Utilization review nurse jobs in Jersey City, NJ - 404 jobs

Requisition ID JR1004947 Category Managed Care Type Regular Full-Time AmTrust Financial Services, a fast-growing commercial insurance company, has a need for Clinical Review Nurse remote or in an office location. PRIMARY PURPOSE: The Clinical Review nurse has the responsibility of reviewing the medical necessity, appropriateness, quality and efficiency of services in the appropriate setting for Workers' Compensation claimants. This position assesses the medical appropriateness of proposed treatments and medications for our injured employees, and partners with the AmTrust Claims Adjuster team to expedite medically necessary treatment for each claim. They also review pharmacy authorizations to determine appropriateness of pharmaceutical treatment. Maintains a solid understanding of AmTrust's mission, vision, and values. Upholds the standards of the AmTrust organization. This position will be hybrid out of one of our AmTrust office locations! Responsibilities Perform Utilization Review activities prospectively, concurrently, or retrospectively in accordance with the appropriate jurisdictional guidelines. Uses clinical/nursing skills to determine whether all aspects of a patient's care, at every level, are medically necessary and appropriately delivered. Responsible for helping to ensure injured employees receive appropriate level and intensity of care directly related to the compensable injury using industry standard and/or state specific medical treatment guidelines and formularies. Objectively and critically assesses all information related to the current treatment request to make the appropriate medical necessity determination. Sends determination letters as needed to requesting physician(s) and refers to physician advisors for second level reviews as necessary. Responsible for accurate comprehensive documentation of Utilization Review activities in the case management and pharmacy benefit management systems. Responsible for completing timely reviews according to state's requirements and communicating the UR determination to all parties. Uses clinical/nursing skills to help coordinate the individual's treatment program while maximizing quality and cost-effectiveness of care. Communicates effectively with providers, claims adjuster, client, and other parties as needed to expedite appropriate medical care Keeps current with market trends and demands. Performs other functionally related duties as assigned Qualifications Active unrestricted RN license in a state or territory of the United States with eligibility to get and/or renew a multistate license. 5+ years of related experience or equivalent combination of education and experience required to include 2+ years of direct clinical care OR2+ years of utilization management required. Education & Licensing Bachelor's degree in nursing (BSN) from accredited college or university or equivalent work experience preferred. Certification in case management, pharmacy, rehabilitation nursing or a related specialty is highly preferred. Acquisition and maintenance of Insurance License(s) may be required to comply with state requirements. Preferred for license(s) to be obtained within three - six months of starting the job. Skills & Knowledge Proficiency in all Microsoft Office products including Project, Word, Excel, PowerPoint, Visio, and SharePoint Knowledge of workers' compensation laws and regulations, behavioral health, case management practice, URAC standards, ODG, Utilization review, pharmaceuticals to treat pain, pain management process, drug rehabilitation, state workers compensation guidelines, periods of disability, and treatment needed Excellent oral and written communication, including presentation skills Ability to interact collaboratively and work effectively with a multi-functional team and throughout the organization; fosters an environment of shared responsibility and accountability Strong organizational, communication and analytical skills Excellent negotiation 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. Mental: Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem solving, analysis, and discretion; ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines Physical: Computer keyboarding Auditory/Visual: Hearing, vision and talking The expected salary range for this role is $53,300-$92,500. Please note that the salary information shown above is a general guideline only. Salaries are based upon a wide range of factors considered in making the compensation decision, including, but not limited to, candidate skills, experience, education and training, the scope and responsibilities of the role, as well as market and business considerations. #LI-GH1 #LI-HYBRID #AmTrust What We Offer AmTrust Financial Services offers a competitive compensation package and excellent career advancement opportunities. Our benefits include: Medical & Dental Plans, Life Insurance, including eligible spouses & children, Health Care Flexible Spending, Dependent Care, 401k Savings Plans, Paid Time Off. AmTrust strives to create a diverse and inclusive culture where thoughts and ideas of all employees are appreciated and respected. This concept encompasses but is not limited to human differences with regard to race, ethnicity, gender, sexual orientation, culture, religion or disabilities. AmTrust values excellence and recognizes that by embracing the diverse backgrounds, skills, and perspectives of its workforce, it will sustain a competitive advantage and remain an employer of choice. Diversity is a business imperative, enabling us to attract, retain and develop the best talent available. We see diversity as more than just policies and practices. It is an integral part of who we are as a company, how we operate and how we see our future. Connect With Us! Not ready to apply? Connect with us for general consideration.

Our groundbreaking hospice and palliative care programs offer a broad range of services in the community or facility-based to help patients and their families ease the burden of managing a life-limiting illness or end of life care. The On Call RN Supervisor provides leadership, support, and guidance to Call Center staff for clinical/non clinical issues and situations. The Supervisor elevates complex issues to Team Manager, AOC or Hospice MD on call. The RN Supervisor also provides quality professional telephonic intervention to patients based on the Plan of Care. Graduate from an accredited School of Nursing, BSN or BS degree preferred Three years of Hospice nursing experience Supervisory or leadership experience preferred 2-5 years Hospice experience/On Call required New York State RN licensure NYS valid license preferred Current CHPN certification preferred

