinations are based on the skills and experience required for the position and commensurate with experience of selected individuals, which may vary above and below the stated amounts. Don't see the dream job you are looking for? Drop off your contact information and resume and we will reach out to you if we find the perfect fit!

Per Diem Medial - Flight Med and Avi Responsibilities include evaluation, coordination, and delivery of medical care provided to patients during transport; also is familiar with the scope of practice of the transport team members and the State rules and regulations in which the transport team operates. Works with the other transport team members to coordinate care of the patient during transport; once called, readily available/arrive at specified location, within 45 minutes before wheels. RESPONSIBILITIES: The following reflects management's definition of essential functions for this job but does not restrict the tasks that may be assigned. Management may assign or reassign duties and responsibilities to this job at any time due to reasonable accommodation or other reasons. Provides pre-hospital advanced life support care from initial contact until patient care is relinquished to the receiving medical facility Maintain thorough electronic charting of patient care. Attends pre-mission briefings and mission debriefing and completes necessary documentation Complies with safety standards to assure safety of self, medical personnel, patient, and equipment prior to takeoff. Must be familiar with scope of practice of the transport team and the State rules and regulations in which the transport team operates. Requirements: Minimum of 3 years of ICU/ED/Trauma experience within the last 5 years Previous flight experience preferred. Flight experience can be substituted year for year for the ICU/ED/Trauma requirement. RN license as appropriate to assigned location Basic Life Support (BLS) certification Advanced Cardiac Life Support (ACLS) Pediatric Advanced Life Support (PALS) Neonatal Resuscitation Program (NRP) certification Pre-hospital Trauma Life Support (PHTLS) or Basic Trauma Life Support (BTLS) certification preferred but not required. Certified Emergency Nurse (CEN), Critical Care Nurse (CCRN) or Flight Registered Nurse (CFRN) strongly recommended. Completing quarterly requirements to maintain active flight status to include: completion of intubations quarterly, attendance at Roundtables. Completing annual requirements to maintain active flight status to include: Advanced Airway course, Mock Codes, AvStar program, safety and infection control, aircraft / personnel security briefing, equipment and supplies competency / currency validation, medical screening update including copy of TB or equivalent, ICU and trauma competencies, wellness form, EMS Rules and Regulations, and Haz-mat recognition and response. Evaluation is contingent upon completion of these items prior to evaluation. Current Passport required Ability to work varied shifts and cover fixed wing air ambulance call shifts Drug screening and a background investigation required. Physical Requirements: While performing the duties of this job, the employee is frequently required to do the following: Walk and stand for prolonged periods Lift and/or move up to 50 pounds Transfer/position patients of all ages and physical conditions Collect, interpret, and/or analyze diagnostic data Utilize visual, auditory, verbal, and olfactory processes required to assess, monitor, and care for patients Interpret complex laws, regulations, and/or policies Coordinate multiple tasks simultaneously Understand and respond to a diverse population Work in a high stress environment while remaining calm composure Work various shifts and schedules Work Environment: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Frequent exposure to blood-borne and airborne pathogens or infectious materials Long transport times in the confined space of the aircraft. Exposure to dynamic cultural diversity Locations: San Juan, PR, Carollna, PR, Fort Lauderdale, FL, Schenectady, NY ABOUT REVA: In the medical transport industry, urgency, reliability, and experience are absolutely critical. We have completed over 30,000 flights in 70 countries. From marooned hikers to critically ill patients, REVA provides medical transport service 24 hours a day, 7 days a week, worldwide. When patients need care that cannot be provided during normal travel or in the region they are currently in, they call REVA. REVA's reach is worldwide. Four bases of operation within North America, the Caribbean, and Europe provide points of departure convenient to even the most distant locales. Our 13 dedicated ICU configured Jets, more than 200 air-ambulance professionals, and Global Alliance with industry partners give us a global profile. If it's on the Earth, it's on our radar. REVA is an equal opportunity employer that celebrates employees and applicants of all identities, backgrounds, abilities, and perspectives. We foster a welcoming work environment that supports diversity and inclusion, and we reject discrimination or harassment of any individual. If you are a person with a disability and require assistance with any part of the application process, please let us know. All employment decisions are made on the basis of qualifications, merit, and business need.

