The incumbent will be responsible for the delivery of training modules on case management, disease specific conditions, disease management and population health, along with CM computer documentation systems and Disease Management Databases. This role supports clinical staff across Health Services which includes UM, Medical Directors, CM, Appeals, Pharmacy, etc. This position assists in the documentation process including training manuals, workflows, “tips” and updates. Participates in the assessment of training effectiveness and partners with our QA team which identifies trends. Assists in development of interventions to ensure workflow compliance.
Tasks & Duties of this position:

Conducts training sessions for JHHP staff using written materials, oral presentations and audio-visual equipment to assist groups in development of sound skills
Assists in the development of programs that reflect the needs of the organization.
Revises training programs based on evaluations and assessments.
Analyzes and evaluates training programs for impact and effectiveness
Identifies problem areas based on data integrity monitoring.
Assists in design of interventions to address problem areas.
Delivers interventions to end users
Requirements:

Education:

Completion of an accredited Nursing Program (RN); BSN and/or MSW degree required
Work Experience:

Requires three years of managed care experience.
Training or teaching experience required.
Salary Range: Minimum 43.61/hour – Maximum 67.59/hour. Compensation will be commensurate with equity and experience for roles of similar scope and responsibility. In cases where the range is displayed as a $0 amount, salary discussions will occur during candidate screening calls, before any subsequent compensation discussion is held between the candidate and any hiring authority.

The Hospital reserves the right to modify employee schedules as needed.

We are committed to creating a welcoming and inclusive environment, where we embrace and celebrate our differences, where all employees feel valued, contribute to our mission of serving the community, and engage in equitable healthcare delivery and workforce practices.

Johns Hopkins Health System and its affiliates are drug-free workplace employers.

Johns Hopkins Health System and its affiliates are an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity and expression, age, national origin, mental or physical disability, genetic information, veteran status, or any other status protected by federal, state, or local law.

SPECIALTIES:

Education

Responsible for providing triage (sorting/ prioritizing patients) telephone service to ensure prompt response to patient/ family calls to assess need to be seen, identify urgency to be seen and offer options for home care and self-management if appropriate
Responsibilities
Nurse talks directly to patients on the telephone and then directs them as appropriate to emergency care, WCU Health Symptom Management Clinic, or to see oncology provider during office hours.
Ability to perform short evaluation of the patient’s situation to estimate severity of illness and/or injury including learning about the chief complaint and, when possible, obtaining vital signs (fever, pulse, respiratory rate, pain, changes in color especially lips, hands, effort of breathing, audible breath sounds) and mental status information (sleeping more, lethargic, irritable), assessing pain, fatigue, and other symptoms related to current therapy/surgical intervention.
Determines urgency need of seeing the patient based on brief assessment and on familiarity with the patient’s condition and history.  Uses approved oncology telephone triage protocols in written form.  Confers with physician as needed.
Sends those with high-risk chief complaints such as increased effort of breathing, shortness of breath, altered level of consciousness, bleeding, trauma, loss of consciousness, or first-time seizure activity to ED immediately or arranges for ambulance per protocol.  May provide appropriate home care advice to those patients who do not need to go directly to the ED.
Sets up appointments for patients who do not need to go to the ED But need to see a physician or arranges for appointment scheduler to make the appointment.
Provides prescription refills per approved policy guidelines, directs other refill requests to the appropriate clinician as a pended prescription.
Minimum Requirements
ADN or higher is required. BSN preferred

Minimum 5 years experience as RN

Current NC or Compact RN license; Current CPR certificate required.

Med/Surg certification or ONS certification preferred.

Pay Range
$34.74 – $50.64

Other Information
Remote position.

ECU Health
About ECU Health Medical Center

ECU Health Medical Center, one of four academic medical centers in North Carolina, is the 974-bed flagship hospital for ECU Health and serves as the primary teaching hospital for The Brody School of Medicine at East Carolina University. ECU Health Medical Center has achieved Magnet® designation twice and provides acute and intermediate care, rehabilitation and outpatient health services to a 29-county region that is home to more than 1.4 million people.

