Acts as Team Lead for specialty programs, medical review, utilization management, and case management areas by providing assistance and support to unit supervisor/manager by giving direction/guidance/training to staff.  Ensures appropriate levels of healthcare services are provided.
**This position is apart of the End-Stage Renal Disease QIP Contract.***

Description

Logistics: Palmetto GBA – one of BlueCross BlueShield’s South Carolina subsidiary companies.

Functions as a team leader/senior-level Medical Reviewer. Provides leadership/guidance/direction/training to staff. Maintains a working knowledge of unit functions and the ability to interpret to new hires, department interworking, and workflow. Acts as a resource for staff/external entities troubleshooting as well as resolving issues. Keeps manager informed of any problems/issues that need resolving.
Assists management with monitoring workflow and workloads (including reassignment of work to meet timelines, redirecting work intake source to balance workloads), reporting, and addressing aging issues.
Participates in departmental quality reviews. Follows a process to ensure quality plan is adhered to and communicated to all parties. Gives/receives feedback regarding medical review decision making and technical claims processing issues. Ensures that quality work instructions/forms/documents are developed/revised as needed.
Provides quality service and communicates effectively with external/internal customers in response to inquiries. Obtains information from internal departments, providers, government, and