Nursing Jobs in Remote, OR

RN Full-time
Ansible

Case Manager Registered Nurse

Ansible Remote, OR
Overview Ansible Government Solutions, LLC (Ansible) is currently recruiting multiple Remote Registered Nurse Case Managers to support the VA Office of Veterans Community Care. If you accept employment with Ansible, you must also acknowledge that any assigned schedule is subject to change at the direction of either Ansible or its customers. Ansible is a Service-Disabled Veteran-Owned Small Business (SDVOSB) providing Federal customers with solutions in many arenas. Our customers face wide-ranging challenges in the fields of health care, national security, and information technology. To address these challenges, we employ intelligent and committed staff who take care of our customers’ success as if it is their own. Responsibilities Manage SEOC work products, reports, and clinical/operational data analysis. Monitor staff activities for compliance and accountability. Review provider information including specialty and NPI. Validate Veteran demographic information and authorization details. Review approved service codes and ensure alignment with authorized care. Interpret SEOC narrative requirements, referral limitations, and follow-up care parameters. Create reports, presentations, white papers, and support meetings/workgroups. Qualifications Bachelor of Science in Nursing (BSN) from an accredited nursing program. Current, full, active, and unrestricted Registered Nurse (RN) license in a U.S. state, territory, commonwealth, or the District of Columbia Nurse III/IV level experience No sponsorship available All candidates must be able to: Sit, stand, walk, lift, squat, bend, twist, and reach above shoulders during the work shift Lift up to 50 lbs from floor to waist Lift up to 20 lbs Carry up to 40 lbs a reasonable distance Push/pull with 30 lbs of force All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.
RN Telehealth Full-time
HealthEdge

UM RN

HealthEdge Remote, OR
Overview: HealthEdge® offers AI-powered operational infrastructure for health insurance companies, guaranteeing an enduring financial edge in an increasingly competitive market. We're experiencing strong market momentum, with a growing number of health plans choosing HealthEdge to modernize their operations and compete more effectively. As we expand, we're investing in the people who power that growth, making this a pivotal moment to join us and shape the future of healthcare technology. Learn more at HealthEdge.com. You Are: HealthEdge is searching for a highly motivated Utilization Review RN to join our team. As a Utilization Review RN, you will perform prospective, concurrent and retrospective review of inpatient, outpatient, ambulatory and ancillary services to ensure medical necessity, appropriate length of stay, intensity of service and level of care, including appeal requests initiated by providers, facilities and members. May establish care plans and coordinate care through the health care continuum including member outreach assessments. The Opportunity: Review, research and authorize requests for authorization of elective, direct, ancillary, urgent, emergency, etc. services. Contact appropriate medical and support personnel to identify and recommend alternative treatment, service levels, length of stays, etc. using approved clinical protocols. Analyze, research, respond to and prepare documentation related to retrospective review requests and appeals in accordance with local, state and federal regulatory and designated accreditation (e.g. NCQA) standards. Establish, coordinate, and communicate discharge planning needs with appropriate internal and external entities. Analyze patterns of care associated with disease progression; identify contractual services and organize delivery through appropriate channels. Research and resolve issues related to benefits, member eligibility, non-elective and non-authorized services, coordination of benefits, care coordination, etc. Identify and document quality of care issues; resolve or route to appropriate area for resolution. Follow out-of-area/out-of-network services and make recommendations on patient transfer to in-network services and/or alternative plans of care. Develop and deliver targeted education for provider community related to policies, procedures, benefits, etc. As needed and in conjunction with Provider Services, may identify and negotiate reimbursement rates for non-contracted providers for services. Other duties may be assigned based on designated department assignment Qualifications: Registered Nurse with current unrestricted Registered Nurse license required. Certification in Case Management may be preferred based upon designated department assignment. Certification or progress toward certification is highly preferred and encouraged. Minimum of 2 years’ clinical experience which may include acute patient care, discharge planning, case management, and utilization review, etc. Demonstrated clinical knowledge and experience relative to patient care and health care delivery processes. Minimum 1 year health insurance plan experience or managed care environment preferred. Skills & Competencies: Excellent written and verbal communication skills. Excellent customer service and interpersonal skills. Working knowledge of current industry Microsoft Office Suite PC applications. Ability to apply clinical criteria/guidelines for medical necessity, setting/level of care and concurrent patient management. Knowledge of current standard medical procedures/practices and their application as well as current trends and developments in medicine and nursing, alternative care settings and levels of service. Knowledge of policies and procedures, member benefits and community resources. Knowledge of applicable accreditation standards, local, state and federal regulations. Other related skills and/or abilities may be required to perform this job based upon designated department assignment. Geographic Responsibility: Remote, US Type of Employment: Full-time, permanent Work Environment: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job: The employee is occasionally required to move around the office. Specific vision abilities required by this job include close vision, color vision, peripheral vision, depth perception, and ability to adjust focus. Work across multiple time zones in a hybrid or remote work environment. Long periods of time sitting and/or standing in front of a computer using video technology. May require travel dependent on company needs. The above statements are intended to describe the general nature and level of the job being performed by the individual(s) assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities, and skills required . HealthEdge reserves the right to modify , add, or remove duties and to assign other duties as necessary. In addition, reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position in compliance with the Americans with Disabilities Act of 1990 . Candidates may be required to go through a pre-employment criminal background check. HealthEdge is an equal opportunity employer. We are committed to workforce diversity and actively encourage all qualified persons to seek employment with us, including, but not limited to, racial and ethnic minorities, women, veterans and persons with disabilities.
NP Outpatient Telehealth Outpatient Full-time
MedStar Health

Primary Care Telemedicine Nurse Practitioner - MedStar Health

MedStar Health Remote, OR
$105,000 - $115,000 / year
About this Job: Remote Opportunity! Nurse Practitioner in Connected Primary Care Telemedicine - MedStar Health MedStar Health offers a uniquely rewarding career in a major marketplace. Shape your future in health care in the kind of setting that’s right for you and your practice. Become part of an organization that welcomes your experience and input — as a clinician and healthcare expert. We are looking for Nurse Practitioners with at least 3 years of primary care experience to join MedStar’s growing telemedicine services in Connected Primary Care. In this position you will work remotely and will see new and returning patients to MedStar Health via our telehealth platform for patients who wish to establish primary care, and for patients seeing acute/follow up care. This program promotes a team-based approach to care, working in conjunction with our other primary care team members, through centralized results monitoring for patients. This program improves patient access to a clinician and facilitates care within the MedStar system. This is a fully remote clinical position in Telemedicine. Nurse Practitioners must currently be licensed in DC, Maryland and Virginia. Providers must be located in the DC/MD/VA area. As a MedStar Medical Group clinician, you can expect: A very competitive salary Opportunity for Incentive bonuses Medical, dental and vision insurance Paid occurrence-based malpractice insurance Generous paid time off CME leave and an annual $3,000 CME allowance Retirement plan options with employer % match Access to a provider concierge service for work/life services Employer paid life insurance for 1X salary Employer paid STD and LTD Access to Care.com Be a part of a nationally-recognized health system and the largest provider of health services in the Baltimore/Washington region. With our vast resources and capabilities at your disposal, you can expand your clinical expertise. Enjoy a rich career and a quality of life unique to the Mid-Atlantic region, which features a mix of urban, suburban and rural communities. Qualifications: Completion of a Master of Science in Nursing or Doctor of Nursing Practice program 3+ years' experience in primary care Pass national certification exam Be the provider you were meant to be, here at MedStar. MedStar Health is the largest health system in the region, with 30,000 associates, working at 10 hospitals, hundreds of ambulatory care sites – all together more than 700 access points of care, covering more than 225 zip codes in 17 counties. We are also ranked among the “Best Places to Work” by Baltimore magazine, Baltimore Business Journal, and Washington Business Journal This position has a hiring range of : USD $105,000.00 - USD $115,000.00 /Yr.
LPN Utilization Review Telehealth Full-time
Personify Health

