RN Registered Nurse - Digital

Company Allegheny Health Network Job Description JOB SUMMARY This position is accountable and responsible for practice as a licensed registered nurse for care delivered in collaboration with the direct care, bedside nurse. The position will use various technologies to communicate with patients and their family members to provide elements of patient care including assessments, data monitoring and patient education. The Digital RN assesses patients, plans, and implements care through the virtual interview process. The Digital RN is fully responsible for all actions as a registered nurse in the State of PA. The position will use various technologies technology to communicate with patients and their family members to provide elements of patient care including assessments, data monitoring and patient education. Essential Responsibilities Develops an individualized plan of care using collaborative approach with the inpatient bedside nurse, patient/family, and other members of the health care team. (10%) Prioritizes care based on the patient's needs, abilities, and preferences. Advocates on patient/family's behalf to identify and resolve clinical concerns. Completes required documentation as appropriate, including documenting in the medical record and event reports. (10%) Develops appropriate education resources and supports unit practices and guidelines. Utilizes effective patient teaching strategies using appropriate resources, incorporating planning for care after discharge. Consistently evaluates the patient's comprehension and adapts teaching methods accordingly. (10%) Utilizes video and EPIC technologies to provide digital bedside patient care. Demonstrates technical knowledge of equipment and the ability to troubleshoot when problems arise. (10%) Partners with inpatient nurses to identify innovative solutions to improve patient care or unit operations, including, but not limited to, reducing patient length of stay, hospital readmissions, and care compliance. (10%) Assesses and documents patient status through digital face-to-face patient interview with video platform and coordinates with nurses at the bedside in care planning. (10%) Chooses an appropriate and meaningful communication style when interacting with others; gives and accepts constructive feedback to/from peers. (10%) Derives culturally and age-appropriate expected outcomes involving the patient, family, and other health care providers. Actively promotes and achieves excellence in customer experience, including patient, family, and healthcare team members. (10%) Acquires and maintains current knowledge and skills in evidence-based nursing practice and advances in digital nursing practice. Partners with a unit-based preceptor to provide training opportunities in real time. (10%) Considers maintenance of a safe environment, patient condition, complexity of the intervention and predictability of the outcome. (10%) Other duties as assigned. QUALIFICATION Required 7 years of inpatient nursing experience including utilization of the Electronic Medical Record Current State of PA RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC). Preferred 6 months of Digital Technology experience Bachelor’s Degree in Nursing Language (Other Than English) None Travel Requirement 0% - 25% Additional Employment Requirements Act 34 Criminal Background Clearance Certificate Act 33 Child Abuse Clearance Certificate Act 73 FBI Fingerprinting Criminal Background Clearance Certificate CPR certification Disclaimer The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job. Compliance Requirement This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies. As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements. Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law. We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below. For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org California Consumer Privacy Act Employees, Contractors, and Applicants Notice

Delegation Oversight Clinical Auditor RN II

L.A. Care Health Plan Los Angeles, CA

$88,854 - $142,166 / year

Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job Summary The Delegation Oversight Clinical Auditor RN II is responsible for ensuring that delegates contracted to perform Utilization Management (UM) functions on behalf of L.A. Care (LAC) is in compliance with all UM regulatory requirements and new legislation through the maintenance of required policies/procedures/workflows/ processes/audit tools necessary to meet the requirements. This position utilizes a rapid team approach for needed improvements identified through external audits of delegated entities. This position assist in maintaining continuous quality improvement in the Delegation Oversight Clinical Audit unit ensuring that departmental/divisional and organizational goals are accomplished through overseeing and facilitating compliance of the Plan Partners, Participating Provider Groups (PPG), Specialty Health Plans (SHP), and contracted provider network as managed by the Delegation Oversight Department. This position is responsible, as part of the oversight team, for ensuring compliance of the Plan Partners and/or Participating Physician Groups (PPG) to regulatory, contractual and L.A. Care requirements. This position is responsible for performing annual and focused audits. This position also acts as a liaison between the Plan Partners and PPGs and L.A. Care Health Plan regarding UM issues. The position assists in improving access and utilization performance of Plan Partners and PPGs by being a resource for best practices and providing continuous feedback. Additionally, the oversight responsibility of this position includes reporting to management and providing consultation/instructional/coaching recommendations to improve overall compliance of Plan Partners and PPGs with all regulations and standards. Duties Continually ensures delegate compliance with UM Policies/Procedures, Letter Templates, Workflows, Processes, and Audit Tools in compliance with all regulatory requirements/new legislation. Works collaboratively with Regulatory Affairs & Compliance. Stay abreast of new UM legislation, regulations, or other changes impacting UM in order to put processes in place for compliance. Prepares the Delegation Oversight Clinical Audit team for internal audits and for conducting PP/PPG audits, developing mechanisms for tracking/ trending of progress for --UM/PPG (internal) and PP (external) for compliance with UM standards, and identities system/individual areas for improvement through these processes. Prepares the Delegation Oversight Department for review by external regulatory bodies. Ensures that the Delegation Oversight Department is continually prepared for external review with staff daily work conducted in a manner that meets regulatory requirements. Ensures that the Delegation Oversight Clinical Audit unit functions as a team in preparing needed documents for an external review. Completes annual, focused and periodic audit activities timely and thoroughly including identification of deficiencies, response to mitigation, review and response to CAPs. Identifies repeat deficiencies. Assures audit documentation is clear, complete and accurate. Completes periodic monitoring of PP or PPG performance in critical deficiency areas. Completes follow-up audits and related reports and recommendations. Identifies options to assist PP or PPGs with continued or significant deficiencies. Updates audit tools to meet regulatory, contractual and L.A. Care requirements. Develops and conducts ongoing monitoring activities including but not limited to file reviews and letters and supplemental reports. Present summary results to L.A. Care's UM Committee. Communicates with assigned PP and PPGs on an ongoing basis. Develop mechanism to track and trend progress of PP and PPG's compliance to UM standards and identify system wide issues. Maintains confidentiality in compliance with all Health Insurance Portability and Accountability Act (HIPAA) requirements. Assists co-workers with special projects or work volume as required. Actively identifies and implements efforts to improve the quality, effectiveness and efficiency of job functions. Actively identifies and makes recommendations to supervisor ideas to improve the quality effectiveness and efficiency of departmental and health services functions. Communicates to supervisors any barriers to completing assignments or daily work in an efficient and effective manner. Duties Continued Provides training, education and consultation as necessary to PP and PPGs. Collaborates with other Clinical Auditors on identifying topics and developing agendas for the JOM's and PP visits/communication. Develops and implements procedures to assure compliance with care coordination and documentation of linked and carved out services. Conducts Interrater Reliability Testing (referral management and oversight) for new staff/physicians and annually or as needed for existing staff/physicians. Works with other departments as necessary to facilitate teamwork for creating and/or improving interdepartmental processes to meet regulatory requirements. Clinical Auditor (Performance Monitoring): In addition to the responsibilities above, the Clinical Auditor (Performance Monitoring) position ensures compliance of the delegates (Participating Physician Groups, Plan Partners and Vendors) with regulatory, contractual and L.A. Care business requirements. This position is responsible for delegation oversight continuous monitoring activities and monitoring corrective action plans from the annual and focused audits. The position also acts as a liaison between the Plan Partners, PPGs and Vendors regarding Utilization Management (UM) issues; assists in improving access and utilization performance of PPGs by being a resource for best practice and providing continuous performance feedback. Additionally, the oversight responsibility of this position includes attendance at UM Committee, Delegation Oversight Committee, Sanctions Committee, Internal Compliance Committee, and Joint Operation Meetings. It includes monitoring supplemental UM reports, reporting to management as well as consultation/coaching/instructional activities to improve overall compliance with all regulations and standards. Clinical Auditor (Behavioral Health): In addition to the duties above, the Clinical Auditor (Behavioral Health) designs an audit program specific to ensuring delegates are meeting behavioral health regulatory requirements. This ensures Specialty Health Plans and Plan Partners are in compliance with regulatory, contractual, and L.A. Care business requirements. This position is responsible for developing and maintaining annual audit tools, policy requirements specific to delegates, and a monitoring program to continually receive and aggregate Behavioral Health specific performance requirements. The position acts as a liaison between Specialty Health Plans and Plan Partners regarding Behavioral Health issues, assists in improving access and Behavioral Health performance by being a resource for best practice and providing continuous performance feedback. Additionally, the oversight responsibility includes liasing with internal Behavioral Health units, the Medical Director of Behavioral Health, attendance at UM Committee, Delegation Oversight Committee, Sanctions Committee, Internal Compliance Committee, and Joint Operation Meetings. It includes monitoring supplemental UM reports, reporting to management as well as consultation/coaching/instructional activities to improve overall compliance with all regulations and standards. Performs other duties as assigned. Education Required Associate's Degree in Nursing Education Preferred Bachelor's Degree in Nursing Experience Required: At least 7 years in a clinical setting with at least 3 years in a managed care setting in Utilization Management/Case Management. Skills Required: Knowledge of issues pertaining to Medi-Cal and other HMO & IPA contracts, & payers. Ability to manage and organize large volumes of data. Knowledge of accreditation entities and their requirements. Excellent verbal and written communication skills and excellent interpersonal skills. Good working knowledge of regulatory requirements/standards. Ability to work independently. Ability to solve complex issues and identify creative solutions. Computer ease & literacy with Word, Excel, PowerPoint Skills. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California License Licenses/Certifications Preferred Required Training Physical Requirements Light Additional Information Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. L.A. Care offers a wide range of benefits including Paid Time Off (PTO) Tuition Reimbursement Retirement Plans Medical, Dental and Vision Wellness Program Volunteer Time Off (VTO)

Manager, Healthcare Services (RN) - Southern California is preferred

Molina Healthcare Long Beach, CA

$84,067 - $163,931 / year

JOB DESCRIPTION Opportunity in Southern California for an experienced Managed Care Leader to join our health plan in California. Candidates must have a minimum of 7 years of healthcare experience, 3 of those should be with a Managed Care Organization focusing on Care Management. Leadership experience of 2 – 3 years, also within an MCO, must show a clear increase in responsibility, including a proven ability to lead teams, drive performance, and support member-centered care initiatives. Strong leadership, collaboration, and operational management skills are essential to successfully advance care delivery goals and improve member outcomes. Job Summary Leads and manages a multidisciplinary team of healthcare services professionals in some or all of the following functions: care management, utilization management, behavioral health, care transitions, long-term services and supports (LTSS), and/or special programs. Ensures members reach desired outcomes through integrated delivery and coordination of care across the continuum, and contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Oversees team performance for one or more of the following healthcare services functions: care management, utilization management (prior authorizations, inpatient/outpatient medical necessity, etc.), transition of care, behavioral health, long-term services and supports (LTSS), and/or special programs. • Facilitates integrated, proactive healthcare services management - ensuring compliance with state and federal regulatory and accrediting standards and implementation of the Molina clinical model. • Functions as a “hands-on” leader - assisting with assessing and evaluation of systems, day-to-day operations and efficiency of services/care delivery. • Ensures adequate staffing and service levels and maintains customer satisfaction by implementing and monitoring staff productivity and other performance indicators. • Assists in implementing care management, utilization management, behavioral health, care transitions, LTSS and other program activities in accordance with regulatory, contract standards and accreditation compliance. • Ensures delivery of member care and services are aligned with Molina's established standards of customer service excellence. • Ensures high-risk, complex members are adequately supported. • Oversees ongoing monitoring of performance, protocols and guidelines related to healthcare services. • Collaborates with and keeps senior level healthcare services leadership apprised of operational issues, staffing, resources, system and program needs. • Performs and promotes interdepartmental/multidisciplinary integration and collaboration to enhance continuity of care. • Oversees interdisciplinary care team (ICT) meetings. • Analyzes and reports on care access and monitoring statistics including plan utilization, staff productivity, cost-effective utilization of services, management of targeted member population, and triage activities. • Ensures completion of staff quality audit reviews evaluates services provided, outcomes achieved and recommends enhancements/improvements for programs and staff development to ensure consistent cost-effectiveness and compliance with all state and federal regulations and guidelines. • Maintains professional relationships with provider community, internal and external customers, and state agencies as appropriate. • Identifies opportunities for care delivery/quality/operational/etc. process improvements. • Hires, trains, develops and manages team demonstrates accountability for team performance and achievement of department-specific goals. • Local travel may be required (based upon state/contractual requirements). Required Qualifications • At least 7 years of health care experience, including at least 3 years of managed care experienced in one or more of the following areas: utilization management, care management, care transitions, behavioral health, long-term services and supports (LTSS), or special programs, or equivalent combination of relevant education and experience, or equivalent combination of relevant education and experience. • At least 1 year of management/leadership experience. • Registered Nurse (RN), Licensed Vocational Nurse (LVN), Licensed Practical Nurse (LPN), Licensed Clinical Social Worker (LCSW), Licensed Marriage and Family Therapist (LMFT), Licensed Professional Clinical Counselor (LPCC), or Licensed Master of Social Work (LMSW). Clinical licensure and/or certification required ONLY if required by state contract, regulation, business operating model, or state board licensing mandates. If licensed, license must be active and unrestricted in state of practice. • Strong customer service skills/member-centric focus. • Ability to work within a variety of settings and adjust style as needed, including ability to work with diverse populations, various personalities and personal situations. • Ability to prioritize and manage multiple deadlines. • Strong organizational and problem-solving skills. • Ability to collaborate cross-functionally within a highly matrixed organization. • Strong written and verbal communication skills. • Microsoft Office suite and applicable software program(s) proficiency. Preferred Qualifications • Clinical experience. • Registered Nurse (RN) or master's level behavioral health (BH) licensure. License must be active and unrestricted in state of practice. • Certified Case Manager (CCM), Certified Professional in Health Care Management certification (CPHM), Certified Professional in Health Care Quality (CPHQ) or other health care or management certification. • Medicaid/Medicare population experience. #PJHS #LI-AC1 To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $84,067 - $163,931 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Compliance Business Partner - RN