General Statement
It is the goal of ECU Health and its entities to employ the most qualified individual who best matches the requirements for the vacant position.

Offers of employment are subject to successful completion of all pre-employment screenings, which may include an occupational health screening, criminal record check, education, reference, and licensure verification.

We value diversity and are proud to be an equal opportunity employer. Decisions of employment are made based on business needs, job requirements and applicant’s qualifications without regard to race, color, religion, gender, national origin, disability status, protected veteran status, genetic information and testing, family and medical leave, sexual orientation, gender identity or expression or any other status protected by law. We prohibit retaliation against individuals who bring forth any complaint, orally or in writing, to the employer, or against any individuals who assist or participate in the investigation of any complaint.

SPECIALTIES:

Triage

The University of Miami/UHealth Department of Neurological Surgery has an exciting opportunity for a remote full time Nurse Specialist – Ambulatory Triage. The Nurse Specialist assesses a healthcare facility’s nursing practice and its impact on patient outcomes. Moreover, the incumbent provides direction to nursing staff in the delivery of patient care programs in an outpatient clinical setting, and acts as a change agent, mentor, and leader. An employee in this position ensures nursing staff sustain an established level of competency.
CORE JOB FUNCTIONS

Performs medical tests in patients to diagnose their health condition.

Interprets laboratory test results of patients.

Recommends treatment plan for patients based on diagnosis.

Counsels individuals and patients on positive health practices.

Provides the latest cost-effective nursing practices.

Collaborates with other team of experts to outline best treatment for patients.

Performs holistic evaluation of specialty population, making use of enhanced proven techniques and procedures to achieve better results.

Implements the improvement of patient care, and healthcare policies and resources.

Mentors other healthcare professionals by functioning as a preceptor or coordinating preceptors for visiting professionals, students, new graduates, and orienteers.

Maintains professional knowledge by affiliating with professional and technical organizations, and participating in applicable continuing education programs, conferences, seminars, and workshops.

Adheres to University and unit-level policies and procedures and safeguards University assets.

Department Specific Functions

Provides specialized outpatient nursing support to patients with complex cranial and spinal conditions and diagnosis’s by triaging, symptom assessment, care coordination, and/or prescribing medications and/or treatments as directed by physicians/providers.

Identifies and prioritizes nursing care needs for patients/families.

Establishes methods to evaluate and document nursing interventions and plan of care

Plans, evaluates or modifies treatment program based on information gathered by reviewing and interviewing patient’s records and/or patient feedback.

Provides education to patient based on current treatment plan including pre and post-operative guidance

Assists with cross coverage between spinal/cranial practices.

Prepares, assists, and attends weekly MRI multidisciplinary committee for base of skull and spinal patients, follow up with recommendations made as needed

Oversees and monitors most recent patient assessment and outcomes to determine if current plan of care should be adjusted

Optimizes patient care by evaluation, current practices, reviewing alternatives, consulting with patient care managers and educating team

Collaborates closely with patient care providers for direction in patient care as needed

Coordinates services with other patient care teams as required; maintains communication with allied services and maintains community liaison as appropriate.

Reviews patient reports for critical and/or incidental findings

This list of duties and responsibilities is not intended to be all-inclusive and may be expanded to include other duties or responsibilities as necessary.

CORE QUALIFICATIONS
Bachelor’s degree in relevant field
Valid Florida RN license
Certification in relevant specialty or field

Experience:
Minimum 3 years of relevant experience

Knowledge, Skills and Abilities:

Ability to maintain effective interpersonal relationships

Ability to communicate effectively in both oral and written form

Skill in collecting, organizing and analyzing data

Proficiency in computer software (i.e. Microsoft Office)

#ED-LI1

The University of Miami offers competitive salaries and a comprehensive benefits package including medical, dental, tuition remission and more.

