Utilization review nurse jobs in Quincy, MA - 395 jobs

Site: The Brigham and Women's Hospital, Inc. Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham. Shift: 36hr variable rotation Job Summary The Registered Nurse is a professional nurse registered in Massachusetts who is responsible and accountable for planning and providing patient care for assigned patients in accordance with Nursing Standards of Care as set forth in the Nursing Department's Clinical Practice Manual. The registered nurse demonstrates initiative, knowledge and clinical skills in caring for the patient with complex needs. The Registered Nurse demonstrates the ability to effectively manage patients by assuming full responsibility for the assessment, plan, implementation and evaluation of patient care and is directly responsible to a designated nurse manager, or supervisor. Qualifications PRINCIPAL DUTIES AND RESPONSIBILITIES CLINICAL PRACTICE A. Organization of Patient Care 1. Accountable for assessing, planning, implementing and evaluating a plan of care for a specific patient assignment. 2. Sets priorities when organizing care for patients with varying acuity. 3. Maintain continuity through clear and concise (verbal and written) communication. 4. Demonstrates appropriate knowledge of growth and development of the adult and geriatric patient. In areas, such as the NICU and Obstetrics the principals of growth and development are applicable to the neonate. B. Quality of Care 1. Documents patient care in a manner that is clear, complete, concise and in compliance with nursing documentation standards. 2. Develops a comprehensive plan of care based on data from an initial assessment of patient and family, information from other members of the health care team, intra-agency referral and previous medical records. 3. Develops a comprehensive educational plan for the patient and family, utilizing appropriate resources and documents according to the department's documentation standards. 4. Develops a comprehensive discharge plan utilizing appropriate resources and referrals including community resources. 5. Evaluates the effectiveness of the plan of care, and documents progress in meeting stated goals. Revises plan of care as needed to achieve desired outcomes. 6. Participates actively in the unit-based and organizational quality management and/or quality improvement programs. 7. Provides a safe environment for patients, staff, family and visitors. 8. Administers medication safely according to established policies and procedures. 9. Performs nursing procedures safely and efficiently. 10. Uses equipment safely and efficiently. 11. Demonstrates awareness of potential/actual risks of infection and modes of transmission. 12. Utilizes universal precautions in nursing practice. C. Coordination/Collaboration 1. Interacts with patients, families, and colleagues in a professional manner. 2. Collaborates with other discipline(s). 3. Develops, utilizes and evaluates unit-specific standards of care. 4. Upholds the A.N.A. code of ethics and acts as a role model to other staff members. 5. Participates in determining and implementing goals and objectives for the unit. 6. Participates in determining goals and objectives in the periodic review and evaluation. 7. Serves on unit-based and organizational committees and disseminates information to peers. D. Education 1. Assumes responsibility for personal and professional growth through identification of own learning needs. 2. Shares knowledge and experience with colleagues. 3. Participates in unit-based and organizational educational programs. 4. Seeks and accepts guidance for additional learning needs. E. Research 1. Utilizes nursing research findings in clinical practice. 2. Contributes to nursing and/or medical research endeavors by supporting investigators. F. Budget 1. Utilizes time and materials in an effective and economical manner. 2. Provides suggestions which support the delivery of cost-effective health care. 3. Assesses patient's acuity accurately when making decisions regarding staffing, transfers and assignments. 4. Demonstrates awareness of the need to manage within established budgetary boundaries. G. Personnel 1. Participates in the orientation of new staff members, students and others as appropriate. 2. Provides input into the clinical evaluation of other staff, as appropriate. 3. Assumes responsibility for the unit in the absence of leadership personnel. 4. Adheres to hospital and nursing policies and aids in their interpretation to others. 5. Recommends change in policies and procedures through appropriate channels. 6. Participates in the cooperative effort and peer support required for the smooth running of the unit, e.g., flexibility in relation to patient assignments, shift assignment, or work schedule. The Staff Nurse will be responsible for: Providing care for patients throughout procedural services Supporting the Procedural Float Pool specialty, the designated staff nurse: Prepares patients for procedures and provides post procedure and extended recovery care for inpatient and ambulatory populations. The rotation will include, but not limited to, pre/intra/post procedure Cross Sectional Interventional Radiology, Interventional (neuro, angio) Radiology, Infusion, Radiation Oncology, Procedural Recovery Unit, Endoscopy (main and BWH 850 offsite campus), Women's Health Center, Echo, Cath Lab, and Electrophysiology Lab. The rotation may also cover echo contrast enhancing administration and pre-procedure evaluation. * Working collaboratively to provide excellent care to patients and families in the safest environment. Additional Job Details (if applicable) A. Education: Graduate of an approved school of nursing with current registration in Massachusetts. For newly licensed nurses a Bachelor of Science Degree in Nursing is required. B. Experience: 1. Medical Intensive Care Unit or Emergency Department experience within 3 years required 2. IV conscious sedation experience preferred 3. IV insertion skills preferred C. Other: Membership in professional organizations is recommended and certification in a specialty area is encouraged. May be required to work weekends and holidays Remote Type Onsite Work Location 75 Francis Street Scheduled Weekly Hours 36 Employee Type Regular Work Shift Rotating (United States of America) Pay Range $41.71 - $105.65/Hourly Grade MNA333 At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package. EEO Statement: 2200 The Brigham and Women's Hospital, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran's Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at **************. Mass General Brigham Competency Framework At Mass General Brigham, our competency framework defines what effective leadership "looks like" by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.