Utilization Review Nurse I LVN/LPN

Personify Health Remote, OR
$25 - $30 / hour
Overview: Who We Are Because health is personal. That's why Personify Health created the first and only personalized health platform—bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one place. We serve employers, health plans, and health systems with data-driven solutions that reduce costs while actually improving health outcomes. Together, our team is on a mission to empower people to lead healthier lives. Learn even more about the work that drives us at personifyhealth.com. Responsibilities: Ready to make sure every member gets the right care at the right time? Why This Role Matters Behind every prior authorization and inpatient stay is a member waiting on a decision, and you’re the one who makes sure that decision is timely, accurate, and grounded in evidence. As a Level I Utilization Management Nurse, you review requests for medical necessity, level of care, and benefit coverage, then apply clinical guidelines and plan policies to keep care appropriate and compliant. Your sharp review work protects members from delays and unnecessary services, supports providers who need clear answers, and keeps our programs ready for URAC and NCQA scrutiny. When your reviews are thorough, well-documented, and delivered on time, our whole organization earns the trust of the members and sponsors who rely on us. Schedule: Monday–Friday, 8:00 AM–5:00 PM Pacific Time, with rotating Saturday coverage as required. What You’ll Actually Do Perform clinical reviews that drive sound determinations: Evaluate requests for medical necessity, appropriate level of care, documentation completeness, and benefit coverage, so members get timely decisions that meet compliance standards. Deliver first-level review across care settings: Review outpatient and ancillary pre-certification and prior authorization requests, inpatient stays (including behavioral health, substance use, skilled nursing, and rehabilitation), and post-service or post-claim reviews as assigned. Apply guidelines in the right hierarchy: Use internal medical policies, group-specific policies, NCCN, and MCG as applicable, and record your criteria and policy rationale in the UM system so every decision stands on solid ground. Escalate the cases that need advanced eyes: Refer requests that fall outside guidelines, fail to meet criteria, or may require adverse determination to senior staff or the Medical Director, and support IRO referrals in line with policy and jurisdictional requirements. Verify benefits and guide members in-network: Review plan documents to support benefit determinations, and redirect providers and members to PPO or in-network options when it fits plan requirements. Build audit-ready case summaries: Prepare clear, complete documentation for Medical Director review, including adverse determination and IRO referral pathways, so every case holds up under scrutiny. Hit productivity, quality, and turnaround targets: Meet established standards, take part in quality activities like inter-rater reliability (IRRA), and apply feedback to keep us audit-ready for URAC, NCQA, and other applicable standards. Protect member privacy at every step: Follow HIPAA and minimum-necessary standards, and complete required annual training and testing on time. Cross-train and cover where the team needs you: Step in to support team operations and service-level commitments, and contribute to staff training as appropriate. Qualifications: What You Bring to Our Team Education & Experience: Graduate of an accredited nursing program (LVN/LPN) Current, unrestricted U.S. or U.S. territory nursing license (compact license acceptable where applicable) Minimum 1-2 years of recent clinical experience in acute care, med-surg, ICU/ED, or another relevant setting Prior utilization review or utilization management experience preferred Technical Skills: Ability to interpret medical records and apply evidence-based criteria and plan medical policies Working knowledge of clinical guidelines such as MCG and NCCN, and UM documentation systems Proficiency with Microsoft Word, Excel, Outlook, and Teams, with the ability to learn additional tools as assigned Comfort working across multiple screens and a headset-based phone system, with proficient typing and accurate data entry Ability to use remote-work technology (e.g., VPN) and departmental platforms (e.g., SharePoint/Drives) in line with security policies Benefits The Highlights: Competitive base salary and benefits effective day one Comprehensive medical and dental through our own health solutions (yes, we use what we build) Paid Time Off—rest and recharge time is non-negotiable Mental health support, retirement planning, and financial protection Professional development with clear career progression and learning budgets Mission-driven culture where diverse perspectives drive real impact on people's health Want the full picture? Visit personifyhealthbenefits.com to explore our complete benefits package, wellness programs, and other employee perks. Compensation: This position offers a base salary range of $25-$30 per hour, depending on location, skills, and experience. You're eligible for our full benefits package starting day one. Our Commitment: Personify Health is an equal opportunity employer committed to diversity, equity, inclusion, and belonging. We cultivate a work environment where differences are celebrated, and employees of all backgrounds are empowered to thrive—because diversity is core to who we are and critical to our work in health and wellbeing. Stay Safe: Personify Health will never ask for payment or sensitive personal information like social security numbers during hiring. All official communication comes from verified company email addresses and or our secure applicant tracking system. Suspicious requests? Report them to talent@personifyhealth.com . View all legitimate openings at personifyhealth.com/careers .
RN Telehealth Full-time
Personify Health

Case Manager Nurse RN

Personify Health Remote, OR
$34 - $36 / hour
Overview: Who We Are Because health is personal. That's why Personify Health created the first and only personalized health platform—bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one place. We serve employers, health plans, and health systems with data-driven solutions that reduce costs while actually improving health outcomes. Together, our team is on a mission to empower people to lead healthier lives. Learn even more about the work that drives us at personifyhealth.com. Responsibilities: Ready to be the difference between a confusing diagnosis and a clear path forward? Why This Role Matters When someone gets a diagnosis that turns their world upside down, they need more than a claim number — they need a person who can guide them through it. As a Case Manager RN, you're that person: the clinical expert who assesses the whole picture, builds a real treatment plan, and stays connected with patients, providers, and families through every step of care. Your work directly shapes whether a member gets the right care at the right time, and whether costs stay manageable for the plans and employers who depend on us. This isn't administrative case tracking — it's clinical judgment applied to real people navigating some of the hardest moments of their lives. The outcomes you drive, case by case, are what make cost-effective, high-quality healthcare possible at scale. What You'll Actually Do Assess the whole patient: Contact patients directly and complete thorough assessments covering physical, psychosocial, emotional, spiritual, environmental, and financial needs to build a full clinical picture. Mine claims data for insight: Use claims processing tools to review paid claim data, identifying members who need case management or would benefit from specific programs. Build individualized treatment plans: Develop treatment plans for standard and catastrophic cases in collaboration with patients, caregivers, community resources, and multi-disciplinary providers, setting clear short- and long-term goals. Track outcomes and adjust course: Monitor interventions, evaluate treatment plan effectiveness in real time, and report measurable outcomes that show what's actually working. Stay connected across the care team: Maintain ongoing contact with patients, families, providers, employers, and the broader care team throughout the full continuum of care. Advocate for the patient: Facilitate access to quality care, help reduce overall costs, and provide direct emotional support and guidance to patients and families navigating difficult diagnoses. Drive cost management strategies: Negotiate and implement cost management approaches that improve outcomes, then reflect that impact in monthly case management reviews and cost avoidance reports. Perform utilization review: Conduct utilization review for assigned members to ensure care aligns with clinical need and plan guidelines. Connect members to wellness resources: Evaluate patient needs and make referrals into wellness programs when appropriate. Maintain airtight documentation: Keep complete, confidential documentation in Eldorado and UM Web, preparing reports at 30-day intervals for high-risk cases and 90-day intervals for low-risk cases, per Company policy and HIPAA. Mentor LVN colleagues: Serve as a clinical resource for LVNs, guiding them through complex cases and clinical decision-making. Qualifications: What You Bring to Our Team Education & Experience: Graduate of an accredited Registered Nursing (RN) program Current California RN license required; multi-state license also required Minimum of 5 years medical/surgical or acute care experience, including 2 years in case management, or an equivalent combination of education and experience Prior case management, emergency room, critical care, or other relevant clinical experience pertinent to case management Technical Skills: Knowledge of medical claims processing and ICD-10, CPT, and HCPCS coding Ability to critically evaluate claims data to inform treatment and discharge planning Knowledge of community resources and alternate funding programs Proficiency with Microsoft Office Suite Working knowledge of case management platforms such as Eldorado and UM Web Benefits The Highlights: Competitive base salary and benefits effective day one Comprehensive medical and dental through our own health solutions (yes, we use what we build) Paid Time Off—rest and recharge time is non-negotiable Mental health support, retirement planning, and financial protection Professional development with clear career progression and learning budgets Mission-driven culture where diverse perspectives drive real impact on people's health Want the full picture? Visit personifyhealthbenefits.com to explore our complete benefits package, wellness programs, and other employee perks. Compensation: This position offers a base salary range of $34.00-$36.00 per hour, depending on location, skills, and experience. You're eligible for our full benefits package starting day one. Our Commitment: Personify Health is an equal opportunity employer committed to diversity, equity, inclusion, and belonging. We cultivate a work environment where differences are celebrated, and employees of all backgrounds are empowered to thrive—because diversity is core to who we are and critical to our work in health and wellbeing. Stay Safe: Personify Health will never ask for payment or sensitive personal information like social security numbers during hiring. All official communication comes from verified company email addresses and or our secure applicant tracking system. Suspicious requests? Report them to talent@personifyhealth.com . View all legitimate openings at personifyhealth.com/careers .
RN Psych Telehealth Full-time
HealthEdge