Work with a great team where you feel appreciated and make a difference! Responsibilities: Provide warm and engaging personal care services, assistance, support and companionship. Administer or assist with medication for residents according to the Resident Care Plan. Engage residents while checking on their wellbeing and communicate changes in condition or Care Plan. Inspire your team and collaborate with the Health Services Director in assessing and documenting resident assessments at state or Brightview specified intervals. Salary range: USD $35.25 - USD $42.25 /Hr. Compensation Disclosure: The salary range mentioned above reflects the potential pay for this role and does not include bonuses or additional incentives (if applicable), nor does it include the value of our benefit program. Offers will consider factors like experience, qualifications, location, community size (if relevant), certifications/training, etc. Brightview regularly reviews and adjusts compensation ranges. Qualifications: You have a positive attitude and love working with people! A graduate of a state approved school of nursing. A current state license as a Registered or Practical/Vocation Nurse. Minimum of one year of experience in assisted living, hospice, home health, acute or long-term care environment. Why work at Brightview?: Discover the Brightview Senior Living Difference! 1. Dedicated to Excellence: We lead the industry with a passion for delivering top-notch services and groundbreaking care. 2. Embracing Community: Join a supportive and inclusive environment that prioritizes your professional growth, development and advancement. 3. Impactful Work: Make a meaningful difference in the lives of our seniors, contributing to their joy and well-being every day. 4. Comprehensive Benefits: Enjoy competitive salaries, health, vision and dental insurance options, retirement plans, tuition reimbursement, employee assistance programs and many more benefits that prioritize your well-being. 5. A Place to Flourish: Embrace diversity, foster innovation, and access the tools and resources for personal and professional growth. Join our vibrant team at Brightview Senior Living and be valued as an integral part of our community. Equal Opportunity Employer At Brightview, we believe that diversity of thought, experience, perspective, and backgrounds makes us stronger. We welcome and celebrate all that makes us unique and we choose not to discriminate on the basis of race, color, creed, religion, sex, pregnancy, age, marital status, national origin, citizenship status, military status, physical or mental disability, sexual orientation, genetic information or any other characteristic protected by law or not related to the specific requirements of a particular role. We are, by choice and without question, an equal opportunity employer. For Massachusetts Applicants: It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.

Centers Dialysis Care is seeking Registered Dialysis Nurses (RN) for our dialysis center in Bronx, NY. Come work at Centers Dialysis Care, a high-level network of dialysis facilities located in Brooklyn, Bronx. and Rockland County NY. We are seeking to hire experienced dialysis nurses as well as train nurses interested in the exciting field of dialysis care. We are waiting eagerly to hear from you! Are you a hard-working professional who is looking to work in a warm environment where employees are appreciated and rewarded for their dedication and hard work? Are you tired of the large corporate dialysis chains, their endless red tape, and where no one understands you? Centers Dialysis Care facilities are managed by local professionals who are at the facility and get what you need! Apply now! DUTIES: Collaborate with the interdisciplinary team to assess patient status and implement and monitor the progression of care Performs care coordination and patient education Administer medications and other treatments, as directed by provider/physician staff Monitor patients throughout treatment and document patient's responses to treatment requirements Mobilizes resources in complex cases to maximize patients' control and participation over his/her own recovery. Integrates assessment and diagnostic information with intuition to foresee potential age-specific healthcare needs. Anticipates patients needs. Ensures handoff communication and includes a report in terms of the situations most likely to develop and the problems awaiting patient. Displays the ability to see the entire unit and is self-motivated to develop a plan for adjusting staffing patterns as needed. Plans and provides unique and individualized comfort measures while utilizing intuitive and innovative approaches which are scientifically sound and are a result of evidence-based practice. Participates in performance improvement activities at the unit level. Performs any other related duties as required or assigned. REQUIREMENTS: Active NY RN License CPR Certification Clinical nursing experience in a dialysis setting is preferred Rate : $45.00 - $55.00 LOCATIONS: Bronx, NY DIAL23 ABOUT US: With five centers, located throughout the Tri-State Area, Centers Health Dialysis' facilities have been providing quality care for over 13 years to our dialysis community. Our focus is on providing the ultimate patient care experience in outpatient dialysis facilities located both onsite and offsite of skilled nursing facilities. We are proud to share that we are independently and locally owned with stellar on-site management giving our facilities the individualized touch often missing from other large organizations. Centers Dialysis Care is a part of Centers Health, a fully integrated post-acute care continuum offering rehabilitation and skilled nursing services in more than 45 locations covering four states. At Centers Health and Centers Health Dialysis, we are well known for our commitment to our employees, offering outstanding ongoing training and development, career advancement opportunities, competitive pay rates, generous compensation packages, and more.

This position is for a Travel Registered Nurse specializing in Wound and Ostomy Care, based in Brooklyn, New York, offering a 13-week assignment with 40 hours per week. The role includes day shifts and provides comprehensive benefits such as weekly pay, medical coverage, retirement plans, and referral bonuses. PRIDE Health specializes in connecting travel nurses with healthcare facilities across the U.S., promoting career growth and diverse work experiences. PRIDE Health is seeking a travel nurse RN Wound Care for a travel nursing job in Brooklyn, New York. Job Description & Requirements Specialty: Wound Care Discipline: RN Start Date: Duration: 13 weeks 40 hours per week Shift: 8 hours, days Employment Type: Travel Pride Health Job ID #. Pay package is based on 8 hour shifts and 40.0 hours per week (subject to confirmation) with tax-free stipend amount to be determined. Posted job title: RN:Wound Care,09:00:00-17:00:00 About PRIDE Health PRIDE Health is the minority-owned healthcare recruitment division of Pride Global-an integrated human capital solutions and advisory firm. With our robust and abundant travel nursing and allied health employment options across the U.S., PRIDE Health will allow you to help change the way the world lives and heals as it connects you with the industry's leading healthcare organizations. Pride Global offers eligible employee's comprehensive healthcare coverage (medical, dental, and vision plans), supplemental coverage (accident insurance, critical illness insurance and hospital indemnity), 401(k)-retirement savings, life & disability insurance, an employee assistance program, legal support, auto, home insurance, pet insurance, and employee discounts with preferred vendors. Benefits Weekly pay Holiday Pay Guaranteed Hours 401k retirement plan Cancelation protection Referral bonus Medical benefits Dental benefits Vision benefits Keywords: travel nurse, wound care nurse, ostomy nurse, registered nurse, RN travel jobs, healthcare jobs, nursing travel assignments, wound and ostomy care, travel nursing benefits, Brooklyn nursing jobs