UnityPoint Health West Des Moines, IA

Area of Interest: Business Professionals FTE/Hours per pay period: 1.0 Department: Compliance Shift: Monday-Friday, standard business hours Job ID: 186016 Overview We are hiring a Compliance Business Partner to join our team at UnityPoint Health! This role serves as a key member of the Corporate Compliance Program, responsible for leading and executing compliance investigations across the health system, including those involving clinical care, regulatory requirements, and professional standards. The Business Partner will partner closely with operational leaders, clinical leadership, legal counsel, human resources, and risk management to assess concerns, ensure objective fact-finding, and support timely resolution consistent with regulatory requirements and organizational expectations. The position plays a critical role in maintaining an effective compliance program by promoting accountability, identifying systemic risks, and supporting continuous improvement. RN's with clinical auditing and/or emergency department experience are highly encouraged to apply! Location: Remote - applicants must reside within the UnityPoint Health footprint of Iowa, Illinois, or Wisconsin. Some travel required. Hours: Monday-Friday, standard business hours Why UnityPoint Health? At UnityPoint Health, you matter. We’re proud to be recognized as a Top 150 Place to Work in Healthcare by Becker's Healthcare several years in a row for our commitment to our team members. Our competitive Total Rewards program offers benefits options that align with your needs and priorities, no matter what life stage you’re in. Here are just a few: Expect paid time off, parental leave, 401K matching and an employee recognition program. Dental and health insurance, paid holidays, short and long-term disability and more. We even offer pet insurance for your four-legged family members. Early access to earned wages with Daily Pay, tuition reimbursement to help further your career and adoption assistance to help you grow your family. With a collective goal to champion a culture of belonging where everyone feels valued and respected, we honor the ways people are unique and embrace what brings us together. And, we believe equipping you with support and development opportunities is a vital part of delivering an exceptional employment experience. Find a fulfilling career and make a difference with UnityPoint Health. Responsibilities Lead Compliance Investigations: Lead and manage end-to-end compliance investigations. Investigation Process: Develop investigation plans, define scope, and execute timely, objective, and well-documented reviews Coordinate with key stakeholders and resources for the investigation Document all key steps in the investigation process; responsible for the maintenance of all key investigation documentation Identify and ensure required notifications to regulatory bodies are completed by appropriate leader, e.g., Pharmacist in Charge to the Drug Enforcement Agency, Chief Nursing Officer to the Iowa Board of Nursing Identify best practices for processes and documentation. Analyze findings to determine root cause, regulatory implications, and risk exposure Prepare clear, defensible investigation reports suitable for executive leadership and legal review Serve as a point of contact for all Markets Coordinate and/or establish a plan of correction if compliance issues are identified. Plan of Correction Create and implement appropriate plan of correction with key stakeholders Monitor action plan status to completion Escalate any documentation or action plan concerns to leader Create, coordinate, and deliver required action and training as applicable Assess need for systemwide training based on investigation findings Ensure updates to annual training, as applicable Conduct internal Auditing/Monitoring for compliance issues Proactive Auditing/Monitoring Establish and periodically review key metrics Collaborate with key stakeholders including, but not limited to, Human Resources, Risk Management, Pharmacy, Nursing, and Legal Review various audits of key data Stay updated on regulatory and policy changes impacting UnityPoint Health Consult and coach leaders to guide them through their responsibilities, including reporting, in high-risk issues Compliance Acumen: Maintain a deep understanding of compliance, direction, challenges and needs Leverage the knowledge to support and guide business solutions that achieve desired outcomes Build an understanding of the external compliance trends and strategy Participate in compliance and business strategies to drive key initiatives and results Partner with leaders during investigations to ensure they are using compliance tools and resources to help front line leaders and team members improve and support compliance guidelines Understands, follows and ensures compliance with relevant laws, regulations and organizational policies and provides guidance accordingly Relationship Management: Act as a trusted advisor and point of contact for any regulatory or governance queries by providing guidance Promote an open line of communication between compliance and business to ensure updates on current compliance investigations are known Leverage one compliance team mindset in collaborating across the business to deliver a global, unified experience for the business Qualifications Education: Required: Bachelor’s degree in nursing or healthcare related field Experience: Required: 5 years of experience in nursing or other clinical experience Required: 5 years of experience in compliance, investigations, auditing, monitoring, data collection, analysis, trending, and reporting Preferred: Clinical auditing and/or emergency department experience Knowledge, Skills, & Abilities: Ability to collect and synthesize large quantities of quantitative and qualitative data Ability to recognize trends and develop recommendations based on data analysis Strong interpersonal, communication, and customer service skills Significant knowledge of Compliance policies, processes and practices Ability to manage multiple investigations, projects and other assignments through prioritization and organization. Proficient use of software applications including but not limited to Microsoft Word, PowerPoint, Excel and Outlook #System123

Clinical Nurse - After Hours Answer Line

BJC HealthCare St. Louis, MO

Additional Information About the Role Answer Line Overview The Answer Line After Hours Service provides after-hours exchange and nurse triage services for over 300 subscribing community pediatricians in the St. Louis and surrounding areas. Answer Line RNs utilize triage guidelines, critical thinking skills, and physician preferences to determine the most appropriate plan of care for each patient. These services are provided Monday-Friday from 4:30pm – 8:00am and 24/7 on weekends. Location Almost all staff work remote, though we do have office space at BJC @ The Commons, 5th floor (4249 Clayton Ave, St. Louis, MO 63110) Staff are expected to work their shift in the call center if experiencing connectivity issues at home Minimum 2-5 years of nursing experience in a variety of the following areas: Emergency Department, NICU, PICU, telephone triage, pediatric primary care office, or pediatric General Medicine Benefits eligible Part-time; three 8-hr shifts; 24 hours per week Monday - Friday Evenings: 4:30pm-12:30am Occassional night shifts (up to four for every 6-week schedule); 12am-8am Every other weekend (Saturday and Sunday); days; primarily 7am-3pm or 8am-4pm, but shifts may vary Holiday rotation Seasonal on-call requirement BJC Nursing Career Ladder The BJC Registered Nurse Career Ladder differentiates BJC as the place for nurses to work in the greater St. Louis area. This is a tool to empower nurses to work at the top of their license and own their career progression. The BJC Registered Nurse Career Ladder promotes professional development, leadership, collaboration, education and service excellence and gives staff the opportunity to continue doing what they do best - caring for patients - while having the opportunity to advance to the next step in their career. Moves to higher ladder levels will result in a percentage increase of current pay that aligns with the new job description. Additional Preferred Requirements At least 3 years of pediatric nursing experience Computer/typing skills Overview St. Louis Children’s Hospital is dedicated to improving the health and lives of children. As one of the top-ranked children’s hospitals in the country, St. Louis Children’s provides care in more than 50 specialty areas through a dedicated team of physicians, nurses, staff and volunteers. Along with inpatient and outpatient medical care, the hospital offers education, wellness and injury-prevention programs to fulfill its mission to “do what’s right for kids.” Providing comprehensive, high-quality care and serving as an advocate for children has been St. Louis Children’s commitment since its inception in 1879. Today, the hospital serves patients and families across a 300-mile service area, and has seen patients from all 50 states and more than 80 countries. St. Louis Children’s consistently ranks among America’s Best Children’s Hospitals by U.S.News & World Report in all surveyed categories. In 2021, St. Louis Children’s was one of eight children’s hospitals to rank in the top 25 of all 10 specialties. The hospital’s academic and physician partner, Washington University School of Medicine, is one of the top-ranked medical schools in the United States. Since 2005, St. Louis Children’s has been designated as a Magnet® hospital for nursing excellence from the American Nurses Credentialing Center® (ANCC). Preferred Qualifications Role Purpose Provides direct patient care activities including assessment, diagnosis, planning implementation, and evaluation within the guidelines of the standards of nursing care. Responsibilities Promotes patient and family centered care in a healing environment. Educates patients and their families on how to manage their illness or injury, including post treatment home care needs and medication administration. Participates in activities that promote patient safety, quality and regulatory compliance. Participates in professional development. Develops, implements, and documents individual plans of care with defined goals in collaboration with other members of the interprofessional team and patient, family or caregiver in accordance with the established guidelines and standards of nursing care. Proactively plans and ensures communication of the plan of care across the continuum of care. Uses critical nursing skills to assess and evaluate physical, psychosocial, and emotional needs according to standards of care. Assess patient preferences and barriers to involvement in care, including their values, emotional, spiritual, cultural, and population-specific needs. BJC has determined this is a safety-sensitive position. The ability to work in a constant state of alertness and in a safe manner is an essential function of this job. Minimum Requirements Education Nursing Diploma/Associate's - Nursing Experience No Experience Supervisor Experience No Experience Licenses & Certifications RN Preferred Requirements Education Bachelor's Degree - Nursing Experience

Utilization Management Claims Review Nurse RN II

L.A. Care Health Plan Los Angeles, CA

$88,854 - $142,166 / year

Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job Summary The Utilization Management (UM) Claims Review Nurse RN II is responsible for conducting clinical review of medical claims to ensure services were medically necessary, appropriately documented, accurately billed, and compliant with established clinical policies and regulatory standards. This position supports payment integrity initiatives through retrospective and pre-payment review processes, helps reduce unnecessary denials, and monitors for potential fraud, waste, and abuse (FWA). The UM Claims Review Nurse RN II collaborates closely with internal teams to ensure accurate adjudication and compliance. This position collaborates closely with internal stakeholders and external entities to support compliance with state, federal, and accreditation requirements. Duties Perform claims pre-payment review by supporting the Claims team in evaluating flagged claims prior to adjudication to ensure services are medically necessary, documentation supports billed services, coding is accurate and aligned with authorization when applicable, and unnecessary denials are reduced through accurate clinical validation. Conduct comprehensive retrospective reviews, applying established clinical criteria, policies, and regulatory guidelines to determine medical necessity and appropriateness of services rendered. Complete Provider Dispute Review (PDR) clinical evaluations for disputed claims requiring medical necessity scrutiny and clinical determination. Apply internal and external clinical policies, including those developed by the Clinical Policy team, to ensure compliance with guidelines intended to limit fraud, waste, and abuse (FWA). Ensure adherence to federal and state regulations, and accreditation standards. Monitor trends related to contested claims and identify potential FWA concerns; escalate findings in accordance with organizational compliance protocols. Collaborate with internal teams to support payment integrity initiatives. Provide clear, well-documented clinical rationales supporting approval, denial, or adjustment decisions. Maintain productivity and quality standards consistent with departmental expectations. Participate in audits, regulatory readiness activities, and quality improvement initiatives as assigned. Document review outcomes clearly and accurately within designated systems, ensuring audit readiness and traceability. Remain current with evolving clinical guidelines, coding standards, reimbursement methodologies, and regulatory requirements. Perform other duties as assigned.Duties Continued Education Required Associate's Degree in NursingEducation Preferred Bachelor's Degree in NursingExperience Required: At least 5 years of experience in Clinical Nursing. At least 3 years of experience with Medi-Cal and Medicare in a managed care environment. Experience in performing and creating clinical documentation. Experience in regulatory compliance for a health plan. Preferred: Experience with Provider Dispute Review (PDR) processes. Experience applying clinical guidelines (e.g., InterQual, MCG, or internally developed criteria) in processes. Prior experience in payment integrity, compliance, or fraud, waste, and abuse (FWA) monitoring.Skills Required: Knowledge of medical necessity criteria, reimbursement principles, and managed care operation. Working knowledge of clinical policies. Working knowledge of CPT/HCPC Codes, and ICD-10. Proficient in claims processing systems and electronic medical record platforms. Strong problem-solving skills and the ability to identify discrepancies, assess risk, and recommend actionable solutions. Strong verbal and written communication skills. Ability to work independently with a high degree of initiative, organization, and self-direction. Ability to work effectively with diverse teams in cross-functional work groups. Ability to multitask, re-prioritize tasking, and streamline day-to-day operations. Familiarity with regulatory and accreditation standards (e.g., CMS, Medi-Cal, NCQA). Understanding of the managed care industry and market conditions. High organizational and time-management skills. Preferred: Strong analytical and investigative skills with the ability to synthesize clinical and claims information into clear, defensible determinations are highly valued. Advanced knowledge of medical necessity criteria tools such as InterQual or MCG. Extensive knowledge in claims reviews includes retrospective reviews, pre-payment claims review, and medical necessity determinations. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California LicenseLicenses/Certifications Preferred Required Training Physical Requirements LightAdditional Information Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. L.A. Care offers a wide range of benefits including Paid Time Off (PTO) Tuition Reimbursement Retirement Plans Medical, Dental and Vision Wellness Program Volunteer Time Off (VTO)