UM RN - Behavioral Health

HealthEdge Remote, OR
$65,000 - $85,000 / year
Overview: HealthEdge® offers AI-powered operational infrastructure for health insurance companies, guaranteeing an enduring financial edge in an increasingly competitive market. We're experiencing strong market momentum, with a growing number of health plans choosing HealthEdge to modernize their operations and compete more effectively. As we expand, we're investing in the people who power that growth, making this a pivotal moment to join us and shape the future of healthcare technology. Learn more at HealthEdge.com. Overview: Telephonic coordination and delivery of clinical behavioral health services designed to meet the wellness and recovery needs of the consumer. In addition to performing prospective, concurrent and retrospective review of inpatient, outpatient, ambulatory and ancillary services to ensure medical necessity, appropriate length of stay, intensity of service and level of care, including appeal requests initiated by providers, facilities and members. May establish care plans and coordinate care through the health care continuum. This candidate will utilize clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. RESPONSIBILITIES/TASKS: Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Review, research and authorize requests for authorization of elective, direct, ancillary, urgent, emergency, etc. services. Contact appropriate medical and support personnel to identify and recommend alternative treatment, service levels, length of stays, etc. using approved clinical protocols. Analyze, research, respond to and prepare documentation related to retrospective review requests and appeals in accordance with local, state and federal regulatory and designated accreditation (e.g. NCQA) standards. Establish, coordinate and communicate discharge planning needs with appropriate internal and external entities. Research and resolve issues related to benefits, member eligibility, non-elective and non-authorized services, coordination of benefits, care coordination, etc. Develop and deliver targeted education for provider community related to policies, procedures, benefits, etc. Communicates with providers and other parties to facilitate care/treatment. Identifies members for referral opportunities to integrate with other products, services and/or programs Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function. Other duties may be assigned based on designated department assignment. This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required. EMPLOYMENT QUALIFICATIONS: EDUCATION: Registered Nurse with current unrestricted Registered Nurse license required. Certification in Case Management may be preferred based upon designated department assignment. Continuous learning, as defined by the Company’s learning philosophy, is required. Certification or progress toward certification is highly preferred and encouraged. EXPERIENCE: 2+ years of acute clinical experience as RN required. One (1) year health insurance plan experience or managed care environment preferred. 1+ years Behavioral Health clinical experience 1+ years Managed Care of Utilization Management experience. SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED: Excellent written and verbal communication skills. Excellent customer service and interpersonal skills. Working knowledge of current industry Microsoft Office Suite PC applications. Ability to apply clinical criteria/guidelines for medical necessity, setting/level of care and concurrent patient management. Knowledge of current standard medical procedures/practices and their application as well as current trends and developments in medicine and nursing, alternative care settings and levels of service. Knowledge of policies and procedures, member benefits and community resources. Knowledge of applicable accreditation standards, local, state and federal regulations. Other related skills and/or abilities may be required to perform this job based upon designated department assignment. Geographic Responsibility: Remote, US Type of Employment: Full-time, permanent FLSA Classification (USA Only): Exempt Work Environment: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job: The employee is occasionally required to move around the office. Specific vision abilities required by this job include close vision, color vision, peripheral vision, depth perception, and ability to adjust focus. Work across multiple time zones in a hybrid or remote work environment. Long periods of time sitting and/or standing in front of a computer using video technology. May require travel dependent on company needs. The above statements are intended to describe the general nature and level of the job being performed by the individual(s) assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities, and skills required . HealthEdge reserves the right to modify , add, or remove duties and to assign other duties as necessary. In addition, reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position in compliance with the Americans with Disabilities Act of 1990 . Candidates may be required to go through a pre-employment criminal background check. HealthEdge is an equal opportunity employer. We are committed to workforce diversity and actively encourage all qualified persons to seek employment with us, including, but not limited to, racial and ethnic minorities, women, veterans and persons with disabilities. #LI-Remote ** The annual US base salary range for this position is $65,000 to $85,000 . This salary range may cover multiple career levels at HealthEdge. Final compensation will be determined during the interview process and is based on a combination of factors including, but not limited to, your skills, experience, qualifications and education.
RN Outpatient Outpatient Full-time
MedStar Health

Clinical Nurse II Ambulatory

MedStar Health Remote, OR
$35.68 - $64.71 / hour
About this Job: General Summary of Position Professional care provider who assesses plans implements and evaluates the nursing care of patients from admission through discharge. In collaboration with the patient and family provides theory-based professional nursing care and coordinates care delivery with various members of the interdisciplinary team. Primary Duties and Responsibilities Contributes to the achievement of established department goals and objectives and adheres to department policies procedures quality standards safety standards and MedStar SPIRIT Values. Complies with governmental and accreditation regulations. Collects and analyzes significant patient's information that pertains to physical psychological socio-cultural economic spiritual and life-style behaviors and efficiently leveraging available technology. Functions autonomously providing relationship-based care that promotes continuous consistent efficient and accountable delivery of nursing care using the nursing process with a favorable focus on patient experience. Identifies current and potential complex problems of specific patient populations critically analyzes trends and changes in patient status and plans appropriate interventions. Incorporates evidence-based practice and research into patient care delivery with a focus on quality and safety. Serves as a patient advocate by independently communicating clinical concerns including ethical decisions in a timely manner to other members of the interdisciplinary team Practices within legal boundaries of nurse practice act and possesses a theoretical understanding of the universal ethical principles. Recognizes ethical discourse in practice and may seek other resources in advocacy for support and counsel. Individualizes patients plan of care focusing on short and long-range goals and effectively uses a variety of teaching resources to meet the learning needs of patients and families. Communicates patient information clearly and accurately in verbal and written format. Maintains a safe and therapeutic environment. Identifies actual and potential patient safety issues and acts accordingly while incorporating HRO quality and safety principles. Demonstrates effective leadership behaviors. Establishes priorities and delegates tasks to peers and ancillary staff as appropriate to scope of practice and unit requirements. Effectively uses problem identification and resolution skills focusing on the clinical scenario to resolve the apparent concern. Follows the chain of command by consulting with other healthcare professionals and seeks assistance as needed. Independently communicates concerns in a timely manner and makes suggestions to members of the interdisciplinary team by seeking and using resources effectively. Evaluates the patient's response to treatment and progress toward short and long-range goals and revises nursing interventions as appropriate. Identifies patient and family needs prior to discharge. Initiates and monitors discharge planning activities in collaboration with other members of the interdisciplinary team. Independently identifies resources and strategies to enhance professional growth and development and commits to life-long learning. Supports and contributes to the unit/office department entity and organizational goals inclusive of the mission vision and values Participates in meetings and on committees and represents the department and hospital in community outreach efforts. Participates in multi-disciplinary quality and service improvement teams. Minimal Qualifications Education Associate's degree in Nursing required Bachelor's degree in Nursing preferred If prepared at the associate degree in nursing level required to enroll in a BSN program within 12 months of hire date and completion within 4 years of hire date Experience 1-2 years RN experience required Licenses and Certifications RN - Registered Nurse - State Licensure and/or Compact State Licensure Current license as a Registered Nurse in the state or jurisdiction of the facility seeking employment Upon Hire required and CPR - Cardiac Pulmonary Resuscitation (includes BLS) for healthcare providers from either the American Heart Association (AHA) or American Red Cross Upon Hire required Additional unit/clinic specialty certifications may vary by department or business unit. Knowledge Skills and Abilities Basic math skills. Verbal and written communication skills. Basic computer skills required This position has a hiring range of : USD $35.68 - USD $64.71 /Hr.
LPN Utilization Review Telehealth Full-time
Personify Health

Utilization Review Nurse-LVN/LPN

Personify Health Remote, OR
$25 - $30 / hour
Overview: Who We Are Because health is personal. That's why Personify Health created the first and only personalized health platform—bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one place. We serve employers, health plans, and health systems with data-driven solutions that reduce costs while actually improving health outcomes. Together, our team is on a mission to empower people to lead healthier lives. Learn even more about the work that drives us at personifyhealth.com. Responsibilities: Utilization Review Nurse (LVN) The Utilization Review Nurse conducts first-level clinical reviews to determine the medical necessity and appropriateness of treatment requests, working under the supervision of a Registered Nurse. This role supports timely, accurate benefit determinations across outpatient, inpatient, and post-service claims while ensuring compliance with clinical guidelines and regulatory standards. Schedule: Monday–Friday, 8:00 AM–5:00 PM Pacific Time, with rotating Saturday coverage as required. What You'll Actually Do Provide first level review for all outpatient and ancillary pre-certification requests for medical appropriateness; all inpatient hospital stays including mental health, substance abuse, skilled nursing and rehabilitation for medical necessity; and all post claim or post service reviews. Ensure proper referral to medical director for denial authorizations through independent review organizations (IRO). Work with hospital staff to prepare patients for discharge and ensure a smooth transition to the next level of care. Refer requests that fall outside of established guidelines to advance review or senior care consultants. Process appeals for non-certification of services; complete non-certification letters when appropriate. Review plan document for benefit determinations; attempt to redirect providers and patients to PPO providers. Identify and refer potential cases to case management, wellness, chronic disease and Nurturing Together program. Complete documentation for all reviews in Eldorado/Episodes; maintain confidentiality. Utilize MCG guidelines, medical policies, Medscape, and NCCN. Ability to meet productivity, quality, and turnaround times daily. Assists with department operations and implementations Qualifications: What You Bring to Our Team Education and Experience: Current LVN license in the United States or U.S. territory. 1+ years of clinical experience required. Required Knowledge, Skills, and Abilities: Knowledge of medical claims and ICD-10, CPT, HCPCS coding. Proficiency in software applications including, but not limited to, Microsoft Word, Microsoft Excel, Microsoft PowerPoint and Outlook Excellent verbal and written communication skills Ability to speak clearly and convey complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others Disclaimer This job description is not intended to contain a comprehensive list of activities, duties, or responsibilities, but constitutes a general description of the scope and function of the role within the company. Activities, duties, and responsibilities are subject to change at any time with or without notice. Benefits The Highlights: Competitive base salary and benefits effective day one Comprehensive medical and dental through our own health solutions (yes, we use what we build) Paid Time Off—rest and recharge time is non-negotiable Mental health support, retirement planning, and financial protection Professional development with clear career progression and learning budgets Mission-driven culture where diverse perspectives drive real impact on people's health Want the full picture? Visit personifyhealthbenefits.com to explore our complete benefits package, wellness programs, and other employee perks. Compensation: This position offers a base salary range of $25-$30 per hour, depending on location, skills, and experience. You're eligible for our full benefits package starting day one. Our Commitment: Personify Health is an equal opportunity employer committed to diversity, equity, inclusion, and belonging. We cultivate a work environment where differences are celebrated, and employees of all backgrounds are empowered to thrive—because diversity is core to who we are and critical to our work in health and wellbeing. Stay Safe: Personify Health will never ask for payment or sensitive personal information like social security numbers during hiring. All official communication comes from verified company email addresses and or our secure applicant tracking system. Suspicious requests? Report them to talent@personifyhealth.com . View all legitimate openings at personifyhealth.com/careers .
NP Telehealth Telehealth Full-time
MedStar Health