About Abridge Abridge was founded in 2018 with the mission of powering deeper understanding in healthcare. Our AI-powered platform was purpose-built for medical conversations, improving clinical documentation efficiencies while enabling clinicians to focus on what matters most-their patients. Our enterprise-grade technology transforms patient-clinician conversations into structured clinical notes in real-time, with deep EMR integrations. Powered by Linked Evidence and our purpose-built, auditable AI, we are the only company that maps AI-generated summaries to ground truth, helping providers quickly trust and verify the output. As pioneers in generative AI for healthcare, we are setting the industry standards for the responsible deployment of AI across health systems. We are a growing team of practicing MDs, AI scientists, PhDs, creatives, technologists, and engineers working together to empower people and make care make more sense. We have offices located in the Mission District in San Francisco, the SoHo neighborhood of New York, and East Liberty in Pittsburgh. The Role Abridge is seeking a Nurse Scientist to drive the development of our AI-powered nursing documentation tools. The ideal candidate is a current/former Practicing Nurse with a strong background in Nursing Informatics and technical expertise, blending clinical knowledge with experience using informatics to drive the development of new technologies. In this role, you will help shape AI-driven documentation tools, ensuring our models generate accurate, high-quality nursing notes that enhance nurses' efficiency and patient care. You'll work closely with engineers, researchers, and other clinicians to refine AI models, validate outputs, and develop new capabilities that improve documentation workflows. This is a high-impact opportunity to be a part of developing the product that will help nurses concentrate on what matters most- connecting with patients and delivering exceptional care. What You'll Do Develop and refine AI-driven nursing documentation tools using clinical expertise and collaborating with prompt engineers. Design experiments to assess and validate the accuracy of AI-generated nursing documentation and provide structured feedback. Build and refine evaluation tools to streamline nursing documentation quality assessment. Collaborate with cross-functional teams (ML researchers, data scientists, clinicians) to integrate nursing insights into AI models. Contribute to product development and broader business initiatives. What You'll Bring RN, or PhD with direct experience working in nursing practice Deep understanding of nursing documentation, nursing workflows, and nursing terminology Ability to evaluate AI-generated clinical notes using a data-driven approach, provide structured feedback, and guide improvements Hands-on experience in clinical data validation and quality assessment. Strong knowledge of healthcare data standards (e.g., FHIR, HL7) and privacy regulations (e.g., HIPAA) Experience collaborating with engineers and product teams to build AI-powered clinical tools Strong analytical and problem-solving skills Excellent written and verbal communication skills Bonus Points If... Experience in software engineering, particularly in prompt engineering or AI model development Previous experience in AI-powered clinical documentation tools or clinical decision support systems Published research in AI, machine learning, or healthcare technology Must be willing to work from our SF or NYC office at least 3x per week This position requires a commitment to a hybrid work model, with the expectation of coming into the office a minimum of (3) three times per week. Relocation assistance is available for candidates willing to move to San Francisco. We value people who want to learn new things, and we know that great team members might not perfectly match a job description. If you're interested in the role but aren't sure whether or not you're a good fit, we'd still like to hear from you. Why Work at Abridge? At Abridge, we're transforming healthcare delivery experiences with generative AI, enabling clinicians and patients to connect in deeper, more meaningful ways. Our mission is clear: to power deeper understanding in healthcare. We're driving real, lasting change, with millions of medical conversations processed each month. Joining Abridge means stepping into a fast-paced, high-growth startup where your contributions truly make a difference. Our culture requires extreme ownership-every employee has the ability to (and is expected to) make an impact on our customers and our business. Beyond individual impact, you will have the opportunity to work alongside a team of curious, high-achieving people in a supportive environment where success is shared, growth is constant, and feedback fuels progress. At Abridge, it's not just what we do-it's how we do it. Every decision is rooted in empathy, always prioritizing the needs of clinicians and patients. We're committed to supporting your growth, both professionally and personally. Whether it's flexible work hours, an inclusive culture, or ongoing learning opportunities, we are here to help you thrive and do the best work of your life. If you are ready to make a meaningful impact alongside passionate people who care deeply about what they do, Abridge is the place for you. How we take care of Abridgers: Generous Time Off: 13 paid holidays, flexible PTO for salaried employees, and accrued time off for hourly employees. Comprehensive Health Plans: Medical, Dental, and Vision plans for all full-time employees. Abridge covers 100% of the premium for you and 75% for dependents. If you choose a HSA-eligible plan, Abridge also makes monthly contributions to your HSA. Paid Parental Leave: 16 weeks paid parental leave for all full-time employees. 401k and Matching: Contribution matching to help invest in your future. Pre-tax Benefits: Access to Flexible Spending Accounts (FSA) and Commuter Benefits. Learning and Development Budget: Yearly contributions for coaching, courses, workshops, conferences, and more. Sabbatical Leave: 30 days of paid Sabbatical Leave after 5 years of employment. Compensation and Equity: Competitive compensation and equity grants for full time employees. ... and much more! Equal Opportunity Employer Abridge 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. Staying safe - Protect yourself from recruitment fraud We are aware of individuals and entities fraudulently representing themselves as Abridge recruiters and/or hiring managers. Abridge will never ask for financial information or payment, or for personal information such as bank account number or social security number during the job application or interview process. Any emails from the Abridge recruiting team will come from *************** email address. You can learn more about how to protect yourself from these types of fraud by referring to this article. Please exercise caution and cease communications if something feels suspicious about your interactions.

This position is for a Travel Emergency Department Nurse (RN) in New York City, providing 36 hours per week over 13 weeks, with 12-hour shifts. The role requires specialized skills in emergency nursing and offers competitive pay including a tax-free stipend. The job is facilitated by Prime Staffing, which focuses on matching qualified healthcare professionals with client needs. Prime Staffing is seeking a travel nurse RN ED - Emergency Department for a travel nursing job in New York City, New York. Job Description & Requirements Specialty: ED - Emergency Department Discipline: RN Start Date: Duration: 13 weeks 36 hours per week Shift: 12 hours Employment Type: Travel Prime Staffing Job ID #. Pay package is based on 12 hour shifts and 36.0 hours per week (subject to confirmation) with tax-free stipend amount to be determined. Posted job title: RN:ED,07:00:00-19:00:00 About Prime Staffing At Prime Staffing, we understand the importance of finding the perfect fit for both our clients and candidates. Prime Staffing utilizes a unique matchmaking approach, providing the most qualified contingent staffing to our clients, and the most competitive contracts to our workforce. Our experienced team takes the time to get to know both our clients and candidates, their needs, and preferences, to ensure that each placement is a success. We offer a wide range of staffing services including temporary, temp-to-perm, and direct hire placements. Our extensive network of qualified candidates includes nurses, allied healthcare professionals, corporate support professionals and executives. Keywords: travel nurse, emergency department nurse, RN, registered nurse, travel nursing job, emergency room nursing, healthcare staffing, temporary nursing job, New York City nurse, 12-hour shifts