Care Manager (RN) (Syracuse, NY)

Molina Healthcare Syracuse, NY

$26.41 - $61.79 / hour

JOB DESCRIPTION Job Summary Provides support for care management/care coordination activities and collaborates with multidisciplinary team coordinating integrated delivery of member care across the continuum. Strives to ensure member progress toward desired outcomes and contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Completes comprehensive assessments of members per regulated timelines and determines who may qualify for care management based on clinical judgment, changes in member health or psychosocial wellness and triggers identified in assessments. • Develops and implements care coordination plan in collaboration with member, caregiver, physician and/or other appropriate health care professionals and member support network to address member needs and goals. • Conducts telephonic, face-to-face or home visits as required. • Performs ongoing monitoring of care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly. • Maintains ongoing member caseload for regular outreach and management. • Promotes integration of services for members including behavioral health, long-term services and supports (LTSS), and home and community resources to enhance continuity of care. • Facilitates interdisciplinary care team (ICT) meetings and informal ICT collaboration. • Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts. • Assesses for barriers to care, provides care coordination and assistance to member to address concerns. • May provide consultation, resources and recommendations to peers as needed. • Care manager RNs may be assigned complex member cases and medication regimens. • Care manager RNs may conduct medication reconciliation as needed. • 25-40% estimated local travel may be required (based upon state/contractual requirements). Required Qualifications • At least 2 years experience in health care, preferably in care management, or experience in a medical and/or behavioral health setting, or equivalent combination of relevant education and experience. • Registered Nurse (RN). License must be active and unrestricted in state of practice. • Valid and unrestricted driver's license, reliable transportation, and adequate auto insurance for job related travel requirements, unless otherwise required by law. • Understanding of the electronic medical record (EMR) and Health Insurance Portability and Accountability Act (HIPAA). • Demonstrated knowledge of community resources. • Ability to operate proactively and demonstrate detail-oriented work. • Ability to work within a variety of settings and adjust style as needed - working with diverse populations, various personalities and personal situations. • Ability to work independently, with minimal supervision and self-motivation. • Responsiveness in all forms of communication, and ability to remain calm in high-pressure situations. • Ability to develop and maintain professional relationships. • Excellent time-management and prioritization skills, and ability to focus on multiple projects simultaneously and adapt to change. • Excellent problem-solving, and critical-thinking skills. • Strong verbal and written communication skills. • Microsoft Office suite/applicable software program proficiency, and ability to navigate online portals and databases. Preferred Qualifications • Certified Case Manager (CCM). To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $26.41 - $61.79 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Registered Nurse - Med Surg/Tele

Northwell Health New Hyde Park, NY

$63 - $94 / hour

195642 Job Description Performs an age specific plan of care for a designated group of patients using the nursing process of assessment, diagnosis, outcome identification, planning, implementation, and evaluation of patient care. Collaborates with physicians and other health team members in coordinating and implementing procedures and treatments. Uses leadership skills/clinical judgment in coordinating patient care and directing/delegating activities of the patient care unit team. Job Responsibility Conducts patient interview, explains policies and procedures to patient/ significant others, reviews patient’s chart and answers questions correctly and courteously; assesses gastrointestinal, cardiovascular, respiratory, renal and neurological health status; determines mobility, sensory deficits, prostheses use, and skin condition and adjusts plan of care, as appropriate; assesses level of pain and pain management; communicates/documents patient’s physiologic health status and plan of care; assesses patient’s psychosocial health status; elicits perception of medical/nursing care and the expectation of care. Determines coping mechanism, knowledge level, and ability to comprehend; identifies cultural/ethnic requirements to reduce anxiety and ensure patient satisfaction; communicates and documents psychological status and care plan of support groups, counseling services, and social services; identifies patient outcome; develops criteria for measurement of patient outcomes; identifies actual/potential patient problems; identifies patient’s need for teaching based on psychosocial and developmental assessment. Develops patient outcome statement (s) and establishes individualized patient goals; identifies care activities and establishes the priorities necessary to achieve expected outcome; coordinates the cost-effective use of supplies, equipment and medication to achieve expected outcome; documents the plan of care and collaborates with physicians and other health team members; implements the plan of care; maintains constant vigilance over patients care to ensure that safety precautions/needs are followed (side rails up, call lights and bedside stand within reach, etc.). Exercises professional skills related to the plan of care; reassesses patients as needed and appropriately revises plan of care; correctly administers prescribed treatments; correctly uses equipment necessary for patient care; provides emotional support to patient and significant other; applies scientific principles in performing procedures; carries them out safely, timely and efficiently; makes accurate observations of patient’s conditions during treatments/procedures; reports and records same as appropriate; Keeps accurate documentation of patient’s treatment, activity and condition, as well as patient’s responses to medical and nursing interventions; uses appropriate methods of documentation according to departmental policy; acts rapidly and effectively during any emergency situation, managing self, patients and other employees; provides a calm, quiet, restful atmosphere; communicates effectively with the patient’s family or caretakers; participates in planning for discharge and coordinates referrals, as appropriate; provides discharge instructions to patient and significant other; evaluates care provided for patient outcome. Demonstrates ability to measure effectiveness of care provided and documents same; performs variance analysis related to outcome data for performance improvement; designs, implements, and evaluates systems to improve care in unit; keeps accurate documentation of patient’s treatment, activity and condition; uses appropriate methods of documentation according to departmental policy; collaborates with other care team members in planning and carrying out treatment regimen; provides direction to other members of the care team; collaborates with the appropriate physician on patient’s plan of care. Accurately interprets and implements treatment regimen as prescribed by the Physician; assists the Physician during treatments and/or diagnostic procedures; keeps the Patient Care Manager/designee and/or physician, abreast of changes in patient’s condition and/or treatments, as appropriate; uses clinical judgment in delegating assignments in providing patient care, and ensures that assignments are completed in a timely fashion; performs grade I-IV Decubitus Care; performs preventive skin care measures; applies simple dressings, maintaining principles of aseptic technique. Applies warm and cold compresses, consistent with facility procedure; performs irrigations, consistent with Facility procedure; performs other procedures related to skin care, as necessary; administers medications correctly and safely; correctly identifies medication in terms of action, dosage, side effects, and implications for the patient; meets standard on medication administration examination; demonstrates preparation of local solutions. Administers and documents medication correctly; educates patients and significant others related to drug and food interactions; educates patients and significant others related to drug and food interactions; participates in patient and family education; provides patient with an explanation of his/her condition as indicated; communicates assessment data in an orderly fashion by recording, updating and verbalizing pertinent information to care team members and to appropriate agencies; recognizes and utilizes health teaching opportunities and resources /materials available for this teaching; provides for early discharge planning and appropriate referrals for post-hospital care; evaluates the effectiveness of teaching by feedback from patient/ family and documents same. Performs related duties as required. All responsibilities noted here are considered essential functions of the job under the Americans with Disabilities Act. Duties not mentioned here, but considered related are not essential functions. Job Qualification Graduate from an accredited School of Nursing. Bachelor’s Degree in Nursing, preferred. Must be enrolled in an accredited BSN program within two (2) years and obtain a BSN Degree within five (5) years of job entry date. Current License to practice as a Registered Professional Nurse in New York State required, plus specialized certifications as needed. Additional Salary Detail The salary range and/or hourly rate listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future.When determining a team member's base salary and/or rate, several factors may be considered as applicable (e.g., location, specialty, service line, years of relevant experience, education, credentials, negotiated contracts, budget and internal equity).

Care Manager (RN) (Omaha and Lincoln, NE)

Molina Healthcare Omaha, NE

$25.08 - $51.49 / hour

JOB DESCRIPTION Job Summary Provides support for care management/care coordination activities and collaborates with multidisciplinary team coordinating integrated delivery of member care across the continuum. Strives to ensure member progress toward desired outcomes and contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Completes comprehensive assessments of members per regulated timelines and determines who may qualify for care management based on clinical judgment, changes in member health or psychosocial wellness and triggers identified in assessments. • Develops and implements care coordination plan in collaboration with member, caregiver, physician and/or other appropriate health care professionals and member support network to address member needs and goals. • Conducts telephonic, face-to-face or home visits as required. • Performs ongoing monitoring of care plan to evaluate effectiveness, document interventions and goal achievement, and suggest changes accordingly. • Maintains ongoing member caseload for regular outreach and management. • Promotes integration of services for members including behavioral health, long-term services and supports (LTSS), and home and community resources to enhance continuity of care. • Facilitates interdisciplinary care team (ICT) meetings and informal ICT collaboration. • Uses motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts. • Assesses for barriers to care, provides care coordination and assistance to member to address concerns. • May provide consultation, resources and recommendations to peers as needed. • Care manager RNs may be assigned complex member cases and medication regimens. • Care manager RNs may conduct medication reconciliation as needed. • 25-40% estimated local travel may be required (based upon state/contractual requirements). Required Qualifications • At least 2 years experience in health care, preferably in care management, or experience in a medical and/or behavioral health setting, or equivalent combination of relevant education and experience. • Registered Nurse (RN). License must be active and unrestricted in state of practice. • Valid and unrestricted driver's license, reliable transportation, and adequate auto insurance for job related travel requirements, unless otherwise required by law. • Understanding of the electronic medical record (EMR) and Health Insurance Portability and Accountability Act (HIPAA). • Demonstrated knowledge of community resources. • Ability to operate proactively and demonstrate detail-oriented work. • Ability to work within a variety of settings and adjust style as needed - working with diverse populations, various personalities and personal situations. • Ability to work independently, with minimal supervision and self-motivation. • Responsiveness in all forms of communication, and ability to remain calm in high-pressure situations. • Ability to develop and maintain professional relationships. • Excellent time-management and prioritization skills, and ability to focus on multiple projects simultaneously and adapt to change. • Excellent problem-solving, and critical-thinking skills. • Strong verbal and written communication skills. • Microsoft Office suite/applicable software program proficiency, and ability to navigate online portals and databases. Preferred Qualifications • Certified Case Manager (CCM). To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $25.08 - $51.49 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Registered Nurse - Poison Control Call Center

SSM Health St. Louis, MO

It's more than a career, it's a calling MO-SSM Health 7980 Clayton RD Worker Type: Regular Job Highlights: Join a team where your work matters—every moment, every patient, every community. At SSM Health, you’ll be empowered to grow, supported to thrive, and inspired to make a lasting impact. Department: Poison Control Schedule: 3:00 PM to 11:30PM. (8 hours shifts) There is an every other weekend requirement with an ABC holiday rotation. Apply today. SSM Health – We bring out the incredible in you, everyday. Job Summary: Creates an environment that leads to a positive patient care experience by evaluating, planning and implementing effective patient care plans within the guidelines of the standards of nursing care and operational guidelines. May acquire knowledge of poison prevention techniques and interpret subtle indications while formulating accurate questions to aid in decision making responses regarding toxicology recommendations. May be responsible for emergency telephone management of poisoning exposures and questions handled for an entire state. Job Responsibilities and Requirements: PRIMARY RESPONSIBILITIES Staffs a telephone service line while acting collaboratively with staff, other health care providers and lay callers. Obtains and documents a complete and accurate history. Provides a calm, reassuring and intelligent interaction with the public and health care professionals. Uses computer for live data collection and documentation, online resources for information gathering, and communication with caller through phone system. Manages beneficial relationships with individuals and departments inside and outside of the ministry structure. Creates an environment that leads to a positive patient care experience by evaluating, planning and implementing effective patient care plans within the guidelines of the standards of nursing care and operational guidelines. May guide treatment advice for both the public and health care providers. May utilize advanced technology with live chat and texting to assist callers with poison information or exposures. May acquire knowledge of toxicological resources that are helpful in managing poison cases. May acquire knowledge of poison prevention techniques and interpret subtle indications while formulating accurate questions to aid in decision making responses regarding toxicology recommendations. Works in a constant state of alertness and safe manner. Performs other duties as assigned. EDUCATION Graduate of accredited school of nursing or education equivalency for licensing EXPERIENCE Three years' registered nurse experience with insight in medical/surgical, pediatric or maternal/child health PHYSICAL REQUIREMENTS Frequent lifting/carrying and pushing/pulling objects weighing 0-25 lbs. Frequent sitting, standing, walking, reaching and repetitive foot/leg and hand/arm movements. Frequent use of vision and depth perception for distances near (20 inches or less) and far (20 feet or more) and to identify and distinguish colors. Frequent use of hearing and speech to share information through oral communication. Ability to hear alarms, malfunctioning machinery, etc. Frequent keyboard use/data entry. Occasional bending, stooping, kneeling, squatting, twisting and gripping. Occasional lifting/carrying and pushing/pulling objects weighing 25-50 lbs. Rare climbing. REQUIRED PROFESSIONAL LICENSE AND/OR CERTIFICATIONS State of Work Location: Illinois Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR) State of Work Location: Missouri Registered Nurse (RN) Issued by Compact State Or Registered Nurse (RN) - Missouri Division of Professional Registration State of Work Location: Oklahoma Registered Nurse (RN) Issued by Compact State Or Registered Nurse (RN) - Oklahoma Board of Nursing (OBN) State of Work Location: Wisconsin Registered Nurse (RN) Issued by Compact State Or Registered Nurse (RN) - Wisconsin Department of Safety and Professional Services Work Shift: Evening Shift (United States of America) Job Type: Employee Department: 8254000010 Poison Control Scheduled Weekly Hours: 20 SSM Health is an Equal Opportunity Employer. SSM Health provides equal employment opportunities to all employees and applicants for employment without regard to race, color, religion, sex, gender, pregnancy, sexual orientation, gender identity, national origin, age, disability, protected veteran status, genetic information, or any other characteristic protected by applicable federal, state, or local law. Click here to learn more.