**Become a part of our caring community and help us put health first** Healthcare isn't just about health anymore. It's about caring for family, friends, finances, and personal life goals. It's about living life fully. At Conviva, a wholly-owned subsidiary of Humana, Inc., we want to help people everywhere, including our team members, lead their best lives. We support our team members to be happier, healthier, and more productive in their professional and personal lives. We encourage our people to build relationships that inspire, support, and challenge them. We promote lifelong well-being by giving our team members fresh perspective, new insights, and exciting opportunities to enhance their careers. At Conviva, we're seeking innovative people who want to make positive changes in their lives, the lives of our patients, and the healthcare industry as a whole. Conviva Care Solutions is seeking a RN who will collaborate with other health care givers in reviewing actual and proposed medical care and services against established CMS Coverage Guidelines/NCQA review criteria and who is interested in being part of a team that focuses on excellent service to others. **Preferred Locations:** Daytona, FL, Louisville, KY, San Antonio, TX **Use your skills to make an impact** **Role Essentials** + Active Unrestricted RN license + Possession of or ability to obtain Compact Nursing License + A minimum of three years clinical RN experience; + Prior clinical experience, managed care experience, DME, Florida Medicaid **OR** utilization management experience + Demonstrates Emotional Maturity + Ability to work independently and within a team setting + Valid driver's license and/or dependable transportation necessary + Travel for offsite Orientation 2 to 8 weeks + Travel to offsite meetings up to 6 times a year as requested + Willing to work in multiple time zones + Strong written and verbal communication skills + Attention to detail, strong computer skills including Microsoft office products + Ability to work in fast paced environment + Ability to form positive working relationships with all internal and external customers + Available for On Call weekend/holiday rotation if needed **Role Desirables** + Education: BSN or bachelor's degree in a related field + Experience with Florida Medicaid + Experience with Physical Therapy, DME, Cardiac or Orthopedic procedures + Compact License preferred + Previous experience in utilization management within Insurance industry + Previous Medicare Advantage/Medicare/Medicaid Experience a plus + Current nursing experience in Hospital, SNF, LTAC, DME or Home Health. + Bilingual **Additional Information** We offer tangible and intangible benefits such as medical, dental and vision benefits, 401k with company matching, tuition reimbursement, 3 weeks paid vacation time, paid holidays, work-life balance, growth, a positive and fun culture and much more. To ensure Home or Hybrid Home/Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. Satellite, cellular and microwave connection can be used only if approved by leadership. Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense. Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information. Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. **Scheduled Weekly Hours** 40 **Pay Range** The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc. $71,100 - $97,800 per year This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance. **Description of Benefits** Humana, Inc. and its affiliated subsidiaries (collectively, "Humana") offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities. Application Deadline: 02-18-2026 **About us** About Conviva Senior Primary Care: Conviva Senior Primary Care provides proactive, preventive care to seniors, including wellness visits, physical exams, chronic condition management, screenings, minor injury treatment and more. As part of CenterWell Senior Primary Care, Conviva's innovative, value-based approach means each patient gets the best care, when needed most, and for the lowest cost. We go beyond physical health - addressing the social, emotional, behavioral and financial needs that can impact our patients' well-being. About CenterWell, a Humana company: CenterWell creates experiences that put patients at the center. As the nation's largest provider of senior-focused primary care, one of the largest providers of home health services, and fourth largest pharmacy benefit manager, CenterWell is focused on whole-person health by addressing the physical, emotional and social wellness of our patients. As part of Humana Inc. (NYSE: HUM), CenterWell offers stability, industry-leading benefits, and opportunities to grow yourself and your career. We proudly employ more than 30,000 clinicians who are committed to putting health first - for our teammates, patients, communities and company. By providing flexible scheduling options, clinical certifications, leadership development programs and career coaching, we allow employees to invest in their personal and professional well-being, all from day one. **Equal Opportunity Employer** It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment. Centerwell, a wholly owned subsidiary of Humana, complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our full accessibility rights information and language options *************************************************************