Stepdown travel nurse job in Boston, MA - earn $2,617/week on a 13 week, Variable shift at a travel-friendly hospital with Advantis Medical. Looking for Stepdown travel nursing jobs near you? This contract follows a (3×12) schedule and offers high pay, clinical experience, and the full support of the #1 rated travel nurse agency. Whether you're planning your next assignment in Massachusetts or searching for "Stepdown travel RN jobs near me", this opportunity could be the perfect fit. This travel assignment is perfect for nurses looking to be near Boston, MA. Don't miss out-click "I'm Interested" to start your application and connect with an Advantis recruiter to explore more travel Stepdown nurse jobs near you. Job Details Facility: Boston Medical Center Location: Boston, MA 02118 Explore the area! See our local guide and an interactive map further down this page. Contract Length: 13 Weeks Shift: Variable (3×12) Travel Nursing Requirements: 2+ years of recent Stepdown nursing experience. Active Massachusetts RN License or Compact License (if applicable) Benefits Day One Benefits - Medical, Dental, Vision & 401(k) Relocation and Travel Reimbursement Dedicated team to help with travel & housing accommodations Weekly Direct Deposit $500 Referral Bonuses Near Boston, MA Boston, MA anchors a historic region where healthcare assignments span world-class teaching hospitals and community facilities. For clinicians seeking travel RN jobs near me, the metro provides steady demand across specialties. During time off, explore the cobblestone lanes of Beacon Hill, browse boutiques along Newbury Street, or spend an afternoon by the Charles River Esplanade. Travel nursing jobs also reach into nearby Cambridge, Somerville, and Quincy, broadening living options while keeping commutes short. From its research institutions to its walkable neighborhoods, Boston, Massachusetts supports travelers with both consistent contracts and cultural enrichment, making it a setting that blends professional access with one of the country's most distinctive urban traditions. FAQs - Stepdown Travel Nurse Jobs Near Boston, MA Expand All Are there Stepdown travel nursing jobs near Boston, Massachusetts? Yes! Advantis Medical frequently staffs Stepdown travel RN jobs in Boston and nearby areas like Cambridge (02138), Somerville (02143) and Quincy (02169). This assignment offers $2,617 per week and is one of our top current opportunities. Is Boston a good location for Stepdown travel nursing jobs? Yes. With competitive pay, career-boosting clinical environments, and great local lifestyle perks, Boston is a top destination for Stepdown travel nurse jobs in Massachusetts. What are the licensing requirements for working as a travel nurse in Massachusetts? Massachusetts Board of Nursing Contact information Website: https://www.mass.gov/orgs/board-of-registration-in-nursing Phone: 800.414.0168 / 617.973.0900 Fees License by Exam: $230 License by Endorsement: $275 Renewal: $120 License Verification Free: $20 Timing Processing Time: 4 - 5 weeks Valid for: 2 years Renewal Schedule: your birthdate on even years General Information Nurse Licensure Compact: No Nursys: Yes CEU Requirements: CEU Requirements: 15 contact hours; a one-time course in Alzheimer's Training Helpful Links Apply Now Check Status Verify License Travel Nursing Jobs With Advantis Medical - The Gold Standard At Advantis Medical Staffing, we take great pride in our commitment to caring for travel nurses. We are dedicated to connecting nurses with the best travel nursing jobs nationwide, while providing exceptional service that fosters a trusted partnership for life. Our mission is to deliver the "Gold Standard" in service -not only by securing your first assignment but by advocating for your long-term career goals and well-being. Experience our gold standard level of service as we create a stress-free and rewarding journey for you. View Similar Stepdown Jobs ⟶ Travel Nursing Job in Boston, MA Weekly Pay: $2,617 This pay combines taxable wages and tax-free stipends. For a full, transparent breakdown, submit the "I'm Interested" form, & a recruiter will send you the details. × Location: Boston, MA 02118 Explore the area! See our local guide and an interactive map further down this page. × Facility: Boston Medical Center Specialty: Stepdown Duration: 13 weeks Shift: Variable (3x12) I'm Interested Have a question? Call us at 214-305-6445

Site: Mass General Brigham Health Plan Holding Company, Inc. Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham. Job Summary The UMCM will utilize clinical knowledge to analyze, assess, and render approval decisions, to determine the need for physician review as well as complete determinations following physician review. The ideal candidate will have prior authorization (outpatient review) experience in a managed care setting with Medicaid/MassHealth knowledge. Principal Duties and Responsibilities: • Expertise in clinical review for prospective, concurrent, retrospective utilization management reviews utilizing Interqual , company policies and procedures, and other resources as determined by review, including physician reviews as needed for all lines of business as per departmental needs • Review authorization requests for medical services, including making initial eligibility and coverage determinations, screening for medical necessity appropriateness, determining if additional information is required, and referral to correct programs within Mass General Brigham Health Plan as needed. • Manage incoming requests for procedures and services including patient medical records and related clinical information. • Strong working knowledge of commercial, self-insured, fully insured and limited network plans. • Adherence to program, departmental and organizational performance metrics including productivity. • Excellent verbal and written communication skills. • Excellent problem solving and customer service skills. • Would need to be available for “on call” for a minimum of once per month with the possibility of that increasing depending on staff availability; Approximately 6 months after hire. • Must be self-directed and highly motivated with an ability to multi-task. • Develop and maintain effective working relationships with internal and external customers • Hold self and others accountable to meet commitments. • Sound decision-making and time management skills. • Proactive in areas of professional development, personally and for the department. • Persist in accomplishing objectives to consistently achieve results despite any obstacles and setbacks that arise. • Build strong relationships and infrastructures that designate Mass General Brigham Health Plan as a people-first organization. • Proficient with Microsoft Word, Excel, Outlook, McKesson InterQual , Outlook, SharePoint, PC based operating system, and web-based phone system. Qualifications Education Associate's Degree Nursing required or Bachelor's Degree Nursing preferred Licenses and Credentials Massachusetts Registered Nurse (RN) license required Experience At least 2-3 years of utilization review experience is highly preferred Experience using Interqual or Milliman is highly preferred At least 1-2 years of experience in a payer setting is highly preferred At least 1-2 years of experience in an acute care setting is highly preferred Knowledge, Skills, and Abilities Demonstrate Mass General Brigham Health Plan's core brand principles of always listening, challenging conventions, and providing value Strong aptitude for technology-based solutions. Embrace opportunities to take the complexity out of how we work and what we deliver. Listen to our constituents, learn, and act quickly in our ongoing pursuit of meaningful innovation Current in healthcare trends. Ability to inject energy, when and where it's needed. Exercise self-awareness; monitor impact on others; be receptive to and seek out feedback; use self-discipline to adjust to feedback. Be accountable for delivering high-quality work. Act with a clear sense of ownership. Bring fresh ideas forward by actively listening to and working with employees and the people we serve. Communicate respectfully and professionally with colleagues Strong EQ; exercises self-awareness; monitors impact on others; is receptive to and seeks out feedback; uses self-discipline to adjust to feedback. Additional Job Details (if applicable) Working Conditions Would need to be available for “on call” for a minimum of once per month with the possibility of that increasing depending on staff availability; Approximately 6 months after hire. This is a remote role with occasional onsite team meetings in Somerville, MA. Remote Type Remote Work Location 399 Revolution Drive Scheduled Weekly Hours 40 Employee Type Regular Work Shift Day (United States of America) Pay Range $58,656.00 - $142,448.80/Annual Grade 98TEMP At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package. EEO Statement: 8925 Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran's Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at **************. Mass General Brigham Competency Framework At Mass General Brigham, our competency framework defines what effective leadership “looks like” by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.