At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and optimized. Ready to make a difference? Join us to start Caring. Connecting. Growing together We're making a solid connection between exceptional patient care and outstanding career opportunities. The result is a culture of performance that's driving the health care industry forward. As a Case Manager RN, you'll support a diverse member population with education, advocacy and connections to the resources they need to feel better and get well. Instead of seeing a handful of patients each day, your work may affect millions for years to come. If you are located within Essex County, New Jersey, territory and willing to travel up to 80% of your time to assigned territory, you will have the flexibility to work remotely as you take on some tough challenges Primary Responsibilities: Comprehensive Assessment & Care Planning Conduct thorough health assessments, including medical history, chronic conditions, behavioral health, and social determinants of health Develop individualized care plans that address medical, rehabilitation, behavioral health, and social needs Create personalized interventions that integrate medical treatment, support services, and community resources Member Engagement, Education & Self-Management Build and maintain relationships with an established caseload of high-risk members Provide education to members and caregivers on disease processes, treatment adherence, and lifestyle changes Encourage self-management strategies that support long-term wellness and reduce complications Maintain consistent outreach to support adherence to care plans and monitor evolving needs Intensive Care Coordination Coordinate services across providers, including PCPs, specialists, hospitals, LTSS, behavioral health, and pharmacy. Facilitate referrals for home health, hospice, palliative care, and DME Collaborate with Medical Directors during interdisciplinary rounds to review and align care for complex cases Discharge Planning & Transitional Care Support members through transitions of care such as hospitalization, skilled nursing, and rehabilitation Conduct "welcome home" and follow-up calls to ensure post-discharge services, medications, and follow-up appointments are in place Deliver intensive outreach during the 30-day post-discharge period to reduce avoidable readmissions and ED utilization Advocate for safe, coordinated, and timely transitions of care that align with the member's individualized care plan Field-Based Care Management (20% of Time) Conduct home and hospital visits in North Jersey as required by program guidelines Perform in-person assessments and provide care coordination to address high-risk needs and ensure continuity of care Collaborate directly with providers, facilities, and families during field visits to close care gaps and reinforce the care plan Monitoring & Clinical Oversight Monitor members' clinical conditions, care plan progress, and treatment adherence Reassess care plans regularly and adjust interventions based on changing needs or barriers Identify red-flag conditions and escalate urgent or complex cases for higher-level review and intervention Documentation, Compliance & Quality Outcomes Document all assessments, care plans, interventions, and communications per NCQA, CMS, and state regulatory requirements Ensure care management services align with DSNP/NCQA standards and contract requirements Track outcomes tied to quality metrics (HEDIS, STARs), utilization management, and member satisfaction Maintain audit readiness through timely, accurate, and comprehensive documentation You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications: Current, unrestricted RN license in New Jersey 2+ years of Case Management Experience serving complex, elderly and disabled Experience with government health programs (Medicaid/Medicare) Proficient in Microsoft Office Suite; tech-savvy with ability to navigate multiple systems simultaneously Demonstrated ability to talk and type proficiently at the same time Access to reliable transportation and the ability to travel up to 80% within assigned territory. Available for occasional in-person meetings as needed Preferred Qualifications: Certified Case Manager (CCM) Experience working with populations with special needs (DSNP) Experience with Managed Care Population Bilingual - English/Spanish Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $40.00 to $54.00 per hour based on full-time employment. We comply with all minimum wage laws as applicable. At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission. UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations. UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

AOM Infusion is a leading provider of home and specialty infusion therapy, dedicated to delivering high-quality, patient-centered care across the communities we serve. Our team of experienced clinicians and professionals work together to ensure every patient receives safe, compassionate, and personalized treatment. AOM Infusion is looking for an Infusion Nurse to join our team. This is role based in the Manhattan/Brooklyn, NY area. POSTION OVERVIEW: An Infusion Nurse is a registered nurse who is capable of diagnosing and treating human responses to actual or potential problems. The Infusion Nurse is responsible for a group of patients that have been assigned to and accepted by her/him for the provision of primary patient care, patient and family education, coordination with AOM Infusion's in house RN staff in the development, implementation, and revision of the patient's plan of care. KEY RESPONSIBILITIES: The professional nurse employed with AOM Infusion will strictly adhere to providing patient care consistent with the applicable State Nurse Practice Act or title acts relating to reporting and peer review. Clinical: Assesses and documents the patient's biophysical, psychosocial, and educational needs. Performs a physical assessment consistent with standards of Nursing Practice and reports any identified problems to the patient's physician and the in-house RN staff. Cooperates with in house RN staff on the design and implementation of the nursing care plan to be consistent with the physician orders and plan of treatment for the purpose of meeting the patient's needs in conjunction with the patient and caregiver. Routinely identifies and reports changes in the patient's condition that require a change in the plan of care by nursing documentation and verbal reporting to the in-house RN staff. Provides comprehensive patient and family education related to the patient's health care needs, prescribed therapy, infection control procedures and disaster planning. Inserts, maintains, and assesses all types of intravenous access devices used for patient care. Reports any changes or issues with the access devices to in house RN staff for the purpose of adjusting supply needs, documentation and tracking of Central Venous Access Devices (CVADs). Demonstrates competence in performing all treatments per the physician's plan of treatment/plan of care. Reports need for discharge planning to in house RN staff and documents all needs and changes in the Patient Visit Record and verbally reports as well. Demonstrates sound clinical judgment and expertise in the planning and decision-making process of the patient's plan of care in cooperation and conjunction with the in-house RN staff. Operational: Coordinates all patient care needs for an assigned group of patients with other members of the health care team. Maintains high standards of nursing care and implements policies and procedures as established by AOM Infusion. Coordinates nursing visits and care consistent with the physician's plan of treatment and the plan of care. Reports necessary changes to the plan of treatment and plan of care as the patient's health care needs require to the in-house RN staff. Monitors and maintains patient's supply inventory on each visit. Reports any supply needs or overstocking issues to the pharmacy department. Maintains an inventory of emergency back-up supplies that are available during patient care visits. Emergency supplies include supplies necessary to maintain infection control procedures and to provide emergency care such as a CPR valved mask. When assigned an infusion pump, the nurse clinician will clean and test the pump as per AOM Infusion policy between each patient use and will document this procedure on the Pump Maintenance Log to be submitted monthly. Completes all required patient care documentation and submits all documents to the office either by fax or via the iPad each Monday by noon as per AOM Infusion policy. If the RN has an iPad, then visit notes must be completed at the end of each patient visit and a patient signature must be obtained. Consistently adheres to universal precautions, aseptic technique and infection control guidelines and includes the need for these techniques in all patient teaching sessions. Maintains confidentiality of patient information in accordance with HIPAA regulations and AOM Infusion policy. Quality Assurance: Participates in the company's quality assurance program as requested by the QA Chairperson. Completes all charting as per AOM Infusion documentation policy. Reports after each visit and to in house RN staff or RN on call after hours for any adverse events and carefully documents any patient incidents or issues that require the writing of an Unusual Occurrence Report. If the RN has an iPad, he or she must email the report. REQUIREMENTS: Graduate of an accredited school of nursing. Licensed and registered as a registered nurse in the States where practicing. Current CPR certification. At least one year of experience as a registered nurse preferably in a home infusion setting. At least one year of experience as a pediatric nurse preferably in a home infusion setting and/or the ability to become competent in pediatric practices associated with pediatric home infusion. Knowledge and experience in managing infusion access devices such as peripheral lines, PICC lines and central venous catheters including implantable ports. Free from any communicable diseases, illnesses or injuries that may interfere with the employee's ability to perform tasks required of the position. Flexible with work schedule. Takes responsibility for primary patients, when an after-hours need for care arises whenever possible the nurse clinician will provide any necessary care needs and communicate all actions performed via the report system or needed to the in-house RN staff or the AOM Infusion On Call RN. Excellent interpersonal, verbal and written communication skills. 40hrs per week. Work week is Monday thru Friday BENEFITS: AOM Infusion recognizes the value of benefits for you and your family, so we offer a comprehensive and competitive benefits program: Medical, Dental, Vision, 401(k) with Employer Match up to 10%, Paid Time Off & Paid Holidays, FSA, Life & AD&D Insurance, Disability Coverage, and Employee Referral Program To learn more about our company culture and career opportunities, please visit Careers - AOM Infusion