Registered Nurse (RN) - Virtual Nursing

MaineHealth Portland, ME

Description MaineHealth Corporate Nursing Req #: 90444 Full Time (Monday through Friday 1130-2000) MaineHealth’s Virtual Nursing team is seeking a Full Time Registered Nurse (RN) to join our innovative virtual care program. This hybrid role provides virtual discharge education and support to patients, ensuring a smooth and safe transition from hospital to home. The RN will collaborate with the interdisciplinary team, review discharge instructions and medications, and use telehealth technology to deliver high-quality patient education. Ideal candidates have an active Maine RN license, acute care experience, strong communication skills, and comfort with technology. Join us in advancing patient-centered care through virtual innovation. Summary The Virtual Nurse will be a member of a new team at MaineHealth responsible for supporting hospital-based care teams, focused on improving quality, patient and family experience, bedside care team experience, and improving hospital efficiency of care. The Virtual Nurse will use virtual communication channels including synchronous video conferencing, secure asynchronous chat, and telephonic tools to interact with patients admitted to a MaineHealth hospital. The Virtual Nurse is also responsible for providing patients with virtual health assessments and treatment solutions through virtual rounds. This position requires collaboration with clinical staff and other care team members across MaineHealth to meet the diverse and continually changing challenges of the healthcare environment. Required Minimum Knowledge, Skills, And Abilities (KSAs) EducationBachelor of Science Degree in Nursing (BSN) preferred. Must matriculate to a BSN program within 1 year of hire with completion attained within 5 years of hire. Evidence of 10 hours of ongoing education per year. License/Certifications:Current license to practice as a Registered Professional Nurse in the State of Maine. BLS certification is also required. Experience:At least 5 years of Acute Care RN work experience. Additional Skills/Requirements Required:Demonstrates the skills necessary to interact effectively with patients, families, and healthcare team members. Additional Skills/Requirements Preferred:Proficiency in the use ofACLS, PALS,and EPIC systems. Additional Information MaineHealth is committed to fostering a supportive, inclusive environment where care team members can thrive while making a meaningful impact in the communities we serve across Maine and New Hampshire. We offer competitive benefits including paid parental leave, flexible work options, student loan assistance, professional development opportunities, and well-being resources—so you can grow your career while feeling supported both personally and professionally. We recognize the value each team member brings to our organization.Any offer of employmentwill depend onqualificationssuch asskills, relevant experience, education, certifications,and otherjob-relatedfactors. Thebase rangeis an estimate and does notreflect the full valueofourtotal compensationpackage. The pay range for this position is $37.09to $50.17 per hour. Compensation for part-time positions isdeterminedon a prorated basis consistent with the scheduled hours and applicable full-time equivalent (FTE). In addition to base pay, MaineHealth offerscomprehensivebenefits, recognition programs, career growth opportunities, and,where applicable,shiftdifferentials or other incentives. If you have questions about this role, please contact amanda.oliveira@mainehealth.org Hiring Scam Alert MaineHealth will never request financial information during the interview or pre-hiring process. All legitimate communications will come from an email address ending in @mainehealth.org. If you suspect fraudulent activity, please report it immediately to mhcareers@mainehealth.org. Notice Regarding Maine Employer Surveillance Statute:Pursuant to Maine's Employer Surveillance Statute, prospective care team members are notified that MaineHealth may monitor, collect, record, review, or retain information related to the use of its systems, networks, applications, files, data, communications platforms (including notified recordings), smart badges, building access, company vehicle GPS data, business calls, and workplace security cameras. Information collected may be used for legitimate business purposes, including security, safety, compliance, investigations, training, quality assurance, and operational management.

Registered Nurse (RN) - National After-Hours Team - Part Time

Curana Health

Registered Nurse (RN) - National After-Hours Team - Part Time Location US-Remote ID 2026-4353 Category Provider Position Type Part-Time At Curana Health, we're on a mission to radically improve the health, happiness, and dignity of older adults—and we're looking for passionate people to help us do it. As a national leader in value-based care, we offer senior living communities and skilled nursing facilities a wide range of solutions (including on-site primary care services, Accountable Care Organizations, and Medicare Advantage Special Needs Plans) proven to enhance health outcomes, streamline operations, and create new financial opportunities. Founded in 2021, we've grown quickly—now serving 200,000+ seniors in 1,500+ communities across 32 states. Our team includes more than 1,000 clinicians alongside care coordinators, analysts, operators, and professionals from all backgrounds, all working together to deliver high-quality, proactive solutions for senior living operators and those they care for. Ranked #147 on the Inc. 5000 list of America's fastest-growing private companies, we're just getting started. If you're looking to make a meaningful impact on the senior healthcare landscape, you're in the right place—and we look forward to working with you. For more information about our company, visit CuranaHealth.com. Summary An RN functions as part of the National After-Hours Team (NAHT), and reports to the NAHT Director of Clinical Operations (DCO) or Clinical Team Lead (CTL). The RN performs activities that fall within the RN scope of practice. This role works in close collaboration with all of the team members and may support multiple providers. The RN works under the direction of the provider, and activities are delegated to the RN by the provider or the DCO/CTL. The RN understands and supports the NAHT models of care including the varying settings including Skilled-Nursing Facilities, Short Term Rehab, Assisted Living Facilities and Independent Living Communities. Essential Duties & Responsibilities The NAHT RN is responsible for providing telephonic care and direction to members and facility staff during various overnight, weekend, and holiday hours. This role is responsible for the delivery of medical care services to a pre-designated group of enrollees in the Midwest Region. In this home-based role you will provide afterhours virtual (primarily telephonic) care for aging residents in various settings. This excellent opportunity affords an autonomous role bringing enormous satisfaction in the care and comfort of our aging population. This is a part time work from home position requiring various shift coverage with a mix of weeknights, weekend, and holiday coverage. Scheduling & Hours: This is a part time work from home position requiring various shift coverage with a mix of weeknights, weekend, and holiday coverage. While shift times can vary, we provide coverage to members on weeknights from 5pm- 8am local time, continuous coverage from Friday at 5pm to Monday at 8am. Holiday coverage is also provided beginning at 5pm of the end of the last business day to 8am of the resumption of business hours. Availability and Coverage expectations for this role While shift times can vary, we provide coverage to members on weeknights from 5pm- 8am local time, continuous coverage from Friday at 5pm to Monday at 8am. Holiday coverage is also provided beginning at 5pm of the end of the last business day to 8am of the resumption of business hours. Availability and Coverage expectations for this role Two Weeknight shifts from 6pm-12am Every other weekend coverage for 12-hour day shifts Overnight and holidays are required for all RNs Holiday scheduling is completed at the beginning of the year for advanced planning Primary Responsibilities : Care Coordination Assist the provider/team with various care coordination activities to support the role of the NAHT APPs Telephonic triage of incoming calls and voicemails to determine the correct level of care. Responsible for collaborating with the nursing facility, APPs, and community members to identify and respond to changes in condition. Assist the provider/team with inbound and outbound communications for members including addressing handoffs, telephonic assessments, and acuity follow-ups. Team Support Assist in the coordination of the follow up of members in the ER. Participate in the onboarding of new clinical staff under the direction of the DCO/CTL; the RN may coordinate onboarding activities and participate in other orientation activities under the direction of the DCO/CTL. Documentation Document all clinical information, telephonic assessments, and activities in the appropriate documentation tool. RN to APP Hand Off One entry by the RN and one responding entry by the APP should be recorded in the appropriate documentation tool. RN is responsible for escalating appropriate calls to the NAHT APP. Use of RN mini soap note for acute change in condition calls escalated to APP. Use of the fall mini soap note for reported falls, escalate to APP. Qualifications Current, unrestricted compact RN license in primary state. (Additional licensure in assigned states must be obtained within 6 months of hire, if home state does not participate in compact license). 3+ years of clinical experience in a hospital, acute care, home health/hospice, direct care, or case management position. Dedicated space for home office set up. Access to high speed internet services Computer/typing proficiency to enter and retrieve data in electronic clinical records. Proficient with Microsoft Word, Outlook, and Excel. Strong problem solving skills. Ability to communicate 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 flex with change and perform positively and efficiently in production driven environment. Preferred Qualifications : Experience working with the needs of vulnerable populations who have chronic or complex bio-psychosocial needs Experience triaging calls Curana Health is dedicated to the principles of Equal Employment Opportunity. We affirm, in policy and practice, our commitment to diversity. We do not discriminate on the basis of actual or perceived race, color, creed, religion, national origin, ancestry, citizenship status, age, sex or gender (including pregnancy, childbirth and related medical conditions), gender identity or gender expression (including transgender status), sexual orientation, marital status, military service and veteran status, physical or mental disability, protected medical condition as defined by applicable or state law, genetic information, or any other characteristic protected by applicable federal, state and local laws and ordinances. The EEO policy applies to all personnel matters as outlined in our company policy including recruitment, hiring, transfers, and general treatment during employment. *The company is unable to provide sponsorship for a visa at this time (H1B or otherwise). We’re thrilled to announce that Curana Health has been named the 147 th fastest growing, privately owned company in the nation on Inc. magazine’s prestigious Inc. 5000 list. Curana also ranked 16 th in the “Healthcare & Medical” industry category and 21 st in Texas. This recognition underscores Curana Health’s impact in transforming senior housing by supporting operator stability and ensuring seniors receive the high-quality care they deserve. Options Apply Apply Submit a Referral Refer Sorry the Share function is not working properly at this moment. Please refresh the page and try again later. Curana Health is dedicated to the principles of Equal Employment Opportunity. We affirm, in policy and practice, our commitment to diversity. We do not discriminate on the basis of actual or perceived race, color, creed, religion, national origin, ancestry, citizenship status, age, sex or gender (including pregnancy, childbirth and related medical conditions), gender identity or gender expression (including transgender status), sexual orientation, marital status, military service and veteran status, physical or mental disability, protected medical condition as defined by applicable or state law, genetic information, or any other characteristic protected by applicable federal, state and local laws and ordinances. The EEO policy applies to all personnel matters as outlined in our company policy including recruitment, hiring, transfers, and general treatment during employment. *The company is unable to provide sponsorship for a visa at this time (H1B or otherwise). Application FAQs Software Powered by ICIMS www.icims.com

RN

Telehealth

3 weeks ago

Clinical Policy Nurse RN II

L.A. Care Health Plan Los Angeles, CA

$88,854 - $142,166 / year

Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job Summary The Clinical Policy Nurse RN II is responsible for analytical research, trending, and assessment based on legislation, regulatory and accreditation requirements that impact claims, Utilization Management (UM) department and healthcare services policies. Reviews and analyzes clinical financial data to assess the effectiveness of existing and proposed policies to identify opportunities for improvement, cost containment, and quality enhancement. This position plays a key role in translating regulatory impacts into operational strategies and works collaboratively with internal and external stakeholders to ensure clinical policies support safe, effective, and compliant care delivery. Assists in development of policies and programs that improve health outcomes and target Fraud, Waste and Abuse (FWA). This position works cross functionally with other departments to develop end to end operational strategies of policy content and roll out timeframes. The Clinical Policy Nurse II serves as a liaison to ensure the ongoing maintenance of clinical coding for the authorization matrix.Duties Assess federal, state, and local legislation, regulatory guidance, and health care policies to identify potential impacts on clinical practice, reimbursement and organizational operations that impact healthcare services policies. Review and interpret clinical, utilization, and financial data to identify trends, opportunities for policy improvement and cost-savings. Research, develop, and evaluate clinical and health policy designed to improve patient outcomes, detect and mitigate Fraud, Waste, and Abuse (FWA), and streamline organizational processes. Monitor the implementation of health programs, clinical initiatives, and community action plans to assess effectiveness, compliance, and impact on patient outcomes. Collaborate with internal stakeholders to evaluate utilization trends and anomalies and contribute to policy development aimed at improving efficiency and compliance identified during risk assessments. Prepare analytical reports, summaries, and analyses assessing policy performance, regulatory impact, and communicate insights and recommendations to stakeholders to drive evidence-based policy and impacted outcomes. Present findings, recommendations, and action plans to key stakeholders. Participate in work groups related to healthcare services clinical policies and procedures including efforts to improve department processes, as needed. Perform other duties as assigned.Duties Continued Education Required Associate's Degree in NursingEducation Preferred Bachelor's Degree in NursingExperience Required: At least 5 years of experience in Clinical Nursing. At least 3 years of experience with Medi-Cal and Medicare in a managed care environment. Experience in performing and creating clinical documentation. Experience in regulatory compliance for a health plan. Preferred: Experience with active participation in state regulatory audits such as Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), Centers for Medicare and Medicaid Services (CMS), and/or National Committee for Quality Assurance (NCQA) audits. At least 1 year of experience in clinical health services policies with a managed care plan. Skills Required: Demonstrated strong reporting skills by preparing clear, concise reports and presentations that communicate findings and performance. Working knowledge of clinical policies. Strong analytical and critical thinking skills with the ability to interpret regulatory requirements and legislation. Ability to translate regulatory requirements into auditable tools. Ability to perform independent research on complex medical topics. Excellent verbal and written communication skills. Strong problem solving and team building skills. Ability to work independently with strong self-direction. Advanced proficiency in Microsoft Word, Excel, and PDF documentation tools. Ability to work effectively with diverse teams in cross-functional work groups. Ability to multitask, re-prioritize tasking, and streamline day-to-day operations. Strong organizational and time-management skills. Preferred: Advanced skills in assessing clinical policy deficiencies through literature searching and clinical research analysis based on the best available evidence. Understanding of the managed care industry and market conditions. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California LicenseLicenses/Certifications Preferred Required Training Physical Requirements LightAdditional Information Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. L.A. Care offers a wide range of benefits including Paid Time Off (PTO) Tuition Reimbursement Retirement Plans Medical, Dental and Vision Wellness Program Volunteer Time Off (VTO)