Ready to help us transform healthcare? Bring your true colors to blue. The Role The Physical Therapy Utilization Management Reviewer is responsible for evaluating the appropriateness and medical necessity of outpatient rehabilitation and other services within scope of practice per business needs. The reviewer will ensure services align with established clinical guidelines and policies. This position is part of a larger team and works independently and collaboratively to facilitate care using clinical skills, principles of managed care, nationally recognized medical necessity criteria, and company medical policies to conduct reviews that promote efficient and medically appropriate use of the member's benefit to provide the best quality care. The Team The commercial Physical Therapy Utilization Management Reviewer is part of a highly dedicated and motivated team of professionals. The team includes clinicians, medical and behavioral health care managers, dietitians, pharmacists, medical directors and more, who collaborate to facilitate care. This position is eligible for the Mobile persona with an in-office requirement to work at our Hingham location 2x/month. Key Responsibilities: * Conduct pre-certification, concurrent, and retrospective reviews with emphasis on utilization management, discharge planning, care coordination, clinical outcomes, and quality of service. * Evaluate members' clinical status, benefits, and appropriateness for programs and sites of service to develop a cost-effective, medically necessary plan of care. * Successfully complete/pass the annual InterQual Interrater Reliability Test. * Interact with treating providers, PCPs, physicians, therapists, and facilities as needed to gather clinical information to support the plan of care. * Monitor clinical quality concerns and make appropriate referrals regarding concerns to the appropriate internal departments. * Understand member insurance products and benefits and apply benefits appropriately * Learn and implement regulatory guidelines related to compliance and regulatory requirements (examples: NCQA, Department of Insurance). * Other duties as assigned and based on business needs. Key Qualifications: * Able to work Independently and collaboratively on a team, adaptable and flexible to change. * Ability to communicate effectively. * Ability to manage ambiguity and assess, analyze, and determine next steps. * Critical thinking and clinical judgment. * Proficient with multiple IT systems. * Demonstration of awareness, attitude, knowledge, and skills needed to work effectively with a culturally and demographically diverse population. Education and Experience: * 3-5 years relevant experience in a variety of appropriate clinical health care settings (outpatient rehabilitation inpatient acute or lower levels of care or differing clinical rehabilitation settings with transferable skills and experience. * Utilization Management experience, preferred. * Active licensure in Massachusetts is required, appropriate to position (PT). * Licensure in additional states a plus. * Note: Any restrictions against a license must be disclosed and reviewed. * Credentials: Doctor of Physical Therapy (DPT) degree, Master's in Physical Therapy (MSPT) or Bachelor's in Physical Therapy (BSPT) from a program accredited by the Commission on Accreditation in Physical Therapy Education (CAPTE). #LI-HYBRID Minimum Education Requirements: High school degree or equivalent required unless otherwise noted above Location Hingham Time Type Full time Hourly Range: $42.18 - $51.56 The job posting range is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee's pay position within the salary range will be based on several factors including, but limited to, relevant education, qualifications, certifications, experience, skills, performance, shift, travel requirements, sales or revenue-based metrics, and business or organizational needs and affordability. This job is also eligible for variable pay. We offer comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees. Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation 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. WHY Blue Cross Blue Shield of MA? We understand that the confidence gap and imposter syndrome can prevent amazing candidates coming our way, so please don't hesitate to apply. We'd love to hear from you. You might be just what we need for this role or possibly another one at Blue Cross Blue Shield of MA. The more voices we have represented and amplified in our business, the more we will all thrive, contribute, and be brilliant. We encourage you to bring us your true colors, , your perspectives, and your experiences. It's in our differences that we will remain relentless in our pursuit to transform healthcare for ALL. As an employer, we are committed to investing in your development and providing the necessary resources to enable your success. Learn how we are dedicated to creating an inclusive and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path by visiting our Company Culture page. If this sounds like something you'd like to be a part of, we'd love to hear from you. You can also join our Talent Community to stay "in the know" on all things Blue. At Blue Cross Blue Shield of Massachusetts, we believe in wellness and that work/life balance is a key part of associate wellbeing. For more information on how we work and support that work/life balance visit our "How We Work" Page.

**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 *************************************************************

· Participates in the development and ongoing implementation of QM Work Plan activities. · Improve quality products and services, by using measurement and analysis to process, evaluate and make recommendations to meet QM objectives Responsibilities: · Reviews documentation and evaluates Potential Quality of Care issues based on clinical policies and benefit determinations. · Considers all documented system information as well as any additional records/data presented to develop a determination or recommendation. · Data gathering requires navigation through multiple system applications. · Staff may be required to contact the providers of record, vendors, or internal Aetna departments to obtain additional information. · Evaluates documentation/information to determine compliance with clinical policy, regulatory and accreditation guidelines. · Responsible for the review and evaluation of clinical information and documentation. · Reviews documentation and interprets data obtained form clinical records or systems to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider issues. · Works Potential Quality of Care cases across all lines of business (Commercial and Medicare). · Independently coordinates the clinical resolution with internal/external clinician support as required. · Processes and evaluates complex data and information sets -Converts the results of data analysis into meaningful business information and reaches conclusions about the data · Prepares and completes QM documents based on interpretation and application of business requirements · Documents QM activities to demonstrate compliance with business, regulatory, and accreditation requirements · Assists in the development and implementation of QM projects and activities · Accountable for completing and implementation of QM Work Plan Activities Experience: · 3+ years of experience as an RN · 1+ years of inpatient hospital experience · Registered Nurse in state of residence · Must have prior authorization utilization experience · Able to work in multiple IT platforms/systems Skills: · MUST HAVE MEDCOMPASS or ASSURECARE exp. · MUST HAVE MANAGED CARE exp and Medicare/Medicaid knowledge. · MUST HAVE UM experience, inpatient utilization management review. · MUST HAVE 1 YEAR OF UTILIZATION MANAGEMENT EXP, pref. knowledge of Milliman/MCG. · MUST HAVE 6 months of Prior Authorization. Education: · Active and unrestricted RN licensure in state of residence **About US Tech Solutions:** US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit *********************** (*********************************** . US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, colour, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