One of the largest health benefits companies in the United States. Through its networks nationwide, the company delivers a number of leading health benefit solutions through a broad portfolio of integrated health care plans and related services, along with a wide range of specialty products such as life and disability insurance benefits, dental, vision, behavioral health benefit services, as well as long term care insurance and flexible spending accounts. Headquartered in Indianapolis, Indiana, WellPoint, Inc. is an independent licensee of the Blue Cross and Blue Shield Association serving members in California, Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, Nevada, New Hampshire, New York, Ohio, Virginia and Wisconsin; and specialty plan members in other states through UniCare. Job Description This role is specific to the LTSS department. RN will be responsible for providing case management services and evaluating the necessity/appropriateness/efficiency of the use of Medical Services for Long-Term Support Services (LTSS). Will be responsible for collaborating with providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources. May also manage appeals for services denied. Provides plan of care for members based on authorization and concurrent review. Provides monthly telephonic outreach to ensure members needs are assessed and met based on information. Responsible for collaborating with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources. MAJOR JOB DUTIES AND RESPONSIBILITIES Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers, programs, or community resources. Applies clinical knowledge to work with facilities and providers for care coordination. Works with medical directors in interpreting appropriateness of care and accurate claims payment. May also manage appeals for services denied. Conducts pre-certification, inpatient, retrospective, out of network and appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts. Ensures member access to medical necessary, quality healthcare in a cost effective setting according to contract. Consult with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost effective care throughout the medical management process. Collaborates with providers to assess member's needs for early identification of and proactive planning for discharge planning. Facilitates member care transition through the healthcare continuum and refers treatment plans/plan of care to clinical reviewers as required and does not issue non-certifications. Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards. Additional Info: *possible remote opportunity after training if candidate demonstrates understanding of processes and policy expectations* Qualifications Must have clear and active RN license in the state of NY Requires an AS/BS in Nursing At least 2 years of acute care clinical experience; or any combination of EDU/experience that would provide an equivalent background Excellent written and verbal communication skills Additional Information Advantages of this Opportunity: Competitive salary, negotiable based on relevant experience Benefits offered, Medical, Dental, and Vision Fun and positive work environment Monday through Friday 8am-5pm