Telemedicine - Cardiology - Nurse Practitioner

MedStar Health Remote, OR
$115,000 - $190,000 / year
About this Job: MedStar Medical Group offers a uniquely rewarding career in a major marketplace. Shape your future in health care in the kind of setting that’s right for you and your practice. Become part of an organization that welcomes your experience and input — as a clinician and healthcare expert. We are looking for a Nurse Practitioner with cardiology experience, with heart failure as a specialty, to join MedStar’s growing telemedicine services. As a Connected Heart Failure Monitoring and Management provider, you will provide on-demand clinical care directly to patients using our telehealth platform (currently MedStar video visit) in compliance with the heart failure clinical guidelines of the program and under the direction of the cardiology physician team. You will effectively transition care of patients from telehealth encounters to in-person care for emergent, urgent, and scheduled follow-up needs. This program improves patient access to a clinician and facilitates care within the MedStar system. We are looking for a provider to join our virtual team that spans Maryland, DC, and northern Virginia regions. At least 3 years of experience in cardiology is required, with heart failure as a specialty preferred, and post-graduation is required. Interested nurse practitioners should have acute-care based certification and reside and have or be able to obtain tristate licensures (MD, DC, and VA), but only one relevant license (MD, DC, or VA) required at time of hire. Majority of the time candidates will be working 8-hr, flexible days remotely, Monday-Friday. *Based on experience, there will be an 8-12-week orientation that includes working 1-2 days per week on-site in the facility . ** As a MedStar Medical Group clinician, you can expect: A competitive salary with opportunity to raise your income yearly Variety of health insurance options for you and your dependents Paid malpractice insurance Generous paid time off - 30 days, plus 7 holidays and 2 personal days Ongoing CME allowance, plus 5 CME days Retirement savings plan – 403(b) with excellent employer match Minimal Qualifications Education Master's degree Graduation from an accredited Nurse Practitioner program approved by the Maryland State and/or DC Board Examiners of Nurses; required Experience 3 years Experience as a nurse practitioner; required Licenses and Certifications NP - Nurse Practitioner - Licensed Graduation from an accredited Nurse Practitioner program approved by the Maryland State and/or DC Board Examiners of Nurses. May require specialty license based on location. required and CPR - Cardiac Pulmonary Resuscitation (includes BLS and NRP) for healthcare providers from either the American Heart Association (AHA) or American Red Cross within 90 Days required and Additional unit/specialty certifications may vary by department or business unit. This position has a hiring range of : USD $115,000.00 - USD $190,000.00 /Yr.
RN Telehealth Full-time
Personify Health

Case Manager Nurse RN

Personify Health Remote, OR
$35 - $40 / hour
Overview: Who We Are Because health is personal. That's why Personify Health created the first and only personalized health platform—bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one place. We serve employers, health plans, and health systems with data-driven solutions that reduce costs while actually improving health outcomes. Together, our team is on a mission to empower people to lead healthier lives. Learn even more about the work that drives us at personifyhealth.com. Responsibilities: Ready to be the difference between a confusing diagnosis and a clear path forward? Why This Role Matters When someone gets a diagnosis that turns their world upside down, they need more than a claim number — they need a person who can guide them through it. As a Case Manager RN, you're that person: the clinical expert who assesses the whole picture, builds a real treatment plan, and stays connected with patients, providers, and families through every step of care. Your work directly shapes whether a member gets the right care at the right time, and whether costs stay manageable for the plans and employers who depend on us. This isn't administrative case tracking — it's clinical judgment applied to real people navigating some of the hardest moments of their lives. The outcomes you drive, case by case, are what make cost-effective, high-quality healthcare possible at scale. What You'll Actually Do Assess the whole patient: Contact patients directly and complete thorough assessments covering physical, psychosocial, emotional, spiritual, environmental, and financial needs to build a full clinical picture. Mine claims data for insight: Use claims processing tools to review paid claim data, identifying members who need case management or would benefit from specific programs. Build individualized treatment plans: Develop treatment plans for standard and catastrophic cases in collaboration with patients, caregivers, community resources, and multi-disciplinary providers, setting clear short- and long-term goals. Track outcomes and adjust course: Monitor interventions, evaluate treatment plan effectiveness in real time, and report measurable outcomes that show what's actually working. Stay connected across the care team: Maintain ongoing contact with patients, families, providers, employers, and the broader care team throughout the full continuum of care. Advocate for the patient: Facilitate access to quality care, help reduce overall costs, and provide direct emotional support and guidance to patients and families navigating difficult diagnoses. Drive cost management strategies: Negotiate and implement cost management approaches that improve outcomes, then reflect that impact in monthly case management reviews and cost avoidance reports. Perform utilization review: Conduct utilization review for assigned members to ensure care aligns with clinical need and plan guidelines. Connect members to wellness resources: Evaluate patient needs and make referrals into wellness programs when appropriate. Maintain airtight documentation: Keep complete, confidential documentation in Eldorado and UM Web, preparing reports at 30-day intervals for high-risk cases and 90-day intervals for low-risk cases, per Company policy and HIPAA. Mentor LVN colleagues: Serve as a clinical resource for LVNs, guiding them through complex cases and clinical decision-making. Qualifications: What You Bring to Our Team Education & Experience: Graduate of an accredited Registered Nursing (RN) program Current California RN license required; multi-state license also required Minimum of 5 years medical/surgical or acute care experience, including 2 years in case management, or an equivalent combination of education and experience Prior case management, emergency room, critical care, or other relevant clinical experience pertinent to case management Technical Skills: Knowledge of medical claims processing and ICD-10, CPT, and HCPCS coding Ability to critically evaluate claims data to inform treatment and discharge planning Knowledge of community resources and alternate funding programs Proficiency with Microsoft Office Suite Working knowledge of case management platforms such as Eldorado and UM Web Benefits The Highlights: Competitive base salary and benefits effective day one Comprehensive medical and dental through our own health solutions (yes, we use what we build) Paid Time Off—rest and recharge time is non-negotiable Mental health support, retirement planning, and financial protection Professional development with clear career progression and learning budgets Mission-driven culture where diverse perspectives drive real impact on people's health Want the full picture? Visit personifyhealthbenefits.com to explore our complete benefits package, wellness programs, and other employee perks. Compensation: This position offers a base salary range of $35.00-$40.00 per hour, depending on location, skills, and experience. You're eligible for our full benefits package starting day one. Our Commitment: Personify Health is an equal opportunity employer committed to diversity, equity, inclusion, and belonging. We cultivate a work environment where differences are celebrated, and employees of all backgrounds are empowered to thrive—because diversity is core to who we are and critical to our work in health and wellbeing. Stay Safe: Personify Health will never ask for payment or sensitive personal information like social security numbers during hiring. All official communication comes from verified company email addresses and or our secure applicant tracking system. Suspicious requests? Report them to talent@personifyhealth.com . View all legitimate openings at personifyhealth.com/careers .
RN Utilization Review Telehealth Full-time
Personify Health