UHealth-University of Miami Health System, South Florida’s only university-based health system, provides leading-edge patient care powered by the ground breaking research and medical education at the Miller School of Medicine. As an academic medical center, we are proud to serve South Florida, Latin America and the Caribbean. Our physicians represent more than 100 specialties and sub-specialties, and have more than one million patient encounters each year. Our tradition of excellence has earned worldwide recognition for outstanding teaching, research and patient care. We’re the challenge you’ve been looking for.

The University of Miami is an Equal Opportunity Employer. Applicants and employees are protected from discrimination based on certain categories protected by Federal law.

Job Status:

Full time
Employee Type:

Staff

SPECIALTIES:

Triage

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.
RN Strongly Preferred – Compact RN License Required

100% Remote

Business Hours are 8a – 6p CST. Shifts include one day on the weekend

Position Purpose: Performs clinical reviews needed to resolve and process appeals by reviewing medical records and clinical data to determine medical necessity for services in accordance with policies, guidelines, and National Committee for Quality Assurance (NCQA) standards.

Prepares case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analyzing the basis for the appeal
Ensures timely review, processing, and response to appeal in accordance with State, Federal and NCQA standards
Communicates with members, providers, facilities, and other departments regarding appeals requests
Generates appropriate appeals resolution communication and reporting for the member and provider in accordance with company policies, State, Federal and NCQA standards
Works with leadership to increase the consistency, efficiency, and appropriateness of responses of all appeals requests
Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices
Performs other duties as assigned
Complies with all policies and standards
Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience.

Knowledge of NCQA, Medicare and Medicaid regulations preferred.
Knowledge of utilization management processes preferred.

License/Certification:

LPN – Licensed Practical Nurse – State Licensure required or
LVN – Licensed Vocational Nurse required or
RN – Registered Nurse – State Licensure and/or Compact State Licensure required or
LCSW- License Clinical Social Worker required or
LMHC-Licensed Mental Health Counselor required or
LPC-Licensed Professional Counselor required or
Licensed Marital and Family Therapist (LMFT) required or
Licensed Psychologist required
Pay Range: $27.02 – $48.55 per hour
Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual’s skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.

Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

SPECIALTIES:

Utilization Review & Management (UR/UM), Denials & Appeals

The Medical Review Nurse Analyst is responsible for conducting clinical reviews of medical records to ensure compliance with regulatory and payer guidelines.  This role ensures that providers are billing and being paid appropriately for services provided based on Medicare guidelines. The Medical Review Nurse Analyst reviews claims and delivers provider education on current billing and documentation requirements.

Salary Range  
68,000-72,000
The base pay offered for this position may vary within the posted range based on your job-related knowledge, skills, and experience.

Work Location

We are open to remote work in the following approved states:
Colorado, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, New Jersey, North Carolina, Ohio, South Carolina, Texas, Virginia, Wisconsin

How do I know this opportunity is right for me?  If you enjoy the following:  

Perform detailed reviews of medical records and documentation to determine the medical necessity of services.
Review submitted claims to ensure that billed services are medically necessary and correctly coded based on Medicare guidelines. Ensure Medicare providers are correctly reimbursed when documentation supports services rendered.
Prepare written clinical summaries and determinations with clear rationale for approvals, denials, or modifications.
Educate providers in accordance with the Targeted Probe and Educate (TPE) program.
Monitor the progress of assigned providers and educate on current billing and documentation requirements.  
Ensure compliance with federal and state regulations, CMS guidelines, and company policies.
Stay current on clinical guidelines, medical policy updates, and industry best practices.
Minimum Qualifications  

Associate’s (ASN) or Bachelor’s Degree in Nursing (BSN).
Active RN license, applicable to state of practice in good standing.
One (1) or more years of clinical experience in a healthcare setting (hospital, homecare, skilled nursing, etc.).
Excellent written and verbal communication skills, with the ability to communicate complex medical information clearly and concisely.
Strong attention to detail and organizational skills to manage multiple cases simultaneously.
Basic knowledge and understanding of medical/clinical review processes.
Solid computer skills with experience working in multiple on-line systems including MS Outlook, Teams, OneNote, Word, and Excel.
Preferred Qualifications  