Director of Clinical Operations

Allara Health New York, NY

$185,250 - $195,000 / year

Allara is a comprehensive women’s health provider that specializes in expert, longitudinal care that supports women through every life stage. Trusted by over 60,000 women nationwide, Allara makes expert healthcare accessible by connecting patients with multidisciplinary care teams that have a deep understanding of hormonal, metabolic, and reproductive care. Allara provides ongoing support for hormonal conditions like PCOS, chronic conditions like insulin resistance, and life stages like perimenopause, helping patients see improved health outcomes . As one of the fastest-growing women’s health platforms in the U.S., Allara is bridging long-overlooked gaps in healthcare for women. The Opportunity The Director of Clinical Operations will own the full provider network operations function end-to-end. The role owns two connected jobs: getting providers live and productive quickly, credentialing, payer enrollment, onboarding, and ramp — and keeping the network running well once they are. You'll own the outcomes , not just the processes. The right person is a seasoned operations leader who is process-obsessed, energized by automation and tooling, comfortable with ambiguity, and motivated by the challenge of scaling something that isn't fully built yet. Healthcare operations experience is preferred and may give you a jump start on understanding the complexities in the environment we are working in, but mindset matters more than resume. Location: Hybrid (NYC). We value in-person collaboration and aim for at least three days per week in our NYC office, with flexibility as needed. Your Impact Build, scale and repeat You have an eye for making processes better and are invigorated about the potential of AI and other tooling to strengthen our impact as we grow. You bring strong analytical rigor, and you have the ability to inspire your team to follow your lead. Design and own the operational infrastructure that makes provider network growth feel frictionless, built to scale from hundreds of providers to thousands Lead multi-state provider credentialing, licensing and cross-licensing, including our APRN collaboration agreement program across all active states Build and maintain systems for delivering provider performance data, dynamic availability management, and capacity and utilization tracking Drive knowledge management systems that reduce tribal knowledge and create self-serve resources for providers and internal teams Lead margin performance and provider compensation strategy Translate strategic goals into concrete operational plans, and activate your team to execute reliably Own the provider lifecycle You lead the teams that make or break whether our provider network scales effectively and efficiently, from forecasting all the way through the provider journey. Own the end-to-end provider experience from hiring through credentialing, onboarding, training, clinical performance management, and offboarding; build a scalable and high quality funnel that can achieve 2-3x provider growth without a proportional increase in operations resourcing Partner cross-functionally with Growth, Recruiting, Payer Operations, Clinical Management, and Product to eliminate friction at every handoff Build the data visibility, dashboards and accountability structures that allow leadership to identify and act on network performance trends and bottlenecks in real time Identify where manual, error-prone processes exist and lead the charge to automate or systematize them Lead the team You coach, inspire and drive performance across a diverse group of team members across multiple functions. You can ruthlessly prioritize, delegate effectively, and manage up, down, and sideways effectively. Effectively coach and manage a team of functional owners including managers and independent contributors to effectively execute against our operational initiatives Lead efforts on AI enablement, automation, and overall efficiency and reliability across the clinical operations team Serve as a thought partner in cross-functional workgroups, strategic planning, and leadership initiatives Turn data and project updates into actionable insights and clear recommendations to leadership Required Qualifications 5-7 years of experience in high growth operations, with a preference for direct exposure to provider network management, credentialing, or multi-state licensing Demonstrated ability to build and improve operational systems in a fast-moving, resource-constrained environment - you've built something from scratch before Process-obsessed and detail-oriented: you see inefficiency and can't help but fix it Margin/ cost / P&L ownership experience Strong analytical skills: comfortable pulling data, identifying trends, and translating insights into operational decisions Excellent cross-functional communicator, able to work across clinical, product, and operations teams and move things forward without direct authority and distill down fuzzy information into clear and direct insights Genuinely excited by automation, tooling, and AI. You see technology as a force multiplier, not a threat and would be excited to share your latest work Preferred Qualifications Experience in telehealth or multi-state provider network operations Familiarity with credentialing systems, EHR platforms, LMS platforms, workflow automation tools, and other practice management tooling Familiarly with women's health, virtual care, or collaborative care models What Allara Offers Compensation & Career Growth $185,250-$195,000 with opportunities for advancement Equity Professional development & employee learning programs Actual compensation will be determined based on a variety of factors, including but not limited to: candidate experience, location, education, certifications, and skill set. In addition to base salary, our total compensation package includes equity, comprehensive health benefits (medical, dental, vision), generous paid time off, and additional wellness and professional development perks. Work Environment & Flexibility 3-day hybrid in NYC Unlimited PTO & 11 company holidays Health & Wellness Medical, dental, and vision benefits Health Savings Account (HSA) & Flexible Spending Account (FSA) Long- and short-term disability coverage Annual employee wellness stipend Family & Future Planning 401(k) plan Parental leave & family planning support benefits Additional Perks Company-issued laptop Annual work-from-home stipend Commuter benefits (if applicable) A collaborative, mission-driven culture focused on improving patient care At Allara , we believe in celebrating everything that makes us human and are proud to be an equal-opportunity workplace. We embrace diversity and are committed to building a team that represents a variety of backgrounds, perspectives, and skills. We believe that the more inclusive we are, the better we can serve our members. We’re an Equal Opportunity Employer and do not discriminate against candidates or patients based on race, color, gender, sexual orientation, gender identity or expression, age, religion, disability, national origin, protected veteran status, or any other status protected by applicable federal, state, or local law.

Care Coordinator Registered Nurse - Remote in Michigan

McLaren Health Care Flint, MI

Position Summary: As an advocate for the patient, the RN care manager will assess, plan, implement, coordinate, monitor, and evaluate the options and services required to meet an individual’s health needs, using clinical and community resources to promote quality, cost effective outcomes. Integrates evidenced based clinical guidelines, preventive guidelines, and protocols, in the development of individualized care plans that are patient centric. Provides targeted interventions to avoid hospitalization and emergency room visits. Essential Functions and Responsibilities: Provides telephonic and face-to-face comprehensive assessment and care management services to patients as part of an interdisciplinary team. Uses multi-dimensional assessment skills, risk assessment and screening tools to target high risk and vulnerable populations. Assesses over time the health care, educational, and psychosocial needs of the patient/caregiver.Uses standardized assessment tools such as depression screening, functionality, and health risk assessment. Provides follow up with patient/family when patient transitions from one setting to another.Completes timely post-hospital follow up: Medication reconciliation, PCP or specialist follow-up appointment, assess symptoms, teach warning signs, review discharge instructions, coordination of care, and problem solve barriers. Uses clinical judgment to determine level of care and collaborates with the PCP, patient and interdisciplinary team, including continuum of care settings and community. Responsible for developing a comprehensive individualized plan of care and targeted interventions.Continually monitors patient/family response to plan of care and revises the care plan as indicated. Provides patient self-management support with a focus on empowering the patient/caregiver to build capacity for self-care. Implements systems of care that facilitate close monitoring of high-risk patients to prevent and/or intervene early during acute exacerbations. Implements clinical interventions and protocols based on risk stratification and evidenced-based clinical guidelines. Coordinates patient care through ongoing collaboration with PCP, patient/caregiver, McLaren Health Care, community agencies, health plans, and other disciplinary team members. Fosters a team approach and includes patient/caregiver as active members of the team. Takes the lead in ensuring the continuity of care which extends beyond the practice boundaries. Serves as liaison to acute care hospitals, specialists, post-acute care services and community services. Demonstrates excellent written, verbal and listening communication skills, positive relationship building skills, and critical analysis skills. Maintains required documentation of all care management activities. Works with MPP Medical leadership to continuously evaluate process, identify problems, and propose/develop process improvement strategies to enhance care management and Patient Centered Medical Home delivery of care model. Reviews the current literature regarding effective engagement and communication strategies, care management strategies, and behavior change strategies and incorporates them into clinical practice. Other duties as assigned or when necessary to maintain efficient operations of the department and the Company as a whole. Required: RN with a valid unrestricted Michigan license. Three (3) years clinical nursing experience serving chronically ill patients and extensive knowledge of issues associated with chronic care and geriatrics. Preferred: RN, BSN. Three (3) years experience in a health plan or Physician Organization environment with care coordination, care management, and/or population health. Telephonic care management experience. Home care and/or hospice experience. Complex Care Management course completion or CCM. Additional Information Schedule: Full-time Requisition ID: 26004629 Daily Work Times: 8:00am-5:00pm Hours Per Pay Period: 80 On Call: No Weekends: No

Practice Telephonic Triage RN - Internal Medicine

TriHealth Cincinnati, OH

Job Description Join Our Team as a Practice Telephonic Triage Registered Nurse! At TriHealth, we are driven by a shared commitment to excellence and innovation in healthcare. We believe that every test, analysis, and result plays a vital role in our mission to provide the highest standard of care to our patients. Join us in our mission to advance healthcare and improve lives. Apply today and be part of a team that is passionate about making a difference. We offer career growth opportunities , and a comprehensive benefits package. Location: TriHealth Internal Medicine – at 375 Dixmyth Avenue Cincinnati, OH 45220 In person position If the office is closed, you will be expected to work from home. Work Schedule Full - Time (80 hours bi-weekly) Day shift - 7:30AM-5:00PM. Rotating Saturday 8am-12pm taking calls for all of group health offices. Incentives & Benefits We offer a comprehensive benefits package, including medical, dental, vision, paid time off, retirement plans, and tuition reimbursement. https://careers.trihealth.com/what-we-offer/benefits Job Requirements Associate's Degree in Nursing (Required) 2 - 3 years Clinical Nursing (Required) Acute Care Strong Computer Skills Ability to type and talk at the same time Knowledge, judgment, and skills derived from the principles of Biological, Physical, Behavioral, Social, and Nursing sciences. Registered Nurse RN - Registered Nurse - State Licensure and/or Compact State Licensure Upon Hire Required Basic Life Support (BLS) Upon Hire Required Job Overview The Telephonic Triage RN is responsible for providing nursing care services to assigned practice(s)/specialty(s). Completes bio-psychosocial telephonic assessment using approved clinical protocols to triage patient needs and provide best course of action or patient disposition. This role serves as a patient/caregiver advocate and acts as a communication link between the patient/caregiver, physician, pharmacy, and or hospital using approved system platforms for communication. This role has a strong working knowledge of patient needs that are emergent and require immediate attention, urgent, and non-urgent. This role utilizes best practices in documentation to ensure communication is efficient, concise, and timely. The goal is to provide first call resolution. This role understand the needs of the organization and supports the mission, values, and management of TriHealth Physician Practices. Job Responsibilities Coaching/Development: Promotes a positive work environment by working collaboratively with team members, recognizing colleagues for excellence, and participating in peer to peer coaching Interdisciplinary Collaboration: Manages In-Basket messages received in a timely manner. Responds to and addresses patient concerns, first call resolution, when in scope. When applicable, ensures all messages sent to providers have complete and accurate information. Implements changes in nursing practice/patient care that have resulted from quality of care activities. Operations Management: Operating in "Ready" mode during work hours with minimum utilization of "AUX/Not Ready". Goal is