The Health Professional 3/RN provides health and wellbeing services as part of the clinic's multidisciplinary team. This key individual promotes and restores patients' health in collaboration with physicians and multidisciplinary team members. The main responsibility will be integrate de psychological and physical areas of our patient. Essential Functions: Completes initial interview with the patient; reviews and analyzes data collected in order to identify specific needs, strengths and limitations. Recognizes and carefully manages urgent patients, as well as implements the necessary actions in case of emergency or hospitalization, based on Law 408 and the company's procedures. Coordinates patient transfers to the appropriate health care setting. Develops a patient treatment plan with a multidisciplinary focus, while promoting patient participation in treatment strategies. Discusses clinical cases and procedures with other team members in order to collect important information for treatment strategy elaboration. Assures that all patients at the clinic triage have completed an arterial pressure, pulse, and vital signs check. Collaborates in urine test collection in order to determine drug abuse/use as needed. Controls and administers the Drug Deposit and evaluates patients for the clinics depot. Contacts and monitors the attendance of depot patients. Keeps drug inventory and temperature monitoring in accordance with Pharmacy regulations. Maintains communication with patient's family members and provides supplementary treatment as needed. Provides individual or group advice to patients and family members about use and abuse of medication, or in any topic needed for treatment. Documents patient intervention and properly stores all suitable forms in the patient's file. Maintains registry of all patient care medication. Identifies potential treatment side effects and reports findings do Clinic Administrator, Physician and or Pharmacy Department. Coordinates and performs medical communication with patient Physical PCP ad necessary. Transfers patients to other facilities when needed. Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS) and guidelines set forth by other regulatory agencies, where applicable. In addition, all other duties assigned by the manager and/or supervisor. Education: Bachelor's degree in Nursing required Must have current, unrestricted PR License to practice in Puerto Rico territory, with current Professional Nursing College Membership. Experience: Minimum 2+ years of experience in the mental health and or/nursing field. Knowledge: Knowledge of medication, drug interactions, side effects, incompatibilities and all issued related to proper treatment. Knowledge of diagnosis and pharmacology. Knowledge of mental health regulations and related laws. Must be able to prioritize and target interventions, consistent with state licensure scope of practice requirements designed to support long-term behavioral change. Personal computer experience should include working with Microsoft Word, Excel, Power Point and Outlook at the intermediate level at a minimum. Knowledge regarding nursing process and correct administration guidelines.

**Become a part of our caring community and help us put health first** The Pre-Authorization Nurse 2 reviews prior authorization requests for appropriate care and setting, following guidelines and policies, and approves services or forward requests to the appropriate stakeholder. The Pre-Authorization Nurse 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. The Pre-Authorization Nurse 2 completes medical necessity and level of care reviews for requested services using clinical judgment, and refers to internal stakeholders for review depending on case findings. Educates providers on utilization and medical management processes. Enters and maintains pertinent clinical information in various medical management systems. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures. **Use your skills to make an impact** **Required Qualifications** + 2+ years Utilization Management experience + Active RN license in the state(s) in which the nurse is required to practice + Ability to be licensed in multiple states without restrictions + A minimum of three years varied nursing experience + Previous experience in utilization management, case management, discharge planning and/or home health or rehab + Proficient with MS Office products including Word, Excel and Outlook + Ability to work independently under general instructions and with a team + Must be passionate about contributing to an organization focused on continuously improving consumer experiences **Preferred Qualifications** + Bachelor's degree + Health Plan experience working with large carriers + Previous Medicare/Medicaid experience a plus + Outpatient or home health experience in Utilization Management + Experience working with MCG or Interqual guidelines **Additional Information** + **Schedule** : Monday through Friday, 8:00 AM - 5:00 PM with flexibility to work overtime/weekend as needed. + **Work Location:** US Nationwide + **Work Style:** Remote + **Travel Requirements** **: Less than 1%** **Work-at-Home (WAH) Internet Statement** To ensure Home or Hybrid Home/Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: + At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. + Satellite, cellular and microwave connection can be used only if approved by leadership. + Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense. + Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job. + Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information. **Interview Format** As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule. Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. **Scheduled Weekly Hours** 40 **Pay Range** The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc. $71,100 - $97,800 per year This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance. **Description of Benefits** Humana, Inc. and its affiliated subsidiaries (collectively, "Humana") offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities. Application Deadline: 01-19-2026 **About us** Humana Inc. (NYSE: HUM) is committed to putting health first - for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health - delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large. **Equal Opportunity Employer** It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment. Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our ***************************************************************************

Job Description The Infusion Admitting / Evaluating Nurse is responsible for providing specialized infusion therapy care in the patient's home, performing clinical evaluations to determine eligibility and continuity of treatment. Administers intravenous therapies, educates the patient and their family, and documents in accordance with clinical, regulatory, and accreditation standards (ACHC, CMS, and Puerto Rico Department of Health). The admitting nurse must foster Alivia's values, support the vision of the infusion department, and actively contribute towards the unit's success. Responsibilities include, but are not limited to the following: Conduct initial clinical assessments at home to determine the feasibility and safety of infusion treatment. Admit patients within 24 hours of receiving the referral. In accordance with regulatory and accreditation standards. Coordinate medication reconciliation and develop the initial care plan in conjunction with the prescribing physician and multidisciplinary team. Monitor the patient's response to treatment and document clinical findings in the electronic system. Educate the patient and family about treatment, devices, infection control, warning signs, and patient rights and responsibilities. Obtain and document the patient's informed consent in the medical record. Identify and report adverse events, incidents, complaints, deviations, or clinical risks to the quality and compliance committee in a timely manner. Required: Bachelor's degree in nursing from an accredited university. Current nursing license in Puerto Rico. Participation in continuing education and documented annual clinical competencies. Valid driver's license in Puerto Rico and availability of a motor vehicle. Minimum of 2 years of experience in home health, infusion, or acute care services. Preferably in a home setting. Knowledge of infusion pumps, central and peripheral catheters. ***Equal Opportunity Employer M/F/V/D***