Utilization Review Nurse - RN

Personify Health Remote, OR
$30 - $40 / hour
Overview: Who We Are Because health is personal. That's why Personify Health created the first and only personalized health platform—bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one place. We serve employers, health plans, and health systems with data-driven solutions that reduce costs while actually improving health outcomes. Together, our team is on a mission to empower people to lead healthier lives. Learn even more about the work that drives us at personifyhealth.com. Responsibilities: Ready to turn clinical expertise into life-changing decisions, one review at a time? Why This Role Matters Every determination you make decides whether a member gets the care they need, when they need it. This role sits at the exact point where clinical judgment meets real-world impact, translating evidence-based criteria into decisions that protect members and keep the organization compliant, efficient, and trusted. Get it right, and members move forward with the right care in the right setting, network partners stay strong, and the organization avoids costly, avoidable risk. Get it wrong, or get it slow, and everyone feels it, from the member waiting on an answer to the Medical Director who depends on a clean, well-documented case. Your reviews are the front line of quality, and your accuracy is what turns a good UM program into a great one. Schedule: Monday–Friday, 8:00 AM–5:00 PM Pacific Time, with rotating Saturday coverage as required. What You'll Actually Do Conduct medical-necessity reviews: Evaluate requested services against benefit language, medical policy, and nationally recognized criteria (MCG, NCCN) to determine the appropriate level of care, applying state and federal requirements at every step. Escalate non-certifications with precision: Route cases that don't meet criteria to the Medical Director for secondary clinical review, ensuring every adverse determination is timely, defensible, and aligned with NCQA/URAC accreditation standards. Dig into the clinical record: Analyze documentation for completeness, flag acuity and risk indicators, catch inconsistencies or gaps, and act fast with outreach or escalation when something doesn't add up. Prioritize with purpose: Manage a caseload by urgency, regulatory deadline, and member impact, and flag barriers early so determinations stay timely and compliant. Redirect care in-network: Confirm eligibility, benefits, authorization, and network status to steer members toward in-network, benefit-compliant options when clinically appropriate. Build the appeals case: Prepare clinical summaries and documentation, coordinate peer-to-peer discussions with physicians, and route appeals (including IRO referrals) accurately and on time. Document with rigor: Capture every review, rationale, criteria citation, and outcome in UM systems in real time, creating a clean audit trail that supports quality oversight and reporting. Hit the bar, every time: Meet productivity, quality, accuracy, and turnaround standards, participate in calibration activities, and put feedback into action immediately. Protect what matters: Maintain HIPAA compliance and confidentiality using minimum-necessary standards, and stay current on required training and annual competencies. Show up for the team: Cross-train and flex into coverage roles as needed, keeping operations running and service commitments met. Qualifications: What You Bring to Our Team Education & Experience: Current, unrestricted RN license in the United States or a U.S. territory (compact license accepted where applicable) Graduate of an accredited nursing program (ADN or diploma required; BSN preferred) 1-2+ years of recent clinical experience (acute care, med-surg, ICU/ED, or similar setting) Utilization review/utilization management experience preferred Technical Skills: Proficiency with Microsoft Word, Excel, and Outlook Working knowledge of ICD-10, CPT, and HCPCS coding and medical claims Ability to interpret medical records and apply evidence-based criteria and plan medical policies Comfort working across multiple screens and systems with strong typing proficiency Ability to work independently within UM platforms and workflows after training Benefits The Highlights: Competitive base salary and benefits effective day one Comprehensive medical and dental through our own health solutions (yes, we use what we build) Paid Time Off—rest and recharge time is non-negotiable Mental health support, retirement planning, and financial protection Professional development with clear career progression and learning budgets Mission-driven culture where diverse perspectives drive real impact on people's health Want the full picture? Visit personifyhealthbenefits.com to explore our complete benefits package, wellness programs, and other employee perks. Compensation: This position offers a base salary range of $30.00-$40.00 per hour, depending on location, skills, and experience. You're eligible for our full benefits package starting day one. Our Commitment: Personify Health is an equal opportunity employer committed to diversity, equity, inclusion, and belonging. We cultivate a work environment where differences are celebrated, and employees of all backgrounds are empowered to thrive—because diversity is core to who we are and critical to our work in health and wellbeing. Stay Safe: Personify Health will never ask for payment or sensitive personal information like social security numbers during hiring. All official communication comes from verified company email addresses and or our secure applicant tracking system. Suspicious requests? Report them to talent@personifyhealth.com . View all legitimate openings at personifyhealth.com/careers .
RN Full-time
MedStar Health

RN CDI Specialist

MedStar Health Remote, OR
$89,065 - $162,801 / year
About this Job: General Summary of Position Ensures that documentation supports accurate complete and consistent unambiguous clinical documentation. Utilizes clinical expertise to support appropriate reflection of the patient's risk of mortality and severity of illness. Develops compliant physician queries guided by the American Health Information Management Associations (AHIMA) Ethical Standards for Clinical Documentation Improvement Professionals the ACDIS/AHIMA Query practice brief and state federal and other appropriate regulatory guidance. Evaluates the medical records for case specific review including mortalities complications quality of care and other needs identified requiring review and/or second level review. Reviews and analyzes inpatient record for compliant documentation. Provides education to all levels of clinical staff. Closely collaborates with coding professionals to ensure appropriate ICD-10 and DRG assignment. Maintains certification and credentials applicable to the Clinical Documentation Integrity Specialist role. Monitors clinical case data to identify areas of improvement. Primary Duties and Responsibilities Contributes to the achievement of established department goals and objectives and adheres to department policies procedures quality standards and safety standards. Complies with governmental and accreditation regulations. Demonstrates a cooperative collaborative and team-oriented approach with CDI team coders nursing staff medical staff and all other ancillary departments. Communicates effectively to ensure a coordinated standardized and effective approach with clinicians. Demonstrates the appropriate utilization of paper and electronic CDI chart review resources to foster transition of cases within the CDI team. Ensures the CDI work sheet includes precise clinical details appropriate data entry into software and complete and updated code set to support physician queries and support case review decisions. Develops written and verbal CDI physician queries in compliance with AHIMA/ACDIS query practice brief and other appropriate regulatory body requirements. Identifies opportunities for education based upon query topics or other identified need and provides on-going education to physicians clinicians and other stakeholders about the need for accurate complete and consistent documentation in the medical record. Inputs daily review data in a timely manner including number of cases reviewed number of queries placed working MS-DRG or APR-DRG secondary diagnoses procedures and determination of MS-DRG or APR-DRG. Maintains continuing education and credentials for clinical documentation integrity specialist job classification. Meets the organizations CDS performance standards including but not limited to productivity (initial reviews and follow up reviews) query rate and documentation clarification rate. Participates in identifying areas of opportunity to improve the success or mitigate barriers in the CDI program and collaborates with the CDI Director to develop action plans to address issues. Participates in meetings and on committees and represents the department and hospital in community outreach efforts as required. Participates in the collection analysis and trending of CDI data to identify opportunities for improvement and to develop education for medical and hospital staff. May be asked to participate in the retrospective review of principal and secondary diagnoses to ensure the accuracy of diagnostic and procedural data. Performs initial and follow-up CDI chart reviews in accordance to the Hospitals CDI Policies and Procedures. Performs quality chart reviews in accordance to the Hospital CDI policies and procedures. Ability to recognize and research clinically complex conditions and associated global exclusions. Utilizes coding and CDI resources in an effort to apply the correct coding guidelines and clinical information to the review of the patients record. Performs other duties as assigned. Provides input in the development of power plans best practice guidelines and power notes within the hospital EMR systems to facilitate adherence to best practices and regulatory requirements. Reviews the medical record and evaluates the documentation to assign the Principal Diagnosis pertinent secondary diagnoses and procedures for accurate MS-DRG or APR-DRG assignment/Severity of Illness and Risk of Mortality. Minimal Qualifications Education Associate's degree in Nursing required or Bachelor's degree in Nursing preferred or Master's degree Nursing or other clinically focused field of study such as Advanced Practice Nursing Physician Assistant preferred or Doctoral degree Foreign Medical Graduate preferred Experience 3-4 years nursing Experience in acute care setting required and Experience in ICD-10 coding review and DRG reimbursements systems required Licenses and Certifications Cert Document Improvement Practitioner - CDIP within 2 years required or CCDS - Certified Clinical Documentation Specialist within 2 years required and CCS-Certified Coding Specialist preferred Knowledge Skills and Abilities Proficient in Microsoft Office applications (Word Excel PowerPoint). Excellent interpersonal skills including verbal and written communication. Ability to collect and analyze data related to the CDI program. Proficient in reviewing medical records and understanding pertinent clinical information. Ability to demonstrate critical-thinking skills. This position has a hiring range of : USD $89,065.00 - USD $162,801.00 /Yr.
RN Utilization Review Telehealth Full-time
Personify Health