Experience working for a Medicare Administrative Contractor (MAC) preferred.
Basic Medicare knowledge and/or experience preferred.
Remote Work Requirements

Wired (ethernet cable) internet connection from your router to your computer.  
High speed cable or fiber internet.  
Minimum of 10 Mbps downstream and at least 1 Mbps upstream internet connection (can be checked at https://speedtest.net).
Please review Remote Worker FAQs for additional information.

Benefits

Remote work option available
Performance bonus and/or merit increase opportunities
401(k) with a 100% match for the first 3% of your salary and a 50% match for the next 2% of your salary (100% vested immediately)
Competitive paid time off
Health insurance, dental insurance, and telehealth services start DAY 1
Professional and Leadership Development Programs  
Review additional benefits: (https://www.wpshealthsolutions.com/careers/)  

SPECIALTIES:

Utilization Review & Management (UR/UM)

At UCHealth, our mission is simple – to improve lives. That starts with you. We improve lives through fresh ideas, innovative approaches and an unwavering commitment to world-class care.
The UCHealth Virtual Behavioral Health Clinic is ready to welcome a Physician Assistant or Nurse Practitioner to their team. The ideal candidate will be enthusiastic, interested in working full-time and focused on excellent patient care. At UCHealth, we believe each person is extraordinary, and together, we make extraordinary possible.

Responsibilities:
Obtains patient history and performs assessment via observation, interview, and examination. Orders, performs and interprets diagnostic procedures.
Provides direct treatment and management of health conditions via prescriptive authority or referral to other healthcare providers or community resources.
Provides counseling and education of patients and their families/caregivers concerning preventative health, treatment options and community resources.
Performs preventative health assessments, screening, immunizations and care.
Within scope of job, requires critical thinking skills, decisive judgement and the ability to work with minimal supervision. Must be able to work in a fast-paced environment and take appropriate action.

REQUIRED:
2+ years of experience working with pediatric and adult patients as an advanced practice provider in Behavioral Health.
Family Nurse Practitioner candidates must have full prescriptive authority to be considered for this position.
We know how fast the world of healthcare is changing, and we push ourselves to stay ahead of the curve. The UCHealth Medical Group is physician led and employs nearly 2,000 physicians and advanced practice providers who aim to anticipate and address patients’ every health need. We call on providers in every career stage and specialty to lead and provide direction for the future of healthcare at UCHealth. Apply today.

This position will be open for a minimum of 3 days and will remain open until a top candidate is identified. The position posting date is 10/22/2025.
We are unable to support visa candidates for this position.

Requirements for Physician Assistants
Master’s Degree in Physician Assistant Studies
Unrestricted license to practice as a Physician Assistant in the State of Colorado.
Physician Assistant Certification (PA-C) issued by the National Commission for Certification of Physician Assistants (NCCPA) is required for hire and must be maintained throughout employment
Unrestricted Drug Enforcement Administration (DEA) permit to prescribe all medications commonly prescribed in the course of practice.
Eligible to provide services reimbursable services and maintain provider status with Medicare and Medicaid.
Eligible to provide services with no sanctions or exclusion from either the Health and Human Services/Office of Inspectors General (HHS/OIG) or the General Services Administration’s (GSA) List of Parties Excluded from Federal Programs.
Unrestricted medical staff membership, with appropriate practice privileges.
Prescriptive authority as appropriate, per medical staff service privileging process.
Basic Life Support (BLS) certification issued by the American Heart Association or the American Red Cross.