Formulary Strategy & Utilization Review Pharmacist Shape the drug benefit landscape-analyze and optimize medication use. Key Responsibilities: Review prescribing trends and propose cost-saving alternatives. Maintain evidence-based formularies across multiple payers. Conduct retrospective DUR and prepare stakeholder reports. Qualifications: PharmD with managed care, DUR, or pharmacy benefit experience. Strong Excel/data analytics background preferred. Understanding of clinical guidelines and P&T processes. Why Join Us? Join a top-tier managed care team Hybrid flexibility Strategic and data-driven focus

Lucid Staffing Solutions is seeking a travel nurse RN Case Management for a travel nursing job in Boston, Massachusetts. Job Description & Requirements Specialty: Case Management Discipline: RN 40 hours per week Shift: 8 hours, days Employment Type: Travel We're looking for a Travel Registered Nurse (RN) ready to make a meaningful impact while enjoying top-tier pay, and a support system that truly understands your journey. Location: Boston, Massachusetts Shift: 8hr Days At Lucid Staffing Solutions, we were founded by healthcare travelers who know first hand the challenges you face. That's why we provide a stress-free, transparent, and honest approach to travel healthcare. Why Choose Lucid? High Pay & Flexible Packages - You'll always know what you're earning and why. Weekly Direct Deposits - Every Friday without fail. Housing & Meals Stipends - Structured up to the maximum GSA.gov limits whenever possible. Stress-Free Compliance - We handle health screens and immunizations; just show up! Travel Reimbursement - $500 upfront for every assignment. Referral Bonuses - $500 per referral, $750 after 5 referrals. Insurance Options - Choose from 4 health plans plus dental, vision, and worker's compensation. 401(k) Match - 4% match to secure your future. Vested after only 6 months. License & Certification Reimbursement - We cover everything you need to stay compliant. Professional Liability Insurance - Always have peace of mind. At Lucid, we believe in honesty, transparency, and providing all the tools you need to succeed. No hidden fees or surprises-just clear communication and unmatched support. What we are looking for: Actively working as Registered Nurse (RN) Licensed in Massachusetts or compact licensure. Minimum of 1-2 years of recent experience in Case Management Ability to adapt quickly to new environments and maintain high patient care standards. Join a team built on understanding and integrity. We're here to make your travel career as rewarding as possible. Apply now to become part of the Lucid Traveler Team! Lucid Staffing Solutions Job ID #17734541. 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: Registered Nurse (RN):Case Management,07:00:00-15:00:00 About Lucid Staffing Solutions Clinician Owned & Operated At Lucid Staffing Solutions, we do things differently-because we've been in your shoes. Founded by actual healthcare professionals, Lucid was built to fix the issues we experienced as travelers. We know what makes a great assignment: competitive pay, seamless onboarding, honest recruiters, and most importantly-working with a team that truly sees and supports you. Our entire team is made up of former clinicians who understand the demands of the job and what travelers truly need to succeed. We offer some of the highest paying allied health and nursing contracts across the country, along with some amazing benefits & perks. Whether you're chasing freedom, flexible schedules, bigger paychecks, or your next adventure, Lucid helps you get there-with real support, real respect, and real healthcare experts. Benefits Dental benefits Medical benefits Vision benefits

Behavioral Health Community Partnership (BHCP) Nurse Case Manager Department: Social Services Supervisor: Director of Nursing Status/Hours Per Week: Non-exempt / 35 hours Pay Range: The expected base pay for the position is $36-$65.02 per hour and may be increased based on other factors, such as language, certifications, etc. Primary Function: The Behavioral Health Community Partnership Nurse Case Manager [BHCP RN Case Manager] functions under the supervision of the Director of Nursing and overall guidance and consultation with the Medical Director and other Primary Care Providers to conduct patient monitoring, tracking, and provide ongoing care coordination and support to patients with behavioral health issues that are enrolled in BHCP. The BHCP RN Case Manager ensures patients' adequate linkages with behavioral health counseling, all levels of substance use care, including medication assisted treatment, and chronic pain management care. Duties & Responsibilities: * Receive and maintain a log of all patients enrolled in BHCP, and ensure adequate follow up and care coordination. * Serve as Clinical Care Manager for enrollees referred to the team, participating in the assessment, care planning, and on-going BHCP service provision specified in program protocols and policies. * Review and approve Comprehensive Health Assessments for members including performing medication reconciliations. * Make patient referrals to behavioral health, and human services providers at the Health Center for needed services such as primary care and other substance use and mental health care. * Make "warm handoffs" and coordinate support to needed services at external organizations including hospitals, substance use treatment programs, etc. * Follow up with members post-discharge to ensure members are seen by a Primary Care provider in a timely manner. * Monitor and track patients including progress in their treatment plan and update PCPs and other members of the team. * Participate in multi-disciplinary team meetings, utilization review, and program planning. * Participate in consultation, sharing of resources and best practices with other Riverside Community Partner teams.