Registered Nurse-OSH

Oak Street Health Tucson, AZ

$54,095 - $116,760 / year

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Title: Registered Nurse Company: Oak Street Health Role Description: The purpose of a Registered Nurse at Oak Street Health is to build strong relationships with Oak Street Health patients by coordinating their care and providing a seamless experience to patients and their support team. At Oak Street Health you will use an integrated approach toward achieving desired patient outcomes by utilizing standards, guidelines and pathways for care delivery. Through clinical assessment, intervention and education you will ensure our patients are provided competent nursing care in a timely manner. Our Registered Nurses drive quality care, it is of vital importance that our nurses incorporate data and information to improve care and enhance our patient outcomes. You will work to create an engaging and welcoming environment through team communication and delegation to empower other members of the care team to deliver the best care to our patients. Our Registered Nurses report to the Practice Manager or Nurse Supervisor (where applicable). Core Responsibilities: Provide competent nursing care by displaying proficiency in this role and executing job responsibilities in a safe and consistent manner Respond to incoming telephonic requests in a dependable manner, ensuring we are responsive to their needs and exceeding expectations Provide clinically competent triage and symptom management to patients who may or may not be physically present Utilize standardized protocols for medication management, prescription refills and prior authorizations. Conduct thorough and accurate reviews of patient medications and update as needed Provide comprehensive education and direct patient care, particularly around chronic conditions; may occur in person, over the phone or in group settings Actively collaborate and monitor the implementation and progress of the care plan for patients on multiple provider panels Form relationships with patients and their caregivers to support preventative care and ED/hospital diversion where appropriate Create a welcoming and engaging environment to meet the needs of our patients, communities, families and teams where they are Delegation of activities to other clinical care team members to support the needs of our patients Participate in care team meetings to discuss patient care and clinic operations Deliver an exceptional patient experience through service, responsiveness and respectful care Perform point of care testing, procedures and specimen collection (including phlebotomy) as needed Performs other related duties as assigned What we're looking for Required Qualifications: Active Registered Nurse (RN) Licensure in good standing with the applicable state BLS Certification Electronic Medical Record (EMR) experience Ability to maintain patient confidentiality and process information in a confidential manner US work authorization Ability to assess patients without face-to face interaction, strong communication and assessment skill Strongly Preferred Qualifications: Ability to collaborate and communicate with members of an interdisciplinary care team Excellent computer skills with ability to read, interpret and analyze data from various computer systems Effective problem solving and prioritization skills 2+ years of healthcare experience, working as an RN Preferred Qualifications: Previous experience in clinic setting Ability to work independently Fluency in Spanish, Polish, Russian, or other languages spoken by people in the communities we serve Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $54,095.00 - $116,760.00 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families. This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility. Additional details about available benefits are provided during the application process and on Benefits Moments . We anticipate the application window for this opening will close on: 10/25/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

Clinical Guide Part A: (UM) Utilization Management Nurse

Devoted Health

$82,680 - $96,460 / year

Job Description A bit about this role: The Clinical Guide Part A will be part of the Utilization Management team, responsible for inpatient, behavioral health, and/or post-acute authorization review in alignment with CMS and Medicare Advantage regulations. Reviews medical records to evaluate the medical necessity and appropriateness of requested inpatient and/or post-acute services in accordance with established clinical criteria and CMS guidelines. Schedule: This is a full-time, remote position working five 8-hour days. We are hiring for several schedules: Tuesday – Saturday, 9:00 AM – 6:00 PM ET Sunday – Thursday, 9:00 AM – 6:00 PM ET Monday – Friday, 11:00 AM – 8:00 PM ET Monday – Friday, 9:00 AM – 6:00 PM ET We'll ask about your schedule preference during the process and will do our best to match it. Because we are filling a limited number of openings on each schedule, availability changes as roles are filled — so we ask that candidates be open to more than one schedule where possible. Most schedules include one weekend day. Weekend and later-day coverage is a core part of how our Utilization Management team meets CMS turnaround requirements. Your Responsibilities and Impact will include: Review Medical Records: Conduct prospective (pre-service), concurrent, and retrospective utilization review to evaluate medical necessity, appropriate level of care (Inpatient vs. Observation), and post-acute services in accordance with established clinical criteria and CMS guidelines. Evaluate Treatment Plans: Assess the appropriateness, timing, and setting of requested services, ensuring alignment with medical necessity criteria and Medicare Advantage requirements. Recommend alternative levels of care when clinically appropriate. Inpatient & Behavioral Health Review: Perform initial, concurrent, and discharge reviews for inpatient and behavioral health admissions. Ensure admission status accuracy and regulatory compliance with CMS timeliness (TAT) standards. Post-Acute Review: Conduct initial authorization and concurrent review for post-acute services (SNF, LTACH, ARU, Home Health), evaluating ongoing medical necessity and appropriate length of stay. Issue NOMNC when coverage criteria are no longer met. Medical Director Collaboration: Refer cases that do not meet criteria to the Medical Director for secondary review and final determination. Prepare clinical summaries and coordinate peer-to-peer (P2P) discussions. Manage authorization reopen requests as appropriate. Resource Stewardship: Monitor utilization of inpatient and post-acute services to promote appropriate resource use while maintaining high-quality, member-centered care. Regulatory & Documentation Compliance: Maintain accurate, defensible documentation of all determinations. Ensure adherence to CMS regulations, Medicare Advantage requirements, and internal compliance standards. Required skills and experience: Unrestricted RN license with a minimum of 4 years of clinical experience 3+ years in utilization review, utilization management, case management, discharge planning, care coordination, or clinical appeals — in a health plan, hospital, or post-acute setting Familiarity with CMS regulations and Medicare Advantage requirements, or comparable payer coverage experience Experience escalating cases that don't meet criteria, including preparing clinical summaries for physician review Ability to work one of the posted schedules, including a weekend day for most schedules; flexibility across more than one schedule preferred. Able to work in a fast paced environment that is constantly evolving. Desired skills and experience: Experience with AI/LLM Certified in InterQual #LI-DS1 #LI-Remote Salary Range: $82,680-$96,460 / year The pay range listed for this position is the range the organization reasonably and in good faith expects to pay for this position at the time of the posting. Once the interview process begins, your talent partner will provide additional information on the compensation for the role, along with additional information on our total rewards package. The actual base salary offered will depend on a variety of factors, including the qualifications of the individual applicant for the position, years of relevant experience, specific and unique skills, level of education attained, certifications or other professional licenses held, and the location in which the applicant lives and/or from which they will be performing the job. Our Total Rewards package includes: Employer sponsored health, dental and vision plan with low or no premium Generous paid time off $100 monthly mobile or internet stipend Stock options for all employees Bonus eligibility for all roles excluding Director and above; Commission eligibility for Sales roles Parental leave program 401K program And more.... *Our total rewards package is for full time employees only. Intern and Contract positions are not eligible. Founded in 2017, Devoted Health is on a mission to dramatically improve the health and well-being of older Americans by caring for everyone like they are family, and that includes our employees. Our robust and seamlessly integrated care platform merges advanced data and AI access with world-class clinical and service experiences to create a member experience that is unlike the industry norm. To continue building upon our mission, we want to bring together those who share our values, embrace change and advancement, and are enthusiastic about where we're going — all the while bringing their own unique qualities, experiences, and expertise, in hopes of further changing the healthcare experience. Devoted is an equal opportunity employer. We are committed to a safe and supportive work environment in which all employees have the opportunity to participate and contribute to the success of the business. We value diversity and collaboration. Individuals are respected for their skills, experience, and unique perspectives. This commitment is embodied in Devoted’s Code of Conduct, our company values and the way we do business. As an Equal Opportunity Employer, the Company does not discriminate on the basis of race, color, religion, sex, pregnancy status, marital status, national origin, disability, age, sexual orientation, veteran status, genetic information, gender identity, gender expression, or any other factor prohibited by law. Our management team is dedicated to this policy with respect to recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, employee activities and general treatment during employment.

Clinical Guide Part A: (UM) Utilization Management Nurse

Devoted Health

$82,680 - $96,460 / year

Job Description A bit about this role: The Clinical Guide Part A will be part of the Utilization Management team, responsible for inpatient, behavioral health, and/or post-acute authorization review in alignment with CMS and Medicare Advantage regulations. Reviews medical records to evaluate the medical necessity and appropriateness of requested inpatient and/or post-acute services in accordance with established clinical criteria and CMS guidelines. Schedule: This is a full-time, remote position working five 8-hour days. We are hiring for several schedules: Tuesday – Saturday, 9:00 AM – 6:00 PM ET Sunday – Thursday, 9:00 AM – 6:00 PM ET Monday – Friday, 11:00 AM – 8:00 PM ET Monday – Friday, 9:00 AM – 6:00 PM ET We'll ask about your schedule preference during the process and will do our best to match it. Because we are filling a limited number of openings on each schedule, availability changes as roles are filled — so we ask that candidates be open to more than one schedule where possible. Most schedules include one weekend day. Weekend and later-day coverage is a core part of how our Utilization Management team meets CMS turnaround requirements. Your Responsibilities and Impact will include: Review Medical Records: Conduct prospective (pre-service), concurrent, and retrospective utilization review to evaluate medical necessity, appropriate level of care (Inpatient vs. Observation), and post-acute services in accordance with established clinical criteria and CMS guidelines. Evaluate Treatment Plans: Assess the appropriateness, timing, and setting of requested services, ensuring alignment with medical necessity criteria and Medicare Advantage requirements. Recommend alternative levels of care when clinically appropriate. Inpatient & Behavioral Health Review: Perform initial, concurrent, and discharge reviews for inpatient and behavioral health admissions. Ensure admission status accuracy and regulatory compliance with CMS timeliness (TAT) standards. Post-Acute Review: Conduct initial authorization and concurrent review for post-acute services (SNF, LTACH, ARU, Home Health), evaluating ongoing medical necessity and appropriate length of stay. Issue NOMNC when coverage criteria are no longer met. Medical Director Collaboration: Refer cases that do not meet criteria to the Medical Director for secondary review and final determination. Prepare clinical summaries and coordinate peer-to-peer (P2P) discussions. Manage authorization reopen requests as appropriate. Resource Stewardship: Monitor utilization of inpatient and post-acute services to promote appropriate resource use while maintaining high-quality, member-centered care. Regulatory & Documentation Compliance: Maintain accurate, defensible documentation of all determinations. Ensure adherence to CMS regulations, Medicare Advantage requirements, and internal compliance standards. Required skills and experience: Unrestricted RN license with a minimum of 4 years of clinical experience 3+ years in utilization review, utilization management, case management, discharge planning, care coordination, or clinical appeals — in a health plan, hospital, or post-acute setting Familiarity with CMS regulations and Medicare Advantage requirements, or comparable payer coverage experience Experience escalating cases that don't meet criteria, including preparing clinical summaries for physician review Ability to work one of the posted schedules, including a weekend day for most schedules; flexibility across more than one schedule preferred. Able to work in a fast paced environment that is constantly evolving. Desired skills and experience: Experience with AI/LLM Certified in InterQual #LI-DS1 #LI-Remote Salary Range: $82,680-$96,460 / year The pay range listed for this position is the range the organization reasonably and in good faith expects to pay for this position at the time of the posting. Once the interview process begins, your talent partner will provide additional information on the compensation for the role, along with additional information on our total rewards package. The actual base salary offered will depend on a variety of factors, including the qualifications of the individual applicant for the position, years of relevant experience, specific and unique skills, level of education attained, certifications or other professional licenses held, and the location in which the applicant lives and/or from which they will be performing the job. Our Total Rewards package includes: Employer sponsored health, dental and vision plan with low or no premium Generous paid time off $100 monthly mobile or internet stipend Stock options for all employees Bonus eligibility for all roles excluding Director and above; Commission eligibility for Sales roles Parental leave program 401K program And more.... *Our total rewards package is for full time employees only. Intern and Contract positions are not eligible. Founded in 2017, Devoted Health is on a mission to dramatically improve the health and well-being of older Americans by caring for everyone like they are family, and that includes our employees. Our robust and seamlessly integrated care platform merges advanced data and AI access with world-class clinical and service experiences to create a member experience that is unlike the industry norm. To continue building upon our mission, we want to bring together those who share our values, embrace change and advancement, and are enthusiastic about where we're going — all the while bringing their own unique qualities, experiences, and expertise, in hopes of further changing the healthcare experience. Devoted is an equal opportunity employer. We are committed to a safe and supportive work environment in which all employees have the opportunity to participate and contribute to the success of the business. We value diversity and collaboration. Individuals are respected for their skills, experience, and unique perspectives. This commitment is embodied in Devoted’s Code of Conduct, our company values and the way we do business. As an Equal Opportunity Employer, the Company does not discriminate on the basis of race, color, religion, sex, pregnancy status, marital status, national origin, disability, age, sexual orientation, veteran status, genetic information, gender identity, gender expression, or any other factor prohibited by law. Our management team is dedicated to this policy with respect to recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, employee activities and general treatment during employment.