The Utilization Management Nurse will conduct reviews of current inpatient services, and determine medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination in accordance with Utilization Management policies and procedures. ESSENTIAL FUNCTIONS Perform utilization management, utilization review, or concurrent review (on-site at a hospital, or telephonic inpatient care management) of hospitalized members ensuring medical necessity, appropriateness of admission, and continued stay following evaluation of medical and benefit determination guidelines. Maintains compliance with all state mandated regulations. Collaboration with hospital staff, physicians, care/service coordinators, plan Medical Director, members and their families to provide the level of care necessary to meet member's health needs. Maintain an active role in assuring the continuity of care for all inpatients through early discharge planning and working with hospital discharge planners and health plan social workers or other staff in the early identification of potential home care candidates or less restrictive level of care placement. Identification and management of members at high risk for readmission or with complex medical and psychosocial needs. Collaboration with Case Manager to coordinate post discharge care and services aimed at: increasing rates of timely outpatient follow-up, ensuring provider treatment plan, medications & outpatient services are in place, safe transition to outpatient setting, improving self management skills, addressing members psychosocial and non-medical needs Communicate directly with physician providers/designees when appropriate to gather all clinical information to determine the medical necessity of requested healthcare services. Maintains courteous, professional attitude when working with Affinity staff, hospital and physician providers, and members. Collect pertinent clinical information and documents all UM review information using the appropriate software system. Manage medical / benefits resources effectively and efficiently while ensuring quality care is provided as determined by guidelines of meeting Medical necessity. Communicate directly with appropriate internal staff regarding all inpatient cases and outpatient/ambulatory requests for health care services that do not meet medical necessity or appropriate level of care and out of network transfer issues. Manage assigned workload within established performance standards. Follow relevant client time frame standards for conducting and communicating UM review determination. Maintain and submit reports and logs on review activities as outlined by the UM program operational procedures. Contribute to MM program goals and objectives in containing health care costs and maintaining a high quality medical delivery system through the program procedures for conducting UM activities. Participate in a multi-disciplinary team approach to address member needs from the acute care phase through the post-acute care phase. Identify and coordinate quality of care issues or trends with the Quality Management department. Demonstrate proficiency with the principles and methodologies of process improvement. Apply these in the execution of responsibilities in support of a process focused approach. Perform other duties as necessary or assigned. QUALIFICATIONS: Registered Nurse or Licensed Practical Nurse with current, unrestricted, licensure required for state of New York Associates degree in Nursing required; BSN preferred 3+ years Clinical experience and 2 or more years experience working in utilization management required Experience working in Medicaid and/or Medicare managed care, including regulatory and compliance requirements strongly preferred Experience with MCG guidelines preferred Proficiency in software applications that include, but are not limited to, Microsoft Word, Microsoft Excel, Microsoft PowerPoint and Outlook required Ability to work with minimal guidance; seeks guidance on only the most complex tasks Problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action Excellent verbal and written communication skills; ability to speak clearly and concisely, conveying complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others. Advanced interpersonal (e.g., mediating, counseling, mentoring, influencing), negotiating and management skills required to manage critical internal and external relationships and activities that are diverse and complex. Ability to collaborate constructively with others within and outside the organization. Ability to work resourcefully and creatively, to think independently, and to exercise sound judgment in a complex and dynamic environment. Commitment to the corporate mission, vision, and values. High level of integrity as demonstrated by a) appropriate treatment of confidential information, b) adherence to policies, procedures, rules and regulations, c) professional conduct in dealing with persons internal and external to the organization, and d) sensitivity to the populations served by Affinity and the providers with which Affinity works.

Drug Utilization Review Pharmacist - Ensure Safe and Effective Use of Medications A confidential managed care organization is seeking a skilled Drug Utilization Review (DUR) Pharmacist to support quality prescribing and improve patient outcomes. This role is ideal for pharmacists who enjoy analyzing medication use, applying clinical guidelines, and collaborating with providers to promote safe, cost-effective care. Key Responsibilities Conduct prospective, concurrent, and retrospective drug utilization reviews. Evaluate prescribing patterns against clinical guidelines and formulary criteria. Identify potential drug interactions, duplications, and inappropriate therapy. Prepare recommendations for prescribers to optimize therapy and reduce risk. Document reviews and ensure compliance with state, federal, and health plan requirements. Contribute to quality improvement initiatives and pharmacy program development. What You'll Bring Education: Doctor of Pharmacy (PharmD) or Bachelor of Pharmacy degree. Licensure: Active and unrestricted pharmacist license in the U.S. Experience: Managed care, PBM, or health plan experience preferred - but hospital and retail pharmacists with strong clinical skills are encouraged to apply. Skills: Analytical mindset, detail-oriented, and excellent written and verbal communication. Why This Role? Impact: Shape prescribing decisions that affect thousands of patients. Growth: Build expertise in managed care and population health pharmacy. Flexibility: Many DUR roles offer hybrid or fully remote schedules. Rewards: Competitive salary, benefits, and career advancement opportunities. About Us We are a confidential healthcare partner providing managed care pharmacy services nationwide. Our DUR pharmacists play a key role in ensuring that medications are used safely, appropriately, and cost-effectively across diverse patient populations. Apply Today Advance your career in managed care pharmacy - apply now for our Drug Utilization Review Pharmacist opening and help lead the way in improving medication safety and outcomes.

**Location: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development.** **_Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law._** **Hours: Monday - Friday 9:00am to 5:30pm EST and 1 late evening 11:30am to 8:00pm EST.** *****This position will service members in different states; therefore Multi-State Licensure will be required.** The **Telephonic Nurse Case Manager II** is responsible for care management within the scope of licensure for members with complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize member health care across the care continuum. Performs duties telephonically. **How you will make an impact:** + Ensures member access to services appropriate to their health needs. + Conducts assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment. + Implements care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangements. + Coordinates internal and external resources to meet identified needs. + Monitors and evaluates effectiveness of the care management plan and modifies as necessary. + Interfaces with Medical Directors and Physician Advisors on the development of care management treatment plans. + Negotiates rates of reimbursement, as applicable. + Assists in problem solving with providers, claims or service issues. + Assists with development of utilization/care management policies and procedures. **Minimum Requirements:** + Requires BA/BS in a health related field and minimum of 5 years of clinical experience; or any combination of education and experience, which would provide an equivalent background. + Current, unrestricted RN license in applicable state(s) required. + Multi-state licensure is required if this individual is providing services in multiple states. **Preferred Capabilities, Skills and Experiences:** + Certification as a Case Manager. + Ability to talk and type at the same time. + Demonstrate critical thinking skills when interacting with members. + Experience with (Microsoft Office) and/or ability to learn new computer programs/systems/software quickly. + Ability to manage, review and respond to emails/instant messages in a timely fashion. + Minimum 2 years' experience in acute care setting. + Minimum 2 years "telephonic" Case Management experience with a Managed Care Company. + Managed Care experience. For candidates working in person or virtually in the below locations, the salary* range for this specific position is $76,944 to $126,408. Locations: Colorado; New York; New Jersey In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws. * The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law. Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health. Who We Are Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. How We Work At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business. We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few. Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws. Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact ******************************************** for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.