Requirements for Nurse Practitioners
Full or provisional prescriptive authority eligibility is required. Provider must apply for prescriptive authority as a condition of employment.
Master’s degree in Nursing and graduate of an accredited Nurse Practitioner program
Nurse Practitioner Certification issued by the American Nurses Credentialing Center (ANCC) or Nurse Practitioner Certification issued by the American Academy of Nurse Practitioners Certification Board (AANPCB) is required for hire and must be maintained throughout employment.
Unrestricted Nurse Practitioner license issued by the State Board of Nursing in the state of practice or compact privileges under the multi-state Nurse Licensure Compact agreement
Unrestricted medical staff membership, with appropriate practice privileges
Full prescriptive authority
Unrestricted Drug Enforcement Administration (DEA) permit to prescribe all medications commonly prescribed in the course of practice.
Eligible to provide services reimbursable services and maintain provider status with Medicare and Medicaid.
Eligible to provide services with no sanctions or exclusion from either the Health and Human Services/Office of Inspectors General (HHS/OIG) or the General Services Administration’s (GSA) List of Parties Excluded from Federal Programs.
Basic Life Support (BLS) certification issued by the American Heart Association or the American Red Cross

Exceptional Benefits
This position offers a competitive compensation package:
The pay range for this full-time position is $114,941 – $158,524 annually. Pay is dependent on applicant’s relevant experience.
Relocation bonus of up to $10,000, if eligible.
Paid malpractice.
Continuing medical education (CME) of up to $3,500 and up to 5 days annually.
403(b) with employer matching contribution; 457(b) voluntary option if eligible.
Exceptional health and welfare benefits including medical, vision, dental, life insurance, and disability coverage including coverage for eligible dependents.
UCHealth is a qualifying employer for the federal Public Service Loan Forgiveness (PSLF) program. UCHealth provides employees with free assistance navigating the PSLF program.
UCHealth provides employer-paid short-term disability (STD) coverage as a supplement to Colorado FAMLI, offering up to 66.67% of your base pay.
We also offer employer-provided long-term disability (LTD) coverage, which equals 50% of your base pay, up to $17,500 per month. Additionally, you have the option to buy up LTD coverage to 60% or 66.7%.
Wellness benefits.
Full suite of voluntary benefits such as flexible spending accounts for health care and dependent care, health savings accounts (available with HD/HSA medical plan only), identity theft protection, pet insurance, and employee discount programs.
Time away from work: paid time off (PTO), paid family and medical leave (inclusive of Colorado FAMLI), leaves of absence; start your employment at UCHealth with PTO in your bank.
Education benefits for employees, including the opportunity to be eligible for 100% tuition, books, and fees paid for by UCHealth for specific educational degrees. Other programs may qualify for up to $5,250 pre-paid by UCHealth or in the form of tuition reimbursement each calendar year.

SPECIALTIES:

Telehealth

The Clinical Call Center Triage Nurse effectively extends care during and outside of regular Oak Street Health clinic hours by addressing patients’ medical, social, and psychological needs telephonically.
Core Responsibilities:

Provide confident and professional service to OSH patients
Follow current Prescription Refill policy
Remain engaged with patients without background distraction.
Clear and precise documentation while on a call
Complete documentation for all patient requests prior to ending a call
Check the CareReq queue and ensure CareReqs are complete
Complete all tasks or requests that are within the scope and ability of the role
Schedule appointments for patients that may be off-cadence or are requesting an appointment
Arrange transportation for clinic visits
Aware of organizational goals and visibly strives to meet departmental metrics
Other duties as assigned
Career Development Opportunities:

The career path from Clinical Call Center Triage Nurse I to  Clinical Call Center Triage Nurse II includes:

A minimum tenure of 6 months in the Triage RN I role
Consistently demonstrates strong problem-solving abilities, effective communication, and a thorough understanding of customer needs
Demonstration of a strong desire to learn and grow in their role
Introductory learning of all the skills and working toward meeting “Exceptional” performance metrics for all job skills:
Average Unavailable Time
Average Handle Time
Average Calls per Hour
Quality Metrics
Care Req Reduction as assigned
CET (Clinical Escalation Tracker) Management as assigned
Demonstrate proven reliability and satisfactory attendance
The progression path from Level I to Level II positions within the Triage RN team is a structured path that encourages nurses to widen their knowledge base, take on more responsibility, demonstrate expertise, and reward team members for their proven success and dedication. Each role level builds upon the skills learned in the previous one, with the ultimate goal of enabling technicians to provide superior support and contribute to the overall success of the contact center.