The Community Clinical Liaison performs a key role in the generation of referrals to HSL Home and Community Based Services with primary focus on Home Health and Hospicereferral generation. This role serves as the entry point for patients into home-based services and has direct impact on the evolving needs of the elders served and the satisfaction of the patient and their family and caregivers with the services provided. The Community Clinical Liaison is responsible for initiating and establishing relationships that result in referrals from hospitals, post-acute facilities, physician practices and assisted living communities by ensuring coordination of care transitions to HSL Home Care and Hospice. The Community Clinical Liaison enhances continuity of patient care by providing liaison between assigned locations (SNFs, RSUs ALs and other), physicians, and home care agency. The Community Clinical Liaison screens patients at hospitals and SNFs that are referred to HSL Home Care and Hospice. The Community Clinical Liaison serves as community educator by attending networking events and vendor fairs and serving as a resource about supportive services available in the home. Position Responsibilities Include: Transfers Patients from facility to HCBS service lines that include home health and hospice services by establishing and maintaining relationships with nurses, case managers, social services, physical and occupational therapy, and other support services. Provide clinical liaison services to the Rehabilitation Services Unit (RSU) at both the Hebrew Rehab Center and New Bridge. These services will be provided primarily via e-mail and telephone but may be via virtual conference and in person as needed. Track patient census on RSUs and communicate to case managers all potential referrals to HSL Home Care based on patient care needs, care address, and insurance. Review Patient PING and update home care staff when a current patient is hospitalized and transferred to a rehabilitation facility; act on and resolve PINGS. Update Home Care Hospitalized Patient List with information obtained from PING, housing sites, home care staff and discharge planners. Provides all necessary information concerning home care/hospice intake coordination and provides input related to clinical concerns for individual patients. Resolves patient care issues by working one-on-one with Patient Care Managers to standardize patient home care assessments; collecting relevant information; conferring with co-care givers; assessing patient home care needs in person, telephonically or remotely as warranted. Keeps facility and attending physician informed of patient status by monitoring and reporting home care services rendered and/or modified; following up on patient reports and other patient information; anticipates additional home care services needed, i.e. wound therapy, physical therapy, social work and/or other specialties. Promotes effective written/verbal communication daily. Gives accurate information to patients and or families regarding home care and related issues. Serves and protects home care/hospice by adhering to professional standards, policies and procedures, federal, state, and local requirements, and professional and licensing standards. Promotes education for patients, their families and the community. Assists in intake process by entering as much documentation as possible regarding patients transfer to home care/hospice Functions as a member of the Intake team as requested. Updates job knowledge by participating in educational opportunities. Serves as a resource and support to patients. Identifies and responds to safety concerns of patients. Maintains compliance with policies, procedures, and regulatory matters. Promotes and maintains an agency environment that is in compliance with federal, state, and local regulatory agencies. Participates in personal and professional growth and development including staff meetings and in-service education. Communicates with patients, families, and other health professionals in a manner that conveys respect, caring, and sensitivity. Contributes to HCBS program effectiveness by identifying short-term and long-range issues that must be addressed; providing information and commentary pertinent to deliberations; recommending options and courses of action; implementing directives Enhances HCBS service reputation by accepting ownership for accomplishing new and different requests; exploring opportunities to add value to job accomplishments. Provides information by responding to queries of hospitals, nursing homes, attending physicians and their practice staffs, sorting and distributing messages and documents; answering questions and requests; preparing statistical reports related to referral and intake activities from assigned locations maintaining databases and entering referral/network contact information into Matrix Care system or other systems. Educates assigned location teams by attending team and community meetings; providing orientation/in-service programs concerning home care intake coordination and hospital relations; providing input relating to clinical concerns for individual patients. Reflects the cultural Belief of Teaming Up with HSL peers including Intake Coordinators and housing site supportive staff to optimize patient transitions. Performs other duties and activities as delegated by the Hospice and Home Health Clinical Managers and the Senior Director, Home and Community-Based Services (HCBS). Markets HCBS services to HSL housing sites, hospitals, physician groups, ALFs, senior centers and at vendor fairs in person and virtually. As requested by hospitals or rehabs screen patients for HSL Home Care and Hospice and or attend family meetings in person with appropriate personal protective equipment. Attends networking events as requested virtually and in person as warranted. Provide succinct update as able to HSL Housing Site Supportive Staff (Social Workers and R3 team) regarding hospitalized residents as needed and able. Attend Supportive Service Meetings with HSL Housing site teams. Qualifications: Two years Community-Based Healthcare experience strongly preferred. Home Health and Hospice Liaison experience preferred. Clinical License preferred. Current License with Massachusetts of related field Healthcare sales experience with a proven track record. Good verbal and written communication skills and the ability to develop and maintain strong relationships Must be motivated to learn and flexible to change. Computer literacy required. Must be able to work independently. Remote Type Salary Range: $84,971.00 - $127,458.00

The Guild utilizes the collaborative efforts of leading professionals, best-practice approaches, tailored curricula and unmatched care to treat the individuals we serve. Mission: The mission of The Guild for Human Services is to educate, encourage and empower individuals with intellectual disabilities so they may achieve their full potential to lead high-quality lives and participate meaningfully in the community. At The Guild you can join a workforce of creative, dedicated, and passionate employees working every day to enhance the lives of youth and adults with intellectual disabilities and other challenges. Summary: Nurse Case Manager acts as a committed member of a multi-disciplinary team to help create and maintain goals of health & wellness for an assigned group of students. Primary Job Responsibilities: * The Nurse Case Manager/ Registered Nurse acts as Nurse Consultant for assigned Group Home students. * Monitor the health and safety issues within all locations of the school and residence. * Provide staff training to ensure optimal health and safety standards. * Provide staff training pertinent to health and safety needs, medical conditions, medical diagnosis and treatment plans. * Assist in scheduling laboratory testing and medical appointments and participates in health examinations as indicated. * Maintain medical records including documentation of treatment and medication administration of students. * Communicate with outside agencies and physicians as necessary. * Complete initial and annual medical assessments for students. * Complete annual Individual Health Plans and quarterly assessments. * Monitor, plan for, and communicate with the team regarding medical appointments, medical issues and other health related matters. * Communicate with outside agencies, physicians and parents/guardians. * Participate in designated team meetings and case reviews for students. * Monitoring Medication systems in residences and school. * Ensure timely submission of Medication Error Reports. * Assess certified staff medication administration competence . * Provide medical on-call coverage at minimum one week monthly * Able to attend training as required * Other related duties as assigned Essential Job Functions * Regular attendance at work is an essential function of the job including inclement weather situations * Physical and mental capacity to work in stressful situations and de-escalate individuals who have limited cognition and complex needs * Proficiency in written and spoken English is an essential function of the job. * Excellent organization and time management skills * Pass Guild Driving test to access Guild vehicles for transportations of individuals. * Must be able to implement crisis intervention techniques as necessary, including Nonviolent Crisis Intervention (via certification through CPI) * Registered Nurses who have an associate's degree (bachelor's preferred) with 2 years Nursing experience * Preference for additional training specific to nursing practice, such as CDDN * Knowledge of Massachusetts regulatory standards is required with preferred experience in regulatory compliance with standards from Department of Developmental Services (DDS) and Department of Public Health (DPH) * Undergo a background check process * Proficiency in Microsoft Office Suite