Are you a high-energy professional with a passion for driving sales and building relationships in the healthcare industry? We are seeking an Hospital Liaison for a reputable Skilled Nursing Facility to help us increase occupancy rates and build strong referral networks. The ideal candidate will already have existing relationships with local healthcare providers, hospitals, and community organizations. Key Responsibilities: Community Outreach: Develop and implement marketing strategies to build and maintain relationships with local healthcare providers, hospitals, social service agencies, and other referral sources. Hospital Liaison: Meet with discharge planners and medical staff at hospitals to promote the facility and ensure smooth transitions for patients needing post-acute care. Lead Generation: Drive new leads through networking events, presentations, and other marketing initiatives to generate interest in the facility. Sales Presentations: Conduct facility tours and deliver compelling presentations to prospective residents and their families, highlighting the facility's services and unique selling points. Relationship Building: Establish and maintain strong, ongoing relationships with key referral sources, offering educational materials and addressing concerns. Market Analysis: Analyze the local healthcare market and competitors, identifying opportunities to strengthen the facility's position. Data Tracking and Reporting: Maintain accurate records of leads, referral sources, conversion rates, and other metrics to ensure success and identify opportunities for improvement. Compliance Adherence: Ensure marketing efforts comply with all relevant healthcare regulations. Required Skills and Qualifications: Proven Sales Acumen: A demonstrated track record of generating leads, closing sales, and exceeding sales targets. Strong Communication Skills: The ability to engage with diverse audiences, including healthcare professionals, families, and potential residents. Healthcare Knowledge: A solid understanding of skilled nursing services, post-acute care needs, and medical terminology. Relationship Building: Excellent interpersonal skills and the ability to build and maintain strong partnerships. Presentation Skills: Confidence in presenting the facility's benefits to prospective residents and referral sources. CRM Proficiency: Ability to use CRM systems to track leads and manage relationships. Results-Oriented: Must be highly motivated to achieve and exceed targets, with a strong drive to succeed. Why Join Us? Be part of a dedicated team making a meaningful impact on the lives of residents and their families. Opportunity for personal and professional growth in the healthcare marketing field. Competitive compensation and performance-based incentives. If you are an energetic, results-driven marketer with existing local healthcare connections and a passion for growth, we want to hear from you! Join us in helping provide compassionate care and improving the lives of those in need. View all jobs at this company

Prime Staffing is seeking a travel nurse RN ED - Emergency Department for a travel nursing job in New York City, New York. Job Description & Requirements Specialty: ED - Emergency Department Discipline: RN Start Date: Duration: 13 weeks 36 hours per week Shift: 12 hours Employment Type: Travel Prime Staffing Job ID #. Pay package is based on 12 hour shifts and 36.0 hours per week (subject to confirmation) with tax-free stipend amount to be determined. Posted job title: RN:ED,07:00:00-19:00:00 About Prime Staffing At Prime Staffing, we understand the importance of finding the perfect fit for both our clients and candidates. Prime Staffing utilizes a unique matchmaking approach, providing the most qualified contingent staffing to our clients, and the most competitive contracts to our workforce. Our experienced team takes the time to get to know both our clients and candidates, their needs, and preferences, to ensure that each placement is a success. We offer a wide range of staffing services including temporary, temp-to-perm, and direct hire placements. Our extensive network of qualified candidates includes nurses, allied healthcare professionals, corporate support professionals and executives.

RN - Labor & Delivery | NYC Contract: Immediate Start | Shift: Nights 7:00 PM - 7:30 AM | Schedule: 3x12s Offer: Immediate - no interviews required! Respond to your recruiter to secure your spot. We are seeking experienced Labor & Delivery RNs to join a high-quality, supportive care team. Multiple positions are available to care for patients in a dynamic L&D environment with a staffing ratio of 1:2. Key Responsibilities: Patient Care & Experience: Provide safe, competent, and evidence-based nursing care in Labor & Delivery. Assess, monitor, and manage the physical and emotional needs of patients throughout labor, delivery, and immediate postpartum care. Collaborate with interdisciplinary teams to implement individualized care plans. Educate patients and families on labor, delivery, and postpartum care. Maintain therapeutic relationships while prioritizing patient safety, comfort, and satisfaction. Quality & Safety: Follow institutional policies and evidence-based practices to ensure high-quality care. Monitor unit metrics and escalate potential safety concerns appropriately. Participate in quality improvement initiatives and documentation requirements. Operations & Teamwork: Float between units as needed. Support unit throughput and maintain efficient, patient-centered operations. Collaborate with colleagues to foster professional growth and shared decision-making. Requirements: License/Certifications: NYS RN License (Active & Good Standing), BLS, ACLS, NRP (Mandatory) Experience: Minimum 2 years L&D experience; minimum 2 years overall RN experience Skills: EPIC experience highly preferred; 1 year travel experience preferred (not required for Per Diem) Education: BSN required Unit Details: Avg Unit Census: 12 patients | Beds: 18 Staffing Ratio: 1:2 Auto Offer: Respond within 2 hours to accept/decline; otherwise, the offer moves to the next qualified applicant. Why Apply: Multiple positions open - secure your role immediately! Immediate offer - no interviews required. Competitive pay: Travel $80/hr | Local $71/hr Work in a dynamic, supportive, professional L&D environment. Pride Health offers eligible employees comprehensive healthcare coverage (medical, dental, and vision plans), supplemental coverage (accident insurance, critical illness insurance, and hospital indemnity), 401(k)-retirement savings, life & disability insurance, an employee assistance program, legal support, auto, home insurance, pet insurance, and employee discounts with preferred vendors

One of the largest health benefits companies in the United States. Through its networks nationwide, the company delivers a number of leading health benefit solutions through a broad portfolio of integrated health care plans and related services, along with a wide range of specialty products such as life and disability insurance benefits, dental, vision, behavioral health benefit services, as well as long term care insurance and flexible spending accounts. Headquartered in Indianapolis, Indiana, WellPoint, Inc. is an independent licensee of the Blue Cross and Blue Shield Association serving members in California, Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, Nevada, New Hampshire, New York, Ohio, Virginia and Wisconsin; and specialty plan members in other states through UniCare. Job Description This role is specific to the LTSS department. RN will be responsible for providing case management services and evaluating the necessity/appropriateness/efficiency of the use of Medical Services for Long-Term Support Services (LTSS). Will be responsible for collaborating with providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources. May also manage appeals for services denied. Provides plan of care for members based on authorization and concurrent review. Provides monthly telephonic outreach to ensure members needs are assessed and met based on information. Responsible for collaborating with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources. MAJOR JOB DUTIES AND RESPONSIBILITIES Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers, programs, or community resources. Applies clinical knowledge to work with facilities and providers for care coordination. Works with medical directors in interpreting appropriateness of care and accurate claims payment. May also manage appeals for services denied. Conducts pre-certification, inpatient, retrospective, out of network and appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts. Ensures member access to medical necessary, quality healthcare in a cost effective setting according to contract. Consult with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost effective care throughout the medical management process. Collaborates with providers to assess member's needs for early identification of and proactive planning for discharge planning. Facilitates member care transition through the healthcare continuum and refers treatment plans/plan of care to clinical reviewers as required and does not issue non-certifications. Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards. Additional Info: *possible remote opportunity after training if candidate demonstrates understanding of processes and policy expectations* Qualifications Must have clear and active RN license in the state of NY Requires an AS/BS in Nursing At least 2 years of acute care clinical experience; or any combination of EDU/experience that would provide an equivalent background Excellent written and verbal communication skills Additional Information Advantages of this Opportunity: Competitive salary, negotiable based on relevant experience Benefits offered, Medical, Dental, and Vision Fun and positive work environment Monday through Friday 8am-5pm