Lead Utilization Review - RN

Personify Health Remote, OR
$38 - $44 / hour
Overview: Who We Are Because health is personal. That's why Personify Health created the first and only personalized health platform—bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one place. We serve employers, health plans, and health systems with data-driven solutions that reduce costs while actually improving health outcomes. Together, our team is on a mission to empower people to lead healthier lives. Learn even more about the work that drives us at personifyhealth.com. Responsibilities: Ready to lead the clinical team that keeps care moving when it matters most? Why This Role Matters Every delayed or unclear coverage decision is a person waiting on care they need. The RN UM Team Lead makes sure that doesn't happen — coaching reviewers to apply medical-necessity criteria consistently, catching risk before it becomes a backlog, and keeping documentation audit-ready so decisions hold up under scrutiny. This isn't a background role: it's the difference between a member getting a timely answer and getting stuck in a queue. You're the person providers and internal teams turn to when a case gets complicated and needs a clear path forward. When your team runs tight, members get faster answers, providers get fewer headaches, and the business stays compliant — that's the job. Schedule: Monday–Friday, 8:00 AM–5:00 PM Pacific Time, with rotating Saturday coverage as required. What You'll Actually Do Set daily direction for your UM team: Establish priorities, reinforce expectations, and build a culture where clinical quality and accountability are the norm, not the exception. Coach reviewers on criteria application: Guide consistent use of medical-necessity criteria, medical policy, and benefit language, and step in with real-time answers when interpretations vary. Monitor workflow health daily: Track intake volume, aging cases, and turnaround risk; flag barriers to the UM Manager with a recommendation attached, not just a problem. Audit for documentation quality: Review reviewer work for completeness and audit readiness, then coach for sharper clinical rationale and tighter regulatory timeliness. Build reviewer capability: Run shadowing plans, job aids, and competency check-ins for new and existing staff; identify training gaps and propose solutions before they become bigger problems. Resolve cross-team barriers: Partner with providers, facilities, Case Management, Appeals, and Provider Relations to clear roadblocks and keep determinations moving. Protect member and company data: Maintain HIPAA compliance and company privacy standards, and model the ethical decision-making you expect from your team. Drive training completion: Complete required training and attestations on time, and keep your team on track to do the same. Qualifications: What You Bring to Our Team What You Bring to Our Team Education & Experience: Active RN license Experience in utilization management, clinical review, or case management Background applying medical-necessity criteria and benefit plan interpretation in a healthcare payer or clinical review setting Technical Skills: Proficiency with UM platforms and standard office/productivity tools Working knowledge of medical terminology and coding concepts (ICD-10, CPT, HCPCS) sufficient to support accurate UM documentation Familiarity with remote collaboration tools for team visibility and responsiveness Benefits The Highlights: Competitive base salary and benefits effective day one Comprehensive medical and dental through our own health solutions (yes, we use what we build) Paid Time Off—rest and recharge time is non-negotiable Mental health support, retirement planning, and financial protection Professional development with clear career progression and learning budgets Mission-driven culture where diverse perspectives drive real impact on people's health Want the full picture? Visit personifyhealthbenefits.com to explore our complete benefits package, wellness programs, and other employee perks. Compensation: This position offers a base salary range of $38.00-$44.00 per hour, depending on location, skills, and experience. You're eligible for our full benefits package starting day one. Our Commitment: Personify Health is an equal opportunity employer committed to diversity, equity, inclusion, and belonging. We cultivate a work environment where differences are celebrated, and employees of all backgrounds are empowered to thrive—because diversity is core to who we are and critical to our work in health and wellbeing. Stay Safe: Personify Health will never ask for payment or sensitive personal information like social security numbers during hiring. All official communication comes from verified company email addresses and or our secure applicant tracking system. Suspicious requests? Report them to talent@personifyhealth.com . View all legitimate openings at personifyhealth.com/careers .
NP Outpatient Telehealth Outpatient Full-time
MedStar Health

Telemedicine Primary Care Nurse Practitioner - MedStar Health

MedStar Health Remote, OR
$105,000 - $115,000 / year
About this Job: Remote Opportunity! Nurse Practitioner in Connected Primary Care Telemedicine - MedStar Health MedStar Health offers a uniquely rewarding career in a major marketplace. Shape your future in health care in the kind of setting that’s right for you and your practice. Become part of an organization that welcomes your experience and input — as a clinician and healthcare expert. We are looking for Nurse Practitioners with at least 3 years of primary care experience to join MedStar’s growing telemedicine services in Connected Primary Care. In this position you will work remotely and will see new and returning patients to MedStar Health via our telehealth platform for patients who wish to establish primary care, and for patients seeing acute/follow up care. This program promotes a team-based approach to care, working in conjunction with our other primary care team members, through centralized results monitoring for patients. This program improves patient access to a clinician and facilitates care within the MedStar system. This is a fully remote clinical position in Telemedicine. Nurse Practitioners must currently be licensed in DC, Maryland and Virginia. Providers must be located in the DC/MD/VA area. As a MedStar Medical Group clinician, you can expect: A very competitive salary Opportunity for Incentive bonuses Medical, dental and vision insurance Paid occurrence-based malpractice insurance Generous paid time off CME leave and an annual $3,000 CME allowance Retirement plan options with employer % match Access to a provider concierge service for work/life services Employer paid life insurance for 1X salary Employer paid STD and LTD Access to Care.com Be a part of a nationally-recognized health system and the largest provider of health services in the Baltimore/Washington region. With our vast resources and capabilities at your disposal, you can expand your clinical expertise. Enjoy a rich career and a quality of life unique to the Mid-Atlantic region, which features a mix of urban, suburban and rural communities. Qualifications: Completion of a Master of Science in Nursing or Doctor of Nursing Practice program 3+ years' experience in primary care Pass national certification exam Be the provider you were meant to be, here at MedStar. MedStar Health is the largest health system in the region, with 30,000 associates, working at 10 hospitals, hundreds of ambulatory care sites – all together more than 700 access points of care, covering more than 225 zip codes in 17 counties. We are also ranked among the “Best Places to Work” by Baltimore magazine, Baltimore Business Journal, and Washington Business Journal. This position has a hiring range of : USD $105,000.00 - USD $115,000.00 /Yr.
RN Utilization Review Telehealth
Personify Health

Utilization Review Nurse RN Part-Time

Personify Health Remote, OR
$30 - $38 / hour
Overview: Who We Are Because health is personal. That's why Personify Health created the first and only personalized health platform—bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one place. We serve employers, health plans, and health systems with data-driven solutions that reduce costs while actually improving health outcomes. Together, our team is on a mission to empower people to lead healthier lives. Learn even more about the work that drives us at personifyhealth.com. Responsibilities: We are seeking a Utilization Review Nurse to join our dynamic team on a part-time basis working up to 28 hours per week and weekends required. What You'll Actually Do Perform utilization management (UM) medical-necessity reviews and level-of-care determinations for requested services using the organization’s hierarchy of guidance (benefit language/plan documents, medical policies, nationally recognized evidence-based criteria such as MCG; NCCN as applicable) and applicable state/federal requirements. Apply criteria and policy consistently; when a request does not meet criteria, route timely to the Medical Director for secondary clinical review and potential adverse determination in accordance with UM policies and accreditation standards (e.g., NCQA/URAC, as applicable). Use critical thinking to analyze clinical documentation for completeness, identify key risk/acuity indicators, recognize inconsistencies or missing information, and initiate timely outreach/escalation per UM workflow. Apply strategic thinking within established guidelines by prioritizing workload based on urgency, regulatory/accreditation time frames, and potential member impact; communicate barriers early to support timely, compliant determinations. Assist with in-network and benefit-compliant redirection when clinically appropriate by confirming eligibility, benefits, authorization requirements, and network status. Support the appeals process by preparing clinical summaries and documentation; coordinating peer-to-peer/MD discussions when indicated; and ensuring timely routing/escalation per policy (including Independent Review Organization (IRO) processes when required). Document reviews, rationale, criteria/policy citations, communications, and outcomes accurately and contemporaneously in designated UM systems to support quality oversight, reporting, and audit readiness. Meet established productivity, quality, accuracy, and turnaround-time standards; participate in calibration/quality activities; and incorporate feedback into daily practice. Maintain HIPAA compliance and confidentiality using minimum-necessary standards; complete required training and annual competencies within established deadlines. Cross-train and provide cross-coverage as needed to support team operations and service-level commitments. Qualifications: What You Bring to Our Team Current, unrestricted RN license in the United States or U.S. territory (compact license acceptable where applicable). Graduate of an accredited nursing program (ADN or diploma required; BSN preferred). Minimum 1-2 years of recent clinical experience (e.g., acute care, med-surg, ICU/ED, or other relevant setting). Prior utilization review/utilization management experience preferred. Ability to interpret medical records and apply evidence-based criteria and plan medical policies with appropriate escalation to Medical Director for non-certifications. UPON HIRE, must have: Basic computer literacy The ability to work on multiple screens, and proficient typing skills. Proficiency in software applications including, but not limited to, Microsoft Word, Microsoft Excel, and Outlook Excellent verbal and written communication skills Ability to speak clearly and convey complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others. Ability to work independently and utilize written resources to problem solve. Ability to work independently within appropriate programs after training. Knowledge of medical claims and ICD-10, CPT, HCPCS coding Excellent verbal and written communication skills for upward and downward conversations Physical and Mental Requirements: Ability to perform the essential job functions safely and successfully with or without reasonable accommodation, including meeting qualitative and/or quantitative productivity standards. Ability to maintain regular, punctual attendance. Ability to sit for 6-8 hours. Constant use of computer keyboard and mouse; repetitive use of both hands. Occasional to frequent twisting of neck; occasional bending of neck and at waist. This job description is not an exclusive or exhaustive list of all job functions that an employee in this position may be asked to perform. Duties and responsibilities can be changed, expanded, reduced, or delegated by management to meet the business needs of MedCom. Want the full picture? Visit personifyhealthbenefits.com to explore our complete benefits package, wellness programs, and other employee perks. Compensation: This position offers a base salary range of $30.00-$38.00 per hour, depending on location, skills, and experience. You're eligible for our full benefits package starting day one. Our Commitment: Personify Health is an equal opportunity employer committed to diversity, equity, inclusion, and belonging. We cultivate a work environment where differences are celebrated, and employees of all backgrounds are empowered to thrive—because diversity is core to who we are and critical to our work in health and wellbeing. Stay Safe: Personify Health will never ask for payment or sensitive personal information like social security numbers during hiring. All official communication comes from verified company email addresses and or our secure applicant tracking system. Suspicious requests? Report them to talent@personifyhealth.com . View all legitimate openings at personifyhealth.com/careers .
LPN Utilization Review Telehealth Full-time
Personify Health