Bilingual Pediatric Registered Nurse

Imagine Pediatrics LA

$40 - $47 / hour

Who We Are Imagine Pediatrics is a tech enabled, pediatrician led medical group reimagining care for children with special health care needs. We deliver 24/7 virtual first and in home medical, behavioral, and social care, working alongside families, providers, and health plans to break down barriers to quality care. We do not replace existing care teams; we enhance them, providing an extra layer of support with compassion, creativity, and an unwavering commitment to children with medical complexity. The primary location for this position is remote (CST required), with a strong preference of those residing in Tennessee, Louisiana, Missouri, or Illinois. Expected schedule will be 3x12s (Monday-Wednesday or Wednesday-Friday) 7:00am-7:00pm CST. Nurses must physically be working in the United States. What You’ll Do As a Pediatric Registered Nurse at Imagine Pediatrics, you are the primary point of contact for our families as you work to deeply know our patients through frequent virtual touchpoints and are the first line of defense when our patients are having a clinical problem. You leverage an integrated technology platform and are complimented by an entire interdisciplinary team including MDs, APPs, social workers, navigators, pharmacists, and dietitians. In this role, you will: Provide professional and friendly proactive care and triage for clinical issues. Embed a family centered care philosophy in care delivery. Demonstrate cultural competence and sensitivity as ability to work with culturally diverse populations and seek out additional resources when needed. Transition of care for ED/IP/UC care coordination with clinical providers following discharge. Perform a comprehensive assessment of a patient’s clinical, psychosocial, discharge planning and financial needs. Establishes clinical milestones and goals related to these issues. Establish rapport and a relationship with the patient and family in order to understand their needs and expectations and to assist them in setting realistic and mutual goals. Integrate an awareness of cultural factors in the patient/family interview process and elicit clinically relevant cultural information. Establish, in conjunction with the physician, the patient and interdisciplinary team, a comprehensive plan of care to appropriately address clinical milestones. Communicate plan of care, including changes and issues related to plan of care to patient/family, physicians and other members of the healthcare team. Gather sufficient information from all relevant sources to determine the effectiveness of the plan of care to assure it is done in an accurate, safe, timely and cost-effective manner. Document all care management assessments and interventions. Refer to Social Worker or Behavioral Health for complex psychosocial and discharge planning issues (per criteria) and ensures appropriate follow-up. Consults with other members of the interdisciplinary team (dietary, pharmacy, etc.) to provide safe discharge as appropriate. Perform other duties as assigned What You Bring & How You Qualify First and foremost, you’re passionate and committed to reimagining pediatric health care and creating a world where every child with special health care needs gets the care and support they deserve. You will need: Licensed RN in at least one state with eligibility to register for other state licensures. Bachelors in nursing from an accredited university required. 5+ years of pediatrics experience required Outpatient (primary care and/or subspecialty), home health, complex care, pediatric ICU, emergency medicine, etc. strongly preferred 1+ years' experience in care coordination or case management experience preferred B ilingual Spanish required Familiarity with Medicaid regulations and services a plus Value Based Care (VBC) experience a plus Virtual care experience a plus What We Offer (Benefits + Perks) The hourly rate for this position ranges from $40 - 47 per hour in addition to competitive company benefits package and eligibility to participate in an employee equity purchase program (as applicable). When determining compensation, we analyze and carefully consider several factors including job-related knowledge, skills and experience. These considerations may cause your compensation to vary. We provide these additional benefits and perks: Competitive medical, dental, and vision insurance Healthcare and Dependent Care FSA; Company-funded HSA 401(k) with 4% match, vested 100% from day one Employer-paid short and long-term disability Life insurance at 1x annual salary 20 days PTO + 10 Company Holidays & 2 Floating Holidays Paid new parent leave Additional benefits to be detailed in offer What We Live By We’re guided by our five core values: Our Values: Children First. We put the best interests of children above all. We know that the right decision is always the one that creates more safe days at home for the children we serve today and in the future. Earn Trust. We listen first, speak second. We build lasting relationships by creating shared understanding and consistently following through on our commitments. Innovate Today. We believe that small improvements lead to big impact. We stay curious by asking questions and leveraging new ideas to learn and scale. Embrace Humanity. We lead with empathy and authenticity, presuming competence and good intentions. When we stumble, we use the opportunity to grow and understand how we can improve. One Team, Diverse Perspectives. We actively seek a range of viewpoints to achieve better outcomes. Even when we see things differently, we stay aligned on our shared mission and support one another to move forward — together. We Value Diversity, Equity, Inclusion and Belonging We believe that creating a world where every child with complex medical conditions gets the care and support, they deserve requires a diverse team with diverse perspectives. We're proud to be an equal opportunity employer. People seeking employment at Imagine Pediatrics are considered without regard to race, color, religion, sex, gender, gender identity, gender expression, sexual orientation, marital or veteran status, age, national origin, ancestry, citizenship, physical or mental disability, medical condition, genetic information, or characteristics (or those of a family member), pregnancy or other status protected by applicable law.

RN

Telehealth

3 weeks ago

Telephonic Nurse Case Manager

Paradigm Dallas, TX

$85,000 - $92,000 / hour

We are seeking a full-time, benefitted Telephonic Case Manager with compact RN license (and preferred additional CA RN license) to work Monday – Friday in Central time zone. As a Telephonic Case Manager (TCM), you will provide remote medical case management services to injured individuals, many of whom were industrially injured. This position will assist consumers in their recovery so that they may return to the highest level of function as possible. The TCM ensures that medical services are coordinated and assessed frequently, vocational options are explored with the injured worker and their employers, and pre-injury employment or alternate employment is secured. In the role of TCM, this position works with all parties to the claim including: the injured person, the claim’s examiner, employer, attorneys (plaintiff and defense) and medical providers. At Paradigm, People Come First It's more than a job. It's a passion. Work at Paradigm, and you’ll find deep satisfaction knowing you’re making a profound difference in people’s lives. Meaningful work : better outcomes for all isn’t just our tagline. It’s what guides us to do our best—every day. At Paradigm, you’ll find an authentic connection between the work you do and your passion for making a difference in the world. Exceptional people : You'll work alongside smart people who share a commitment to excellence and a dedication to service. We're not here just for a "job." We're here to transform lives. Collaborative culture: At Paradigm, a spirit of collaboration and care is evident in everything we do. We promote a culture of inclusivity and value diversity of all kinds including thought, knowledge, and experience. No matter the team, everyone works together toward a common goal to deliver exceptional outcomes. Qualifications: Unencumbered compact RN license required Additional unencumbered CA RN license preferred CCM strongly preferred. Case Managers may also need regional or national certifications and must adhere to the standards of practice outlined by the specific national certifying body or the jurisdictionally accepted standards of practice. Professional licenses or certifications required to meet qualifications for this position must be current, unrestricted and allow for practice within a state or territory of the United States

RN

Telehealth

3 weeks ago

Triage Clinical Guide (Registered Nurse) - Care OnDemand

Devoted Health

$85,000 - $110,000 / year

Job Description A bit about this role We want to help members navigate the healthcare system in a better and safer way. This means getting the right care at the right place, at the right time. As a Triage Clinical Guide (Registered Nurse), you’ll be responsible for providing telephonic advice and clinical triage when Devoted Health members call us for support. You'll serve as a fierce advocate, helping them achieve better health outcomes and connecting them with the necessary resources. Our ideal Triage Clinical Guide is caring, compassionate, solution-oriented, and enthusiastic about providing an outstanding member experience. You possess excellent clinical judgment, are ready to innovate, and are excited about changing the way healthcare is delivered. You will be joining a team of adaptable, scrappy, and resilient professionals who are proud to be part of the Devoted family, creating a revolution in care delivery. Schedule Details: This is a full-time, night shift role. You will work five (5) scheduled clinical shifts per week on a rotating basis, including weekends and holidays. Shift days are scheduled based on business needs but will primarily be: 6:00 PM – 2:30 AM ET Shift assignments are subject to change based on operational needs. Your Responsibilities & Impact: Clinical Triage: Engage with members via telephone and the patient portal to provide clinical advice, educational materials, answer questions, and direct patients to the appropriate level of care. Care Coordination: Connect members with the exact care they need, whether routing them to providers within Devoted Medical, primary care, urgent care, or emergency services. Telehealth Support: Deliver exceptional support to patients with urgent complaints across multiple geographies, leveraging video telehealth visits to keep them safely at home whenever possible. Portal Chat Monitoring: Monitor clinical chat queues and respond directly to inbound patient portal messages within established response goals. Escalate to acute clinical triage via phone for new active symptoms, create appropriate Care OnDemand support episodes, and send templated replies for non-urgent administrative or routine needs. Securely share relevant educational handouts and clinical summaries after obtaining patient consent. Interdisciplinary Collaboration: Work seamlessly alongside a multidisciplinary team—including other RNs, NPs, PAs, MDs, and medical assistants—safeguarding our collaborative, team-based culture. Continuous Growth: Enthusiastically participate in learning sessions and be eager to grow your own skills while teaching others. Patient Advocacy: Fiercely promote our model of treating and caring for patients like they are our own family members. Required Skills & Experience: Licensure: An active, unencumbered Compact RN license OR a willingness to obtain additional state licenses as needed (for non-compact states). Experience: A minimum of 5 years of direct patient care experience. Triage Expertise: Prior clinical triage experience in an Emergency Department, Intensive Care Unit, Primary Care, or Telephonic Triage setting. Telehealth: Prior telehealth experience is required. Technical Agility: Eager to learn and able to quickly master electronic medical records (EMR), remote telephone software, and virtual video systems. Work Style: Exceptional communication and active listening skills. You enjoy fast-paced work, are eager to task-switch, and are always happy to help colleagues. Desired Skills & Experience: BSN (Bachelor of Science in Nursing) degree preferred. Experience caring for older adult populations. Experience working within population health or value-based care programs. Attributes to Success: Curious & Compassionate: You listen to others, lead with empathy, and aren't afraid to be wrong or change your mind. Detail-Oriented: You hold high standards for patient care, are well-organized, and possess meticulous attention to detail. Happy Warrior: As long as you’re in a great environment with smart, caring people working toward a common aim, you’re comfortable working hard and tackling tough challenges. Innovative: You are wired for learning and change. You want to make a difference by testing new ways of doing things to build a better care system. Agile: Agility and collaboration are critical. We are a growing organization with a start-up mentality—you believe we can do hard things together! Salary Range: $85,000 - $110,000 / year The pay range listed for this position is the range the organization reasonably and in good faith expects to pay for this position at the time of the posting. Once the interview process begins, your talent partner will provide additional information on the compensation for the role, along with additional information on our total rewards package. The actual base salary offered will depend on a variety of factors, including the qualifications of the individual applicant for the position, years of relevant experience, specific and unique skills, level of education attained, certifications or other professional licenses held, and the location in which the applicant lives and/or from which they will be performing the job. Our Total Rewards package includes: Employer sponsored health, dental and vision plan with low or no premium Generous paid time off $100 monthly mobile or internet stipend Stock options for all employees Bonus eligibility for all roles excluding Director and above; Commission eligibility for Sales roles Parental leave program 401K program And more.... *Our total rewards package is for full time employees only. Intern and Contract positions are not eligible. Founded in 2017, Devoted Health is on a mission to dramatically improve the health and well-being of older Americans by caring for everyone like they are family, and that includes our employees. Our robust and seamlessly integrated care platform merges advanced data and AI access with world-class clinical and service experiences to create a member experience that is unlike the industry norm. To continue building upon our mission, we want to bring together those who share our values, embrace change and advancement, and are enthusiastic about where we're going — all the while bringing their own unique qualities, experiences, and expertise, in hopes of further changing the healthcare experience. Devoted is an equal opportunity employer. We are committed to a safe and supportive work environment in which all employees have the opportunity to participate and contribute to the success of the business. We value diversity and collaboration. Individuals are respected for their skills, experience, and unique perspectives. This commitment is embodied in Devoted’s Code of Conduct, our company values and the way we do business. As an Equal Opportunity Employer, the Company does not discriminate on the basis of race, color, religion, sex, pregnancy status, marital status, national origin, disability, age, sexual orientation, veteran status, genetic information, gender identity, gender expression, or any other factor prohibited by law. Our management team is dedicated to this policy with respect to recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, employee activities and general treatment during employment.