The Utilization Management Nurse will conduct reviews of current inpatient services, and determine medicalappropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination in accordance with Utilization Management policies and procedures. ESSENTIAL FUNCTIONS Perform utilization management, utilization review, or concurrent review (on-site at a hospital, or telephonic inpatient care management) of hospitalized members ensuring medical necessity, appropriateness of admission, and continued stay following evaluation of medical and benefit determination guidelines. Maintains compliance with all state mandated regulations. Collaboration with hospital staff, physicians, care/service coordinators, plan Medical Director, members and their families to provide the level of care necessary to meet member's health needs. Maintain an active role in assuring the continuity of care for all inpatients through early discharge planning and working with hospital discharge planners and health plan social workers or other staff in the early identification of potential home care candidates or less restrictive level of care placement. Identification and management of members at high risk for readmission or with complex medical and psychosocial needs. Collaboration with Case Manager to coordinate post discharge care and services aimed at: increasing rates of timely outpatient follow-up, ensuring provider treatment plan, medications & outpatient services are in place, safe transition to outpatient setting, improving self management skills, addressing members psychosocial and non-medical needs Communicate directly with physician providers/designees when appropriate to gather all clinical information to determine the medical necessity of requested healthcare services. Maintains courteous, professional attitude when working with Affinity staff, hospital and physician providers, and members. Collect pertinent clinical information and documents all UM review information using the appropriate software system. Manage medical / benefits resources effectively and efficiently while ensuring quality care is provided as determined by guidelines of meeting Medical necessity. Communicate directly with appropriate internal staff regarding all inpatient cases and outpatient/ambulatory requests for health care services that do not meet medical necessity or appropriate level of care and out of network transfer issues. Manage assigned workload within established performance standards. Follow relevant client time frame standards for conducting and communicating UM review determination. Maintain and submit reports and logs on review activities as outlined by the UM program operational procedures. Contribute to MM program goals and objectives in containing health care costs and maintaining a high quality medical delivery system through the program procedures for conducting UM activities. Participate in a multi-disciplinary team approach to address member needs from the acute care phase through the post-acute care phase. Identify and coordinate quality of care issues or trends with the Quality Management department. Demonstrate proficiency with the principles and methodologies of process improvement. Apply these in the execution of responsibilities in support of a process focused approach. Perform other duties as necessary or assigned. QUALIFICATIONS: Registered Nurse or Licensed Practical Nurse with current, unrestricted, licensure required for state of New York Associates degree in Nursing required; BSN preferred 3+ years Clinical experience and 2 or more years experience working in utilization management required Experience working in Medicaid and/or Medicare managed care, including regulatory and compliance requirements strongly preferred Experience with MCG guidelines preferred Proficiency in software applications that include, but are not limited to, Microsoft Word, Microsoft Excel, Microsoft PowerPoint and Outlook required Ability to work with minimal guidance; seeks guidance on only the most complex tasks Problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action Excellent verbal and written communication skills; ability to speak clearly and concisely, conveying complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others. Advanced interpersonal (e.g., mediating, counseling, mentoring, influencing), negotiating and management skills required to manage critical internal and external relationships and activities that are diverse and complex. Ability to collaborate constructively with others within and outside the organization. Ability to work resourcefully and creatively, to think independently, and to exercise sound judgment in a complex and dynamic environment. Commitment to the corporate mission, vision, and values. High level of integrity as demonstrated by a) appropriate treatment of confidential information, b) adherence to policies, procedures, rules and regulations, c) professional conduct in dealing with persons internal and external to the organization, and d) sensitivity to the populations served by Affinity and the providers with which Affinity works.

Drug Utilization Review Pharmacist - Ensure Safe and Effective Use of Medications A confidential managed care organization is seeking a skilled Drug Utilization Review (DUR) Pharmacist to support quality prescribing and improve patient outcomes. This role is ideal for pharmacists who enjoy analyzing medication use, applying clinical guidelines, and collaborating with providers to promote safe, cost-effective care. Key Responsibilities Conduct prospective, concurrent, and retrospective drug utilization reviews. Evaluate prescribing patterns against clinical guidelines and formulary criteria. Identify potential drug interactions, duplications, and inappropriate therapy. Prepare recommendations for prescribers to optimize therapy and reduce risk. Document reviews and ensure compliance with state, federal, and health plan requirements. Contribute to quality improvement initiatives and pharmacy program development. What You'll Bring Education: Doctor of Pharmacy (PharmD) or Bachelor of Pharmacy degree. Licensure: Active and unrestricted pharmacist license in the U.S. Experience: Managed care, PBM, or health plan experience preferred - but hospital and retail pharmacists with strong clinical skills are encouraged to apply. Skills: Analytical mindset, detail-oriented, and excellent written and verbal communication. Why This Role? Impact: Shape prescribing decisions that affect thousands of patients. Growth: Build expertise in managed care and population health pharmacy. Flexibility: Many DUR roles offer hybrid or fully remote schedules. Rewards: Competitive salary, benefits, and career advancement opportunities. About Us We are a confidential healthcare partner providing managed care pharmacy services nationwide. Our DUR pharmacists play a key role in ensuring that medications are used safely, appropriately, and cost-effectively across diverse patient populations. Apply Today Advance your career in managed care pharmacy - apply now for our Drug Utilization Review Pharmacist opening and help lead the way in improving medication safety and outcomes.