The Health Professional 3/RN provides health and wellbeing services as part of the clinic's multidisciplinary team. This key individual promotes and restores patients' health in collaboration with physicians and multidisciplinary team members. The main responsibility will be integrate de psychological and physical areas of our patient. Essential Functions: * Completes initial interview with the patient; reviews and analyzes data collected in order to identify specific needs, strengths and limitations. Recognizes and carefully manages urgent patients, as well as implements the necessary actions in case of emergency or hospitalization, based on Law 408 and the company's procedures. Coordinates patient transfers to the appropriate health care setting. * Develops a patient treatment plan with a multidisciplinary focus, while promoting patient participation in treatment strategies. Discusses clinical cases and procedures with other team members in order to collect important information for treatment strategy elaboration. * Assures that all patients at the clinic triage have completed an arterial pressure, pulse, and vital signs check. Collaborates in urine test collection in order to determine drug abuse/use as needed. * Controls and administers the Drug Deposit and evaluates patients for the clinics depot. Contacts and monitors the attendance of depot patients. Keeps drug inventory and temperature monitoring in accordance with Pharmacy regulations. * Maintains communication with patient's family members and provides supplementary treatment as needed. Provides individual or group advice to patients and family members about use and abuse of medication, or in any topic needed for treatment. * Documents patient intervention and properly stores all suitable forms in the patient's file. Maintains registry of all patient care medication. * Identifies potential treatment side effects and reports findings do Clinic Administrator, Physician and or Pharmacy Department. * Coordinates and performs medical communication with patient Physical PCP ad necessary. Transfers patients to other facilities when needed. * Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS) and guidelines set forth by other regulatory agencies, where applicable. * In addition, all other duties assigned by the manager and/or supervisor. Education: * Bachelor's degree in Nursing required * Must have current, unrestricted PR License to practice in Puerto Rico territory, with current Professional Nursing College Membership. Experience: * Minimum 2+ years of experience in the mental health and or/nursing field. Knowledge: * Knowledge of medication, drug interactions, side effects, incompatibilities and all issued related to proper treatment. * Knowledge of diagnosis and pharmacology. * Knowledge of mental health regulations and related laws. * Must be able to prioritize and target interventions, consistent with state licensure scope of practice requirements designed to support long-term behavioral change. * Personal computer experience should include working with Microsoft Word, Excel, Power Point and Outlook at the intermediate level at a minimum. * Knowledge regarding nursing process and correct administration guidelines.

Job Description The Infusion Admitting / Evaluating Nurse is responsible for providing specialized infusion therapy care in the patient's home, performing clinical evaluations to determine eligibility and continuity of treatment. Administers intravenous therapies, educates the patient and their family, and documents in accordance with clinical, regulatory, and accreditation standards (ACHC, CMS, and Puerto Rico Department of Health). The admitting nurse must foster Alivia's values, support the vision of the infusion department, and actively contribute towards the unit's success. Responsibilities include, but are not limited to the following: Conduct initial clinical assessments at home to determine the feasibility and safety of infusion treatment. Admit patients within 24 hours of receiving the referral. In accordance with regulatory and accreditation standards. Coordinate medication reconciliation and develop the initial care plan in conjunction with the prescribing physician and multidisciplinary team. Monitor the patient's response to treatment and document clinical findings in the electronic system. Educate the patient and family about treatment, devices, infection control, warning signs, and patient rights and responsibilities. Obtain and document the patient's informed consent in the medical record. Identify and report adverse events, incidents, complaints, deviations, or clinical risks to the quality and compliance committee in a timely manner. Required: Bachelor's degree in nursing from an accredited university. Current nursing license in Puerto Rico. Participation in continuing education and documented annual clinical competencies. Valid driver's license in Puerto Rico and availability of a motor vehicle. Minimum of 2 years of experience in home health, infusion, or acute care services. Preferably in a home setting. Knowledge of infusion pumps, central and peripheral catheters. ***Equal Opportunity Employer M/F/V/D***