Remote Work Requirements:

Proficient PC skills, computer literacy, basic Google Suite skills, and ability to navigate systems
Prior remote work experience
Ability to obtain high-speed internet and hardwire equipment to router/modem
Distraction-free and private remote work environment required as well as reliable dependent care during working hours
Ability to provide own transportation for instances where on-site support is required for employees located within 50 miles of a physical OSH location/center
https://www.oakstreethealth.com/locations
Call center/home office locations: Downers Grove, IL; Chicago, IL; Charlotte, NC
Ability to participate in classroom-style remote training sessions
An understanding of the high level of conscientiousness, professionalism, and reliability that is required in a remote work environment
What are we looking for?

Active, non-probationary state Registered Nurse license in all states of OSH practice
Proactive maintenance of licenses without prompt or audit
Ability to manage time and work autonomously with consistent reliability
High-level of conscientiousness
Focus on delivering an Unmatched Patient Experience on every call and interaction
Motivated to complete all CE (Continuing Education) and licensure requirements without being prompted
Ability to work flexible shifts outside of core business hours, such as evenings, weekends, and holidays
US work authorization
Anticipated Weekly Hours

40
Time Type

Full time
Pay Range

The typical pay range for this role is:

$26.01 – $56.14
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.

SPECIALTIES:

Triage

The Clinical Call Center Triage Nurse effectively extends care during and outside of regular Oak Street Health clinic hours by addressing patients’ medical, social, and psychological needs telephonically.
Core Responsibilities:

Provide confident and professional service to OSH patients
Follow current Prescription Refill policy
Remain engaged with patients without background distraction.
Clear and precise documentation while on a call
Complete documentation for all patient requests prior to ending a call
Check the CareReq queue and ensure CareReqs are complete
Complete all tasks or requests that are within the scope and ability of the role
Schedule appointments for patients that may be off-cadence or are requesting an appointment
Arrange transportation for clinic visits
Aware of organizational goals and visibly strives to meet departmental metrics
Other duties as assigned
Career Development Opportunities:

The career path from Clinical Call Center Triage Nurse I to  Clinical Call Center Triage Nurse II includes:

A minimum tenure of 6 months in the Triage RN I role
Consistently demonstrates strong problem-solving abilities, effective communication, and a thorough understanding of customer needs
Demonstration of a strong desire to learn and grow in their role
Introductory learning of all the skills and working toward meeting “Exceptional” performance metrics for all job skills:
Average Unavailable Time
Average Handle Time
Average Calls per Hour
Quality Metrics
Care Req Reduction as assigned
CET (Clinical Escalation Tracker) Management as assigned
Demonstrate proven reliability and satisfactory attendance
The progression path from Level I to Level II positions within the Triage RN team is a structured path that encourages nurses to widen their knowledge base, take on more responsibility, demonstrate expertise, and reward team members for their proven success and dedication. Each role level builds upon the skills learned in the previous one, with the ultimate goal of enabling technicians to provide superior support and contribute to the overall success of the contact center.

Remote Work Requirements:

Proficient PC skills, computer literacy, basic Google Suite skills, and ability to navigate systems
Prior remote work experience
Ability to obtain high-speed internet and hardwire equipment to router/modem
Distraction-free and private remote work environment required as well as reliable dependent care during working hours
Ability to provide own transportation for instances where on-site support is required for employees located within 50 miles of a physical OSH location/center
https://www.oakstreethealth.com/locations
Call center/home office locations: Downers Grove, IL; Chicago, IL; Charlotte, NC
Ability to participate in classroom-style remote training sessions
An understanding of the high level of conscientiousness, professionalism, and reliability that is required in a remote work environment
What are we looking for?