Bilingual Pediatric Registered Nurse

Imagine Pediatrics LA

$40 - $47 / hour

Who We Are Imagine Pediatrics is a tech enabled, pediatrician led medical group reimagining care for children with special health care needs. We deliver 24/7 virtual first and in home medical, behavioral, and social care, working alongside families, providers, and health plans to break down barriers to quality care. We do not replace existing care teams; we enhance them, providing an extra layer of support with compassion, creativity, and an unwavering commitment to children with medical complexity. The primary location for this position is remote (CST required), with a strong preference of those residing in Tennessee, Louisiana, Missouri, or Illinois. Expected schedule will be 3x12s (Monday-Wednesday or Wednesday-Friday) 7:00am-7:00pm CST. Nurses must physically be working in the United States. What You’ll Do As a Pediatric Registered Nurse at Imagine Pediatrics, you are the primary point of contact for our families as you work to deeply know our patients through frequent virtual touchpoints and are the first line of defense when our patients are having a clinical problem. You leverage an integrated technology platform and are complimented by an entire interdisciplinary team including MDs, APPs, social workers, navigators, pharmacists, and dietitians. In this role, you will: Provide professional and friendly proactive care and triage for clinical issues. Embed a family centered care philosophy in care delivery. Demonstrate cultural competence and sensitivity as ability to work with culturally diverse populations and seek out additional resources when needed. Transition of care for ED/IP/UC care coordination with clinical providers following discharge. Perform a comprehensive assessment of a patient’s clinical, psychosocial, discharge planning and financial needs. Establishes clinical milestones and goals related to these issues. Establish rapport and a relationship with the patient and family in order to understand their needs and expectations and to assist them in setting realistic and mutual goals. Integrate an awareness of cultural factors in the patient/family interview process and elicit clinically relevant cultural information. Establish, in conjunction with the physician, the patient and interdisciplinary team, a comprehensive plan of care to appropriately address clinical milestones. Communicate plan of care, including changes and issues related to plan of care to patient/family, physicians and other members of the healthcare team. Gather sufficient information from all relevant sources to determine the effectiveness of the plan of care to assure it is done in an accurate, safe, timely and cost-effective manner. Document all care management assessments and interventions. Refer to Social Worker or Behavioral Health for complex psychosocial and discharge planning issues (per criteria) and ensures appropriate follow-up. Consults with other members of the interdisciplinary team (dietary, pharmacy, etc.) to provide safe discharge as appropriate. Perform other duties as assigned What You Bring & How You Qualify First and foremost, you’re passionate and committed to reimagining pediatric health care and creating a world where every child with special health care needs gets the care and support they deserve. You will need: Licensed RN in at least one state with eligibility to register for other state licensures. Bachelors in nursing from an accredited university required. 5+ years of pediatrics experience required Outpatient (primary care and/or subspecialty), home health, complex care, pediatric ICU, emergency medicine, etc. strongly preferred 1+ years' experience in care coordination or case management experience preferred B ilingual Spanish required Familiarity with Medicaid regulations and services a plus Value Based Care (VBC) experience a plus Virtual care experience a plus What We Offer (Benefits + Perks) The hourly rate for this position ranges from $40 - 47 per hour in addition to competitive company benefits package and eligibility to participate in an employee equity purchase program (as applicable). When determining compensation, we analyze and carefully consider several factors including job-related knowledge, skills and experience. These considerations may cause your compensation to vary. We provide these additional benefits and perks: Competitive medical, dental, and vision insurance Healthcare and Dependent Care FSA; Company-funded HSA 401(k) with 4% match, vested 100% from day one Employer-paid short and long-term disability Life insurance at 1x annual salary 20 days PTO + 10 Company Holidays & 2 Floating Holidays Paid new parent leave Additional benefits to be detailed in offer What We Live By We’re guided by our five core values: Our Values: Children First. We put the best interests of children above all. We know that the right decision is always the one that creates more safe days at home for the children we serve today and in the future. Earn Trust. We listen first, speak second. We build lasting relationships by creating shared understanding and consistently following through on our commitments. Innovate Today. We believe that small improvements lead to big impact. We stay curious by asking questions and leveraging new ideas to learn and scale. Embrace Humanity. We lead with empathy and authenticity, presuming competence and good intentions. When we stumble, we use the opportunity to grow and understand how we can improve. One Team, Diverse Perspectives. We actively seek a range of viewpoints to achieve better outcomes. Even when we see things differently, we stay aligned on our shared mission and support one another to move forward — together. We Value Diversity, Equity, Inclusion and Belonging We believe that creating a world where every child with complex medical conditions gets the care and support, they deserve requires a diverse team with diverse perspectives. We're proud to be an equal opportunity employer. People seeking employment at Imagine Pediatrics are considered without regard to race, color, religion, sex, gender, gender identity, gender expression, sexual orientation, marital or veteran status, age, national origin, ancestry, citizenship, physical or mental disability, medical condition, genetic information, or characteristics (or those of a family member), pregnancy or other status protected by applicable law.

Bilingual Pediatric Registered Nurse

Imagine Pediatrics MO

$40 - $47 / hour

Who We Are Imagine Pediatrics is a tech enabled, pediatrician led medical group reimagining care for children with special health care needs. We deliver 24/7 virtual first and in home medical, behavioral, and social care, working alongside families, providers, and health plans to break down barriers to quality care. We do not replace existing care teams; we enhance them, providing an extra layer of support with compassion, creativity, and an unwavering commitment to children with medical complexity. The primary location for this position is remote (CST required), with a strong preference of those residing in Tennessee, Louisiana, Missouri, or Illinois. Expected schedule will be 3x12s (Monday-Wednesday or Wednesday-Friday) 7:00am-7:00pm CST. Nurses must physically be working in the United States. What You’ll Do As a Pediatric Registered Nurse at Imagine Pediatrics, you are the primary point of contact for our families as you work to deeply know our patients through frequent virtual touchpoints and are the first line of defense when our patients are having a clinical problem. You leverage an integrated technology platform and are complimented by an entire interdisciplinary team including MDs, APPs, social workers, navigators, pharmacists, and dietitians. In this role, you will: Provide professional and friendly proactive care and triage for clinical issues. Embed a family centered care philosophy in care delivery. Demonstrate cultural competence and sensitivity as ability to work with culturally diverse populations and seek out additional resources when needed. Transition of care for ED/IP/UC care coordination with clinical providers following discharge. Perform a comprehensive assessment of a patient’s clinical, psychosocial, discharge planning and financial needs. Establishes clinical milestones and goals related to these issues. Establish rapport and a relationship with the patient and family in order to understand their needs and expectations and to assist them in setting realistic and mutual goals. Integrate an awareness of cultural factors in the patient/family interview process and elicit clinically relevant cultural information. Establish, in conjunction with the physician, the patient and interdisciplinary team, a comprehensive plan of care to appropriately address clinical milestones. Communicate plan of care, including changes and issues related to plan of care to patient/family, physicians and other members of the healthcare team. Gather sufficient information from all relevant sources to determine the effectiveness of the plan of care to assure it is done in an accurate, safe, timely and cost-effective manner. Document all care management assessments and interventions. Refer to Social Worker or Behavioral Health for complex psychosocial and discharge planning issues (per criteria) and ensures appropriate follow-up. Consults with other members of the interdisciplinary team (dietary, pharmacy, etc.) to provide safe discharge as appropriate. Perform other duties as assigned What You Bring & How You Qualify First and foremost, you’re passionate and committed to reimagining pediatric health care and creating a world where every child with special health care needs gets the care and support they deserve. You will need: Licensed RN in at least one state with eligibility to register for other state licensures. Bachelors in nursing from an accredited university required. 5+ years of pediatrics experience required Outpatient (primary care and/or subspecialty), home health, complex care, pediatric ICU, emergency medicine, etc. strongly preferred 1+ years' experience in care coordination or case management experience preferred B ilingual Spanish required Familiarity with Medicaid regulations and services a plus Value Based Care (VBC) experience a plus Virtual care experience a plus What We Offer (Benefits + Perks) The hourly rate for this position ranges from $40 - 47 per hour in addition to competitive company benefits package and eligibility to participate in an employee equity purchase program (as applicable). When determining compensation, we analyze and carefully consider several factors including job-related knowledge, skills and experience. These considerations may cause your compensation to vary. We provide these additional benefits and perks: Competitive medical, dental, and vision insurance Healthcare and Dependent Care FSA; Company-funded HSA 401(k) with 4% match, vested 100% from day one Employer-paid short and long-term disability Life insurance at 1x annual salary 20 days PTO + 10 Company Holidays & 2 Floating Holidays Paid new parent leave Additional benefits to be detailed in offer What We Live By We’re guided by our five core values: Our Values: Children First. We put the best interests of children above all. We know that the right decision is always the one that creates more safe days at home for the children we serve today and in the future. Earn Trust. We listen first, speak second. We build lasting relationships by creating shared understanding and consistently following through on our commitments. Innovate Today. We believe that small improvements lead to big impact. We stay curious by asking questions and leveraging new ideas to learn and scale. Embrace Humanity. We lead with empathy and authenticity, presuming competence and good intentions. When we stumble, we use the opportunity to grow and understand how we can improve. One Team, Diverse Perspectives. We actively seek a range of viewpoints to achieve better outcomes. Even when we see things differently, we stay aligned on our shared mission and support one another to move forward — together. We Value Diversity, Equity, Inclusion and Belonging We believe that creating a world where every child with complex medical conditions gets the care and support, they deserve requires a diverse team with diverse perspectives. We're proud to be an equal opportunity employer. People seeking employment at Imagine Pediatrics are considered without regard to race, color, religion, sex, gender, gender identity, gender expression, sexual orientation, marital or veteran status, age, national origin, ancestry, citizenship, physical or mental disability, medical condition, genetic information, or characteristics (or those of a family member), pregnancy or other status protected by applicable law.

Bilingual Pediatric Registered Nurse

Imagine Pediatrics MO

$40 - $47 / hour

Who We Are Imagine Pediatrics is a tech enabled, pediatrician led medical group reimagining care for children with special health care needs. We deliver 24/7 virtual first and in home medical, behavioral, and social care, working alongside families, providers, and health plans to break down barriers to quality care. We do not replace existing care teams; we enhance them, providing an extra layer of support with compassion, creativity, and an unwavering commitment to children with medical complexity. The primary location for this position is remote (CST required), with a strong preference of those residing in Tennessee, Louisiana, Missouri, or Illinois. Expected schedule will be 3x12s (Monday-Wednesday or Wednesday-Friday) 7:00am-7:00pm CST. Nurses must physically be working in the United States. What You’ll Do As a Pediatric Registered Nurse at Imagine Pediatrics, you are the primary point of contact for our families as you work to deeply know our patients through frequent virtual touchpoints and are the first line of defense when our patients are having a clinical problem. You leverage an integrated technology platform and are complimented by an entire interdisciplinary team including MDs, APPs, social workers, navigators, pharmacists, and dietitians. In this role, you will: Provide professional and friendly proactive care and triage for clinical issues. Embed a family centered care philosophy in care delivery. Demonstrate cultural competence and sensitivity as ability to work with culturally diverse populations and seek out additional resources when needed. Transition of care for ED/IP/UC care coordination with clinical providers following discharge. Perform a comprehensive assessment of a patient’s clinical, psychosocial, discharge planning and financial needs. Establishes clinical milestones and goals related to these issues. Establish rapport and a relationship with the patient and family in order to understand their needs and expectations and to assist them in setting realistic and mutual goals. Integrate an awareness of cultural factors in the patient/family interview process and elicit clinically relevant cultural information. Establish, in conjunction with the physician, the patient and interdisciplinary team, a comprehensive plan of care to appropriately address clinical milestones. Communicate plan of care, including changes and issues related to plan of care to patient/family, physicians and other members of the healthcare team. Gather sufficient information from all relevant sources to determine the effectiveness of the plan of care to assure it is done in an accurate, safe, timely and cost-effective manner. Document all care management assessments and interventions. Refer to Social Worker or Behavioral Health for complex psychosocial and discharge planning issues (per criteria) and ensures appropriate follow-up. Consults with other members of the interdisciplinary team (dietary, pharmacy, etc.) to provide safe discharge as appropriate. Perform other duties as assigned What You Bring & How You Qualify First and foremost, you’re passionate and committed to reimagining pediatric health care and creating a world where every child with special health care needs gets the care and support they deserve. You will need: Licensed RN in at least one state with eligibility to register for other state licensures. Bachelors in nursing from an accredited university required. 5+ years of pediatrics experience required Outpatient (primary care and/or subspecialty), home health, complex care, pediatric ICU, emergency medicine, etc. strongly preferred 1+ years' experience in care coordination or case management experience preferred B ilingual Spanish required Familiarity with Medicaid regulations and services a plus Value Based Care (VBC) experience a plus Virtual care experience a plus What We Offer (Benefits + Perks) The hourly rate for this position ranges from $40 - 47 per hour in addition to competitive company benefits package and eligibility to participate in an employee equity purchase program (as applicable). When determining compensation, we analyze and carefully consider several factors including job-related knowledge, skills and experience. These considerations may cause your compensation to vary. We provide these additional benefits and perks: Competitive medical, dental, and vision insurance Healthcare and Dependent Care FSA; Company-funded HSA 401(k) with 4% match, vested 100% from day one Employer-paid short and long-term disability Life insurance at 1x annual salary 20 days PTO + 10 Company Holidays & 2 Floating Holidays Paid new parent leave Additional benefits to be detailed in offer What We Live By We’re guided by our five core values: Our Values: Children First. We put the best interests of children above all. We know that the right decision is always the one that creates more safe days at home for the children we serve today and in the future. Earn Trust. We listen first, speak second. We build lasting relationships by creating shared understanding and consistently following through on our commitments. Innovate Today. We believe that small improvements lead to big impact. We stay curious by asking questions and leveraging new ideas to learn and scale. Embrace Humanity. We lead with empathy and authenticity, presuming competence and good intentions. When we stumble, we use the opportunity to grow and understand how we can improve. One Team, Diverse Perspectives. We actively seek a range of viewpoints to achieve better outcomes. Even when we see things differently, we stay aligned on our shared mission and support one another to move forward — together. We Value Diversity, Equity, Inclusion and Belonging We believe that creating a world where every child with complex medical conditions gets the care and support, they deserve requires a diverse team with diverse perspectives. We're proud to be an equal opportunity employer. People seeking employment at Imagine Pediatrics are considered without regard to race, color, religion, sex, gender, gender identity, gender expression, sexual orientation, marital or veteran status, age, national origin, ancestry, citizenship, physical or mental disability, medical condition, genetic information, or characteristics (or those of a family member), pregnancy or other status protected by applicable law.