Full-time, Part-time Description Job Title: Wellness Nurse Hours: Per Diem The Resident Care Nurse is responsible for assisting the Resident Care Director with the overall implementation, delivery and coordination of Resident Care services at the Community. Nurse will also assist in monitoring the medication management program. Duties and Responsibilities: The following essential functions are the fundamental job duties of the position to be completed with or without appropriate reasonable accommodation. • Assist in supervising the medication program and assisting the residents with self-administration of their medication. • Assist residents with Activities of Daily Living and Independent with Activities of Daily Living as needed. • Maintain positive relations with residents, families and physicians. • Report any significant incidents and/or changes in the residents needs to the Executive Director/Resident Care Director. • Assist in the completion of resident assessments and services plans. • Assist in the training of assisted living staff and participates in orientation of new staff. • Attend and participates in scheduled in-service programs, training programs and staff meetings. • Assist with scheduling and staffing of Resident Care Assistants • RN will maintain GAFC. • May perform other duties as assigned. Requirements Minimum Qualifications: • Registered Nurse/Licensed Practical Nurse/Licensed Vocational Nurse with a current license in good standing. • Certification or licensed per state guidelines. • Must successfully complete all HallKeen • Community specified training programs. • Able to apply common sense understanding to carry out detailed but uninvolved written or oral instructions. Able to deal with problems involving a few concrete variables in standardized situations. • Able to work various schedules and shifts as needed. • Required Behavior: • Appearance is neat, clean, and according to dress code. • Able to demonstrate a high level of service delivery; does what is necessary to ensure customer satisfaction; deals with service failures and prioritizes customer needs. • Able to clearly present information through the spoken word; reads and interprets complex information; talks with residents, family members and customers; listens well. • Able to communicate with others in a warm and helpful manner while simultaneously building credibility and rapport. • Able to work cooperatively with a group of people to achieve goals and objectives. • Able to be tactful; maintains confidences, and fosters an ethical work environment; prevents inappropriate behavior by coworkers; gives proper credit to others; handles all situations honestly. • Able to keep an open mind and change opinions on the basis of new information; performs a variety tasks and changes focus quickly as demands change; manages transitions effectively from task to task; adapts to varying customer needs. Physical Demands: • Physically able to move at least 50 lbs. without assistance. • Physically able to bend, reach, and work in small areas. • Physically able to push and pull equipment and furnishings. • Physically able to stand for long periods of time.

When you join the growing BILH team, you're not just taking a job, you're making a difference in people's lives.Reisman 12 is an inpatient Surgery unit caring for Plastics and Reconstructive Surgery, ENT Surgery, Breast Surgery, and Colorectal surgery patients. We pride ourselves in providing the highest level of care possible and a great work environment.The BIDMC Nursing Mission is to build on a legacy of nursing excellence by caring with compassion, advancing the art & science of nursing, and advocating for the health of patients, families, and communities. The Clinical Nurse I utilizes the nursing process as the frame of reference for practice as a professional registered nurse and provides direct patient care to patients and families. This is an entry-level nursing position for new graduate nurses. Training, evaluation and competencies for this role are overseen by a Nurse Leader to the department.As a Clinical Nurse I, you will automatically enroll in our Transition to Practice: Nurse Residency Program. This program consists of a 12-month curriculum designed to complement and enhance your unit-based, precepted clinical orientation. Together, these elements empower newly licensed nurses to successfully transition into clinical practice, using a structured, evidence-based approach. The curriculum is a blend of monthly seminars in a classroom setting and hands-on precepted work experiences. The monthly seminar sessions are presented by expert facilitators that will help you develop critical thinking skills and hone your clinical competence. Didactic presentations are blended with opportunities for you to reflect on your clinical experiences and receive feedback and guidance as you chart your professional growth.Job Description:Essential Responsibilities: Provides direct care to patients and makes necessary nursing judgments. Responsible for systematically assessing the health care needs of individuals or groups and for the formulation of a care plan, its implementation and evaluation. Demonstrates the ability for decision making by integrating theoretical knowledge with practical experience in caring for patients.Coordinates the care of patients and directs assistive personnel in order to provide safe, effective, efficient, equitable and timely, patient-centered care. Demonstrates initial awareness of environmental forces on health care of patients and their families. .Develops a collegial and collaborative relationship with other health professionals to determine healthcare needs of patients and families. Learns to develop relationships with patients and families that maintain and communicate trust and respect. Communicates effectively in the exchange of information. Begins to demonstrate the ability to act as a patient advocate Maintains annual mandatory education requirements, which include emergency skills and unit based competencies. Identifies needs for continued growth and development in conjunction with the unit based educator or clinical nurse specialist.Demonstrates a commitment to patients, staff, and to Beth Israel Deaconess Medical Center. The individual nursing practice reflects the goals of the Medical Center. Demonstrates responsibility and accountability for own nursing practice and patient safety Required Qualifications:Bachelor's degree in Nursing required. License Registered Nurse required., and Certificate 1 Basic Life Support required.0-1 years related work experience required.American Heart Association - Basic Life Support CertificateBasic familiarity with computers. Ability to navigate at a basic level within web-based applications.Competencies:Decision Making: Ability to make decisions that are guided by general instructions and practices requiring some interpretation. May make recommendations for solving problems of moderate complexity and importance.Problem Solving: Ability to address problems that are varied, requiring analysis or interpretation of the situation using direct observation, knowledge and skills based on general precedents.Independence of Action: Ability to follow precedents and procedures. May set priorities and organize work within general guidelines. Seeks assistance when confronted with difficult and/or unpredictable situations. Work progress is monitored by supervisor/manager.Written Communications: Ability to summarize and communicate in English moderately complex information in varied written formats to internal and external customers.Oral Communications: Ability to comprehend and communicate complex verbal information in English to medical center staff, patients, families and external customers.Knowledge: Ability to demonstrate full working knowledge of standard concepts, practices, procedures and policies with the ability to use them in varied situations.Team Work: Ability to work collaboratively in small teams to improve the operations of immediate work group by offering ideas, identifying issues, and respecting team members.Customer Service: Ability to provide a high level of customer service to patients, visitors, staff and external customers in a professional, service-oriented, respectful manner using skills in active listening and problem solving. Ability to remain calm in stressful situations.Age based Competencies: Employees in this job must be competent to provide patient care to the following age groups: Neonatal:Birth to 6 months, Young adult: 16-30 years, Middle Age: 30 - 60 years, Elderly: 60 -.Physical Nature of the Job:Medium work: Exerting up to 50 pounds of force occasionally and or up to 20 pounds of force frequently. Job is physical in nature and employee needs to stand and/or move around through the majority of their shift. Pay Range: $38.00 - $98.19The pay range listed for this position is the base hourly wage range the organization reasonably and in good faith expects to pay for this position at this time. Actual compensation is determined based on several factors, that may include seniority, education, training, relevant experience, relevant certifications, geography of work location, job responsibilities, or other applicable factors permissible by law. Compensation may exceed the base hourly rate depending on shift differentials, call pay, premium pay, overtime pay, and other additional pay practices, as applicable to the position and in accordance with the law.As a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) as a condition of employment.More than 35,000 people working together. Nurses, doctors, technicians, therapists, researchers, teachers and more, making a difference in patients' lives. Your skill and compassion can make us even stronger.Equal Opportunity Employer/Veterans/Disabled