Utilization Review Nurse - LVN / LPN

Personify Health Remote, OR
$25 - $31 / hour
Overview: Who We Are Because health is personal. That's why Personify Health created the first and only personalized health platform—bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one place. We serve employers, health plans, and health systems with data-driven solutions that reduce costs while actually improving health outcomes. Together, our team is on a mission to empower people to lead healthier lives. Learn even more about the work that drives us at personifyhealth.com. Responsibilities: Ready to be the clinical judgment call that keeps care on track? Why This Role Matters Every pre-certification, every inpatient stay, every appeal that lands on your desk is a moment where your review decides what happens next for a real person's care. This role is where clinical assessment meets real consequence, making sure treatment requests get matched to the right level of care, the right setting, and the right guidelines every single time. Get it right, and patients move through the system smoothly, providers stay aligned with plan benefits, and the organization avoids unnecessary cost and risk. Get it wrong, or get it slow, and care gets delayed or denied when it shouldn't be. Your accuracy and pace are what keep the entire utilization review process trustworthy. Schedule: Monday–Friday, 8:00 AM–5:00 PM Pacific Time, with rotating Saturday coverage as required. What You'll Actually Do Own first-level reviews: Assess outpatient, ancillary, and inpatient pre-certification requests, including mental health, substance abuse, skilled nursing, and rehab stays, for medical appropriateness and necessity. Drive post-service reviews: Evaluate post-claim and post-service requests against clinical guidelines to confirm medical necessity after the fact. Escalate the right cases: Route denial authorizations to the Medical Director and, when required, through Independent Review Organizations (IRO), and refer out-of-guideline requests to advance review or senior care consultants. Coordinate smooth discharges: Work directly with hospital staff to prepare patients for discharge and set up a clean transition to the next level of care. Manage the appeals process: Process appeals for non-certified services and complete non-certification letters accurately and on time. Redirect care in-network: Review plan documents for benefit determinations and steer providers and patients toward PPO options whenever possible. Connect patients to the right program: Identify and refer cases to case management, wellness, chronic disease, and Nurturing Together programs when clinical needs point that way. Document every review: Complete accurate, timely documentation in Eldorado/Episodes for every case, maintaining strict confidentiality throughout. Apply the right criteria: Use MCG guidelines, medical policies, Medscape, and NCCN to ground every determination in evidence-based standards. Hit the bar, every time: Meet daily productivity, quality, and turnaround-time standards, and support department operations and new initiatives as they roll out. Qualifications: What You Bring to Our Team Education & Experience: Current LVN license in the United States or a U.S. territory 1+ years of clinical experience Technical Skills: Working knowledge of medical claims and ICD-10, CPT, and HCPCS coding Proficiency with Microsoft Word, Excel, PowerPoint, and Outlook Familiarity with MCG guidelines, NCCN criteria, and Medscape Experience documenting reviews in utilization management systems (e.g., Eldorado/Episodes) Benefits The Highlights: Competitive base salary and benefits effective day one Comprehensive medical and dental through our own health solutions (yes, we use what we build) Paid Time Off—rest and recharge time is non-negotiable Mental health support, retirement planning, and financial protection Professional development with clear career progression and learning budgets Mission-driven culture where diverse perspectives drive real impact on people's health Want the full picture? Visit personifyhealthbenefits.com to explore our complete benefits package, wellness programs, and other employee perks. Compensation: This position offers a base salary range of $25.00-$31.00 per hour, depending on location, skills, and experience. You're eligible for our full benefits package starting day one. Our Commitment: Personify Health is an equal opportunity employer committed to diversity, equity, inclusion, and belonging. We cultivate a work environment where differences are celebrated, and employees of all backgrounds are empowered to thrive—because diversity is core to who we are and critical to our work in health and wellbeing. Stay Safe: Personify Health will never ask for payment or sensitive personal information like social security numbers during hiring. All official communication comes from verified company email addresses and or our secure applicant tracking system. Suspicious requests? Report them to talent@personifyhealth.com . View all legitimate openings at personifyhealth.com/careers .
RN Utilization Review Telehealth Full-time
Personify Health

Utilization Review Nurse - RN

Personify Health Remote, OR
$35 - $43 / hour
Overview: Who We Are Because health is personal. That's why Personify Health created the first and only personalized health platform—bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one place. We serve employers, health plans, and health systems with data-driven solutions that reduce costs while actually improving health outcomes. Together, our team is on a mission to empower people to lead healthier lives. Learn even more about the work that drives us at personifyhealth.com. Responsibilities: Ready to turn clinical expertise into life-changing decisions, one review at a time? Why This Role Matters Every determination you make decides whether a member gets the care they need, when they need it. This role sits at the exact point where clinical judgment meets real-world impact, translating evidence-based criteria into decisions that protect members and keep the organization compliant, efficient, and trusted. Get it right, and members move forward with the right care in the right setting, network partners stay strong, and the organization avoids costly, avoidable risk. Get it wrong, or get it slow, and everyone feels it, from the member waiting on an answer to the Medical Director who depends on a clean, well-documented case. Your reviews are the front line of quality, and your accuracy is what turns a good UM program into a great one. Schedule: Monday–Friday, 8:00 AM–5:00 PM Pacific Time, with rotating Saturday coverage as required. What You'll Actually Do Conduct medical-necessity reviews: Evaluate requested services against benefit language, medical policy, and nationally recognized criteria (MCG, NCCN) to determine the appropriate level of care, applying state and federal requirements at every step. Escalate non-certifications with precision: Route cases that don't meet criteria to the Medical Director for secondary clinical review, ensuring every adverse determination is timely, defensible, and aligned with NCQA/URAC accreditation standards. Dig into the clinical record: Analyze documentation for completeness, flag acuity and risk indicators, catch inconsistencies or gaps, and act fast with outreach or escalation when something doesn't add up. Prioritize with purpose: Manage a caseload by urgency, regulatory deadline, and member impact, and flag barriers early so determinations stay timely and compliant. Redirect care in-network: Confirm eligibility, benefits, authorization, and network status to steer members toward in-network, benefit-compliant options when clinically appropriate. Build the appeals case: Prepare clinical summaries and documentation, coordinate peer-to-peer discussions with physicians, and route appeals (including IRO referrals) accurately and on time. Document with rigor: Capture every review, rationale, criteria citation, and outcome in UM systems in real time, creating a clean audit trail that supports quality oversight and reporting. Hit the bar, every time: Meet productivity, quality, accuracy, and turnaround standards, participate in calibration activities, and put feedback into action immediately. Protect what matters: Maintain HIPAA compliance and confidentiality using minimum-necessary standards, and stay current on required training and annual competencies. Show up for the team: Cross-train and flex into coverage roles as needed, keeping operations running and service commitments met. Qualifications: What You Bring to Our Team Education & Experience: Current, unrestricted RN license in the United States or a U.S. territory (compact license accepted where applicable) Graduate of an accredited nursing program (ADN or diploma required; BSN preferred) 1-2+ years of recent clinical experience (acute care, med-surg, ICU/ED, or similar setting) Utilization review/utilization management experience preferred Technical Skills: Proficiency with Microsoft Word, Excel, and Outlook Working knowledge of ICD-10, CPT, and HCPCS coding and medical claims Ability to interpret medical records and apply evidence-based criteria and plan medical policies Comfort working across multiple screens and systems with strong typing proficiency Ability to work independently within UM platforms and workflows after training Benefits The Highlights: Competitive base salary and benefits effective day one Comprehensive medical and dental through our own health solutions (yes, we use what we build) Paid Time Off—rest and recharge time is non-negotiable Mental health support, retirement planning, and financial protection Professional development with clear career progression and learning budgets Mission-driven culture where diverse perspectives drive real impact on people's health Want the full picture? Visit personifyhealthbenefits.com to explore our complete benefits package, wellness programs, and other employee perks. Compensation: This position offers a base salary range of $35.00-$43.00 per hour, depending on location, skills, and experience. You're eligible for our full benefits package starting day one. Our Commitment: Personify Health is an equal opportunity employer committed to diversity, equity, inclusion, and belonging. We cultivate a work environment where differences are celebrated, and employees of all backgrounds are empowered to thrive—because diversity is core to who we are and critical to our work in health and wellbeing. Stay Safe: Personify Health will never ask for payment or sensitive personal information like social security numbers during hiring. All official communication comes from verified company email addresses and or our secure applicant tracking system. Suspicious requests? Report them to talent@personifyhealth.com . View all legitimate openings at personifyhealth.com/careers .
RN Psych Telehealth Full-time
HealthEdge