Active, non-probationary state Registered Nurse license in all states of OSH practice
Two (2) years experience in a hospital or clinic setting is strongly preferred
Proactive maintenance of licenses without prompt or audit
Ability to manage time and work autonomously with consistent reliability
High-level of conscientiousness
Focus on delivering an Unmatched Patient Experience on every call and interaction
Motivated to complete all CE (Continuing Education) and licensure requirements without being prompted
Ability to work flexible shifts outside of core business hours, such as evenings, weekends, and holidays
US work authorization
Anticipated Weekly Hours

40
Time Type

Full time
Pay Range

The typical pay range for this role is:

$29.10 – $62.32
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.

SPECIALTIES:

Triage

At UnitedHealthcare, we’re simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us to start Caring. Connecting. Growing together.
The Clinical Quality RN will be responsible for conducting quality of care (QOC) investigation, review and management of the regulatory Incident/Accident/Death (IAD) portal, documenting and communicating findings from these reviews, and preparing reports or summaries for internal and external customers.  This position collaborates with the Chief Medical Officer or other Medical Directors to review QOC and other investigations and ensures that QOC investigations comply with all applicable State, Federal, and regulatory requirements.  These activities are used to ensure care and services provided to our members are timely, adequate, and compliant with regulatory and professional standards and guidelines.

If you are willing to work 8:00am – 5:00pm Mountain Standard Time zone, you will have the flexibility to work remotely* as you take on some tough challenges.

Primary Responsibilities:

Perform clinical documentation review of inpatient and outpatient care delivered to adults and children with Medicaid, Medicare health care benefits through Arizona United Health Care Community Plans for peer review and internal investigations of Quality of Care concerns
Create professionally written case investigation summaries for Peer Review, present case summaries at the Provider Advisory Committee as applicable
Review plans of correction from providers in response to a substantiated QOC occurrence
Effectively interface with external customers, facilities, members and providers to resolve quality of care concerns, obtain medical records and other information  
Conduct delegated oversight reviews of contractors that perform work on behalf of UnitedHealthcare.  This includes reviewing samples of contractor work against an audit tool or information found in medical charts
Collaborate internally with Medical Directors and staff in other UHCCP departments
Manage multiple tasks and projects and changing priorities; prioritize work products effectively
Maintain timeliness for deliverables and regulator requests
Be able to work independently, good critical thinking skills, excellent verbal and written communication skills
You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

Active, unrestricted RN license in the state of Arizona or compact license
5+ years of experience working as a Registered Nurse
2+ years of hospital experience as a Registered Nurse
Experience evaluating and auditing medical records
Demonstrated intermediate skills in Microsoft Office, Word, and Excel ability to work with multiple databases to retrieve and enter information
Demonstrated excellent writing skills – ability to analyze information and prepare written summaries
Willingness to work a shift of 8am – 5pm Mountain Standard Time
Preferred Qualifications:

1+ years of experience in quality management and clinical quality investigations, or equivalent experience
Proven knowledge of Medicare/Medicaid regulations
Demonstrated solid understanding of quality improvement principles and practices
Experience working in a deadline driven environment prioritizing responsibilities
Experience in Behavioral Health Services
*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you’ll find a far-reaching choice of benefits and incentives. The salary for this role will rangefrom $60,200 to $107,400 annually based on full-time employment. We comply with all minimum wage laws as applicable.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes – an enterprise priority reflected in our mission.

UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

UnitedHealth Group is a drug – free workplace. Candidates are required to pass a drug test before beginning employment.