Site: Mass General Brigham Health Plan Holding Company, Inc. Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham. Job Summary The UMCM will utilize clinical knowledge to analyze, assess, and render approval decisions, to determine the need for physician review as well as complete determinations following physician review. The ideal candidate will have prior authorization (outpatient review) experience in a managed care setting with Medicaid/MassHealth knowledge. Principal Duties and Responsibilities: * Expertise in clinical review for prospective, concurrent, retrospective utilization management reviews utilizing Interqual , company policies and procedures, and other resources as determined by review, including physician reviews as needed for all lines of business as per departmental needs * Review authorization requests for medical services, including making initial eligibility and coverage determinations, screening for medical necessity appropriateness, determining if additional information is required, and referral to correct programs within Mass General Brigham Health Plan as needed. * Manage incoming requests for procedures and services including patient medical records and related clinical information. * Strong working knowledge of commercial, self-insured, fully insured and limited network plans. * Adherence to program, departmental and organizational performance metrics including productivity. * Excellent verbal and written communication skills. * Excellent problem solving and customer service skills. * Would need to be available for "on call" for a minimum of once per month with the possibility of that increasing depending on staff availability; Approximately 6 months after hire. * Must be self-directed and highly motivated with an ability to multi-task. * Develop and maintain effective working relationships with internal and external customers * Hold self and others accountable to meet commitments. * Sound decision-making and time management skills. * Proactive in areas of professional development, personally and for the department. * Persist in accomplishing objectives to consistently achieve results despite any obstacles and setbacks that arise. * Build strong relationships and infrastructures that designate Mass General Brigham Health Plan as a people-first organization. * Proficient with Microsoft Word, Excel, Outlook, McKesson InterQual , Outlook, SharePoint, PC based operating system, and web-based phone system. Qualifications Education * Associate's Degree Nursing required or Bachelor's Degree Nursing preferred Licenses and Credentials * Massachusetts Registered Nurse (RN) license required Experience * At least 2-3 years of utilization review experience is highly preferred * Experience using Interqual or Milliman is highly preferred * At least 1-2 years of experience in a payer setting is highly preferred * At least 1-2 years of experience in an acute care setting is highly preferred Knowledge, Skills, and Abilities * Demonstrate Mass General Brigham Health Plan's core brand principles of always listening, challenging conventions, and providing value * Strong aptitude for technology-based solutions. * Embrace opportunities to take the complexity out of how we work and what we deliver. * Listen to our constituents, learn, and act quickly in our ongoing pursuit of meaningful innovation * Current in healthcare trends. * Ability to inject energy, when and where it's needed. * Exercise self-awareness; monitor impact on others; be receptive to and seek out feedback; use self-discipline to adjust to feedback. * Be accountable for delivering high-quality work. Act with a clear sense of ownership. * Bring fresh ideas forward by actively listening to and working with employees and the people we serve. * Communicate respectfully and professionally with colleagues * Strong EQ; exercises self-awareness; monitors impact on others; is receptive to and seeks out feedback; uses self-discipline to adjust to feedback. Additional Job Details (if applicable) Working Conditions * Would need to be available for "on call" for a minimum of once per month with the possibility of that increasing depending on staff availability; Approximately 6 months after hire. * This is a remote role with occasional onsite team meetings in Somerville, MA. Remote Type Remote Work Location 399 Revolution Drive Scheduled Weekly Hours 40 Employee Type Regular Work Shift Day (United States of America) Pay Range $58,656.00 - $142,448.80/Annual Grade 98TEMP At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package. EEO Statement: 8925 Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran's Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at **************. Mass General Brigham Competency Framework At Mass General Brigham, our competency framework defines what effective leadership "looks like" by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.