UM RN - Behavioral Health

HealthEdge Remote, OR
$65,000 - $85,000 / year
Overview: Overview: Telephonic coordination and delivery of clinical behavioral health services designed to meet the wellness and recovery needs of the consumer. In addition to performing prospective, concurrent and retrospective review of inpatient, outpatient, ambulatory and ancillary services to ensure medical necessity, appropriate length of stay, intensity of service and level of care, including appeal requests initiated by providers, facilities and members. May establish care plans and coordinate care through the health care continuum. This candidate will utilize clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. RESPONSIBILITIES/TASKS: Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Review, research and authorize requests for authorization of elective, direct, ancillary, urgent, emergency, etc. services. Contact appropriate medical and support personnel to identify and recommend alternative treatment, service levels, length of stays, etc. using approved clinical protocols. Analyze, research, respond to and prepare documentation related to retrospective review requests and appeals in accordance with local, state and federal regulatory and designated accreditation (e.g. NCQA) standards. Establish, coordinate and communicate discharge planning needs with appropriate internal and external entities. Research and resolve issues related to benefits, member eligibility, non-elective and non-authorized services, coordination of benefits, care coordination, etc. Develop and deliver targeted education for provider community related to policies, procedures, benefits, etc. Communicates with providers and other parties to facilitate care/treatment. Identifies members for referral opportunities to integrate with other products, services and/or programs Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function. Other duties may be assigned based on designated department assignment. This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required. EMPLOYMENT QUALIFICATIONS: EDUCATION: Registered Nurse with current unrestricted Registered Nurse license required. Certification in Case Management may be preferred based upon designated department assignment. Continuous learning, as defined by the Company’s learning philosophy, is required. Certification or progress toward certification is highly preferred and encouraged. EXPERIENCE: 2+ years of acute clinical experience as RN required. One (1) year health insurance plan experience or managed care environment preferred. 1+ years Behavioral Health clinical experience 1+ years Managed Care of Utilization Management experience. SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED: Excellent written and verbal communication skills. Excellent customer service and interpersonal skills. Working knowledge of current industry Microsoft Office Suite PC applications. Ability to apply clinical criteria/guidelines for medical necessity, setting/level of care and concurrent patient management. Knowledge of current standard medical procedures/practices and their application as well as current trends and developments in medicine and nursing, alternative care settings and levels of service. Knowledge of policies and procedures, member benefits and community resources. Knowledge of applicable accreditation standards, local, state and federal regulations. Other related skills and/or abilities may be required to perform this job based upon designated department assignment. Geographic Responsibility: Remote, US Type of Employment: Full-time, permanent FLSA Classification (USA Only): Exempt Work Environment: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job: The employee is occasionally required to move around the office. Specific vision abilities required by this job include close vision, color vision, peripheral vision, depth perception, and ability to adjust focus. Work across multiple time zones in a hybrid or remote work environment. Long periods of time sitting and/or standing in front of a computer using video technology. May require travel dependent on company needs. The above statements are intended to describe the general nature and level of the job being performed by the individual(s) assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities, and skills required . HealthEdge reserves the right to modify , add, or remove duties and to assign other duties as necessary. In addition, reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position in compliance with the Americans with Disabilities Act of 1990 . Candidates may be required to go through a pre-employment criminal background check. HealthEdge is an equal opportunity employer. We are committed to workforce diversity and actively encourage all qualified persons to seek employment with us, including, but not limited to, racial and ethnic minorities, women, veterans and persons with disabilities. #LI-Remote ** The annual US base salary range for this position is $65,000 to $85,000 . This salary range may cover multiple career levels at HealthEdge. Final compensation will be determined during the interview process and is based on a combination of factors including, but not limited to, your skills, experience, qualifications and education.
RN Psych Telehealth Full-time
HealthEdge

UM RN - Behavioral Health

HealthEdge Remote, OR
$65,000 - $85,000 / year
Overview: Overview: Telephonic coordination and delivery of clinical behavioral health services designed to meet the wellness and recovery needs of the consumer. In addition to performing prospective, concurrent and retrospective review of inpatient, outpatient, ambulatory and ancillary services to ensure medical necessity, appropriate length of stay, intensity of service and level of care, including appeal requests initiated by providers, facilities and members. May establish care plans and coordinate care through the health care continuum. This candidate will utilize clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. RESPONSIBILITIES/TASKS: Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Review, research and authorize requests for authorization of elective, direct, ancillary, urgent, emergency, etc. services. Contact appropriate medical and support personnel to identify and recommend alternative treatment, service levels, length of stays, etc. using approved clinical protocols. Analyze, research, respond to and prepare documentation related to retrospective review requests and appeals in accordance with local, state and federal regulatory and designated accreditation (e.g. NCQA) standards. Establish, coordinate and communicate discharge planning needs with appropriate internal and external entities. Research and resolve issues related to benefits, member eligibility, non-elective and non-authorized services, coordination of benefits, care coordination, etc. Develop and deliver targeted education for provider community related to policies, procedures, benefits, etc. Communicates with providers and other parties to facilitate care/treatment. Identifies members for referral opportunities to integrate with other products, services and/or programs Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function. Other duties may be assigned based on designated department assignment. This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required. EMPLOYMENT QUALIFICATIONS: EDUCATION: Registered Nurse with current unrestricted Registered Nurse license required. Certification in Case Management may be preferred based upon designated department assignment. Continuous learning, as defined by the Company’s learning philosophy, is required. Certification or progress toward certification is highly preferred and encouraged. EXPERIENCE: 2+ years of acute clinical experience as RN required. One (1) year health insurance plan experience or managed care environment preferred. 1+ years Behavioral Health clinical experience 1+ years Managed Care of Utilization Management experience. SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED: Excellent written and verbal communication skills. Excellent customer service and interpersonal skills. Working knowledge of current industry Microsoft Office Suite PC applications. Ability to apply clinical criteria/guidelines for medical necessity, setting/level of care and concurrent patient management. Knowledge of current standard medical procedures/practices and their application as well as current trends and developments in medicine and nursing, alternative care settings and levels of service. Knowledge of policies and procedures, member benefits and community resources. Knowledge of applicable accreditation standards, local, state and federal regulations. Other related skills and/or abilities may be required to perform this job based upon designated department assignment. Geographic Responsibility: Remote, US Type of Employment: Full-time, permanent FLSA Classification (USA Only): Exempt Work Environment: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job: The employee is occasionally required to move around the office. Specific vision abilities required by this job include close vision, color vision, peripheral vision, depth perception, and ability to adjust focus. Work across multiple time zones in a hybrid or remote work environment. Long periods of time sitting and/or standing in front of a computer using video technology. May require travel dependent on company needs. The above statements are intended to describe the general nature and level of the job being performed by the individual(s) assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities, and skills required . HealthEdge reserves the right to modify , add, or remove duties and to assign other duties as necessary. In addition, reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position in compliance with the Americans with Disabilities Act of 1990 . Candidates may be required to go through a pre-employment criminal background check. HealthEdge is an equal opportunity employer. We are committed to workforce diversity and actively encourage all qualified persons to seek employment with us, including, but not limited to, racial and ethnic minorities, women, veterans and persons with disabilities. #LI-Remote ** The annual US base salary range for this position is $65,000 to $85,000 . This salary range may cover multiple career levels at HealthEdge. Final compensation will be determined during the interview process and is based on a combination of factors including, but not limited to, your skills, experience, qualifications and education.