SPECIALTIES:

Quality

This position is responsible for handling all Utilization Management medical appeal cases.  Ensures that timeliness guidelines are met and appeal handled in compliance with regulatory requirements of various agencies including but not limited to NCQA,URAC and NJ/Federal regulations. Provides mentoring and clinical liaison support to appeals staff. Performs special projects as assigned by management What You’ll Do

Assesses patient’s clinical need against established guidelines and standards to ensure that the level of care and length of stay of the patient are medically appropriate for inpatient stay.

Evaluates the necessity, appropriateness and efficiency of medical services and procedures by inpatient facilities.

Performs review of medical records and prepares medical records for review by Medical Director as appropriate.

Investigates and resolves complicated appeals, coordinating with legal department as necessary and handles appeals concerning pre existing conditions.

Investigates and resolves high priority cases involving DOBI and Executive inquiries.

Prepares and presents appeals to Appeals Committee in accordance with criteria including coordination with independent URO.

Conducts presentations of appeals process to internal customers and works with Delegate and Vendor Oversight to assist vendors in establishing procedures to ensure their appeals process complies with requirements.

Plans appropriate allocation of resources to provide quality patient care in the most cost effective manner.

Documents accurately and comprehensively based on the standards of practice and current organization policies.

Interacts and communicates with facilities, physicians and or members/families, either telephonically and or on site striving for continuity and efficiency as the member is managed along the continuum of care.

Evaluates care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes.

Facilitates the external review process with the IURO and IRO.

Provides 24/7 on call appeal support as scheduled.

Actively participates in enterprise meetings as management-s proxy as necessary.

Performs special projects as assigned by management.

Appeals Resolution RN’s are required to work a specified number of weekends and holidays to meet Regulatory and Accrediting body standards. Requirements may vary based on department’s business needs.

What You Bring

Education/Experience:

High School Diploma/GED required.

Bachelor degree in health care management preferred or relevant experience in lieu of degree.

Requires 2 years clinical experience.

Requires 3 years experience in the health care delivery system/industry.

Additional licensing, certifications, registrations:

Requires a Registered Nurse License.

Knowledge:

Specialized knowledge/skills: Requires working knowledge of principles of utilization management.

Requires knowledge of health care contracts and benefit eligibility requirements.

Requires knowledge of hospital structures and payment systems.

Requires excellent oral and written communication skills.

Requires the ability to work in a high volume environment with moderate supervision.

Require the ability to apply an understanding of business fundamentals and administrative expense management of day-to-day decision-making.

Skills & Abilities:

Requires the ability to utilize a personal computer and applicable software.

Strong negotiation skills with the demonstrated sales ability to convert prospect to client in addition to demonstrated persuasive skills with carriers

Must have effective verbal and written communication skills and demonstrate the ability to work well within a team. Demonstrated ability to deliver highly technical information to less technical individuals.

Must demonstrate professional and ethical business practices, adherence to company standards, and a commitment to personal and professional development.

Proven time management skills are necessary. Must demonstrate the ability to manage multiple priorities [or tasks], deliver timely and accurate work products with a customer service focus, and respond with a sense of urgency as required. Demonstrated ability to work in a production focused environment.

Proven ability to exercise sound judgment and strong problem solving skills.

Proven ability to ask probing questions and obtain thorough and relevant information.

Must be client service focused with effective ability to empathize.

Why Horizon?

At Horizon, you’ll do meaningful work that directly improves lives—while being supported by a mission‑driven organization that values expertise, collaboration, and growth.  We believe that when our people thrive, our communities do too.  If you are passionate about making an impact, we’d love to hear from you!

Salary Range:

$79,100 – $105,945
​This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity.  This range has been created in good faith based on information known to Horizon at the time of posting.  Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes:

Comprehensive health benefits (Medical/Dental/Vision)

Retirement Plans

Generous PTO

Incentive Plans

Wellness Programs

Paid Volunteer Time Off

Tuition Reimbursement

Disclaimer:

Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware. This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job.

SPECIALTIES:

Utilization Review & Management (UR/UM), Denials & Appeals