Ready to help us transform healthcare? Bring your true colors to blue. BCBSMA is seeking a new Dental Utilization Reviewer to join our elite Dental Utilization Management Division! Our dental utilization management team reviews certain types of procedures for quality of care, necessity, and appropriateness of treatment based on the documentation submitted. The team includes dentists, dental hygienists, and dental assistants. Based on a review of the submitted procedure documentation, our dental consultants determine available benefits for certain types of procedures, including, but not limited to, cast and milled restorations, periodontal services, oral surgery services, and fixed and removable prosthetics. A dental consultant reviews the treatment plan objectively and determines whether the services are within the scope of benefits, and whether these services appear to be necessary and appropriate for the member. Based on these findings, we may determine that a service is not necessary and appropriate for the member, even if a dentist has recommended, approved, prescribed, ordered, or furnished the service. This position is eligible for the following persona(s): eWorker, mobile, resident. RESPONSIBILITIES: * Review and evaluate dental claims and clinical information to determine necessity and appropriateness of services using established dental policy, guidelines and contracts * Flexible decision-making outside of policy and guidelines * Work with dental consultants in the decision-making process * Review/analyze irregular provider utilization patterns and trends and determine appropriate course of action * Effectively communicate final disposition of reviewed claims to internal and external customers * Maintain proficiency in systems and programs * Review processes and make recommendations to management to improve these processes * Monitor utilization savings * Monitor inventory levels and recommend effective inventory reduction plans to management * Assignments as required by leader QUALIFICATIONS: * Demonstrated ability to read and interpret dental radiographs, surgical documentation, treatment notes * Excellent verbal and written communication skills * Ability to work in a fast-paced, detail-oriented work environment under tight timeframes and deadlines * Capacity to work in both a team environment and on individual assignments * Ability to respond to internal customers in a fast-paced environment * Proven problem solver who can work under their own initiative * Proficiency in Microsoft software, Excel, Access * Excellent organizational skills EDUCATION & TRAINING EXPERIENCE: * Minimum 5 years' experience in a dental office environment * MA Registered Dental Hygienist or MA Certified Dental Assistant * Knowledge of industry claims billing process #LI-REMOTE Minimum Education Requirements: High school degree or equivalent required unless otherwise noted above Location Hingham Time Type Full time Hourly Range: $38.40 - $46.93 The job posting range is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee's pay position within the salary range will be based on several factors including, but limited to, relevant education, qualifications, certifications, experience, skills, performance, shift, travel requirements, sales or revenue-based metrics, and business or organizational needs and affordability. This job is also eligible for variable pay. We offer comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees. Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation 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. WHY Blue Cross Blue Shield of MA? We understand that the confidence gap and imposter syndrome can prevent amazing candidates coming our way, so please don't hesitate to apply. We'd love to hear from you. You might be just what we need for this role or possibly another one at Blue Cross Blue Shield of MA. The more voices we have represented and amplified in our business, the more we will all thrive, contribute, and be brilliant. We encourage you to bring us your true colors, , your perspectives, and your experiences. It's in our differences that we will remain relentless in our pursuit to transform healthcare for ALL. As an employer, we are committed to investing in your development and providing the necessary resources to enable your success. Learn how we are dedicated to creating an inclusive and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path by visiting our Company Culture page. If this sounds like something you'd like to be a part of, we'd love to hear from you. You can also join our Talent Community to stay "in the know" on all things Blue. At Blue Cross Blue Shield of Massachusetts, we believe in wellness and that work/life balance is a key part of associate wellbeing. For more information on how we work and support that work/life balance visit our "How We Work" Page.

**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 *************************************************************

Utilization Review Pharmacist Shape the drug benefit landscape-analyze and optimize medication use. Key Responsibilities: Review prescribing trends and propose cost-saving alternatives. Maintain evidence-based formularies across multiple payers. Conduct retrospective DUR and prepare stakeholder reports. Qualifications: PharmD with managed care, DUR, or pharmacy benefit experience. Strong Excel/data analytics background preferred. Understanding of clinical guidelines and P&T processes. Why Join Us? Join a top-tier managed care team Hybrid flexibility Strategic and data-driven focus

Part-time Description Job Title: Wellness Nurse Hours: Part Time 8am to 4pm 24 Hours Per Week The Resident Care Nurse is responsible for assisting the Resident Care Director with the overall implementation, delivery and coordination of Resident Care services at the Community. Nurse will also assist in monitoring the medication management program. Duties and Responsibilities: The following essential functions are the fundamental job duties of the position to be completed with or without appropriate reasonable accommodation. • Assist in supervising the medication program and assisting the residents with self-administration of their medication. • Assist residents with Activities of Daily Living and Independent with Activities of Daily Living as needed. • Maintain positive relations with residents, families and physicians. • Report any significant incidents and/or changes in the residents needs to the Executive Director/Resident Care Director. • Assist in the completion of resident assessments and services plans. • Assist in the training of assisted living staff and participates in orientation of new staff. • Attend and participates in scheduled in-service programs, training programs and staff meetings. • Assist with scheduling and staffing of Resident Care Assistants • RN will maintain GAFC. • May perform other duties as assigned. Requirements Minimum Qualifications: • Registered Nurse/Licensed Practical Nurse/Licensed Vocational Nurse with a current license in good standing. • Certification or licensed per state guidelines. • Must successfully complete all HallKeen • Community specified training programs. • Able to apply common sense understanding to carry out detailed but uninvolved written or oral instructions. Able to deal with problems involving a few concrete variables in standardized situations. • Able to work various schedules and shifts as needed. • Required Behavior: • Appearance is neat, clean, and according to dress code. • Able to demonstrate a high level of service delivery; does what is necessary to ensure customer satisfaction; deals with service failures and prioritizes customer needs. • Able to clearly present information through the spoken word; reads and interprets complex information; talks with residents, family members and customers; listens well. • Able to communicate with others in a warm and helpful manner while simultaneously building credibility and rapport. • Able to work cooperatively with a group of people to achieve goals and objectives. • Able to be tactful; maintains confidences, and fosters an ethical work environment; prevents inappropriate behavior by coworkers; gives proper credit to others; handles all situations honestly. • Able to keep an open mind and change opinions on the basis of new information; performs a variety tasks and changes focus quickly as demands change; manages transitions effectively from task to task; adapts to varying customer needs. Physical Demands: • Physically able to move at least 50 lbs. without assistance. • Physically able to bend, reach, and work in small areas. • Physically able to push and pull equipment and furnishings. • Physically able to stand for long periods of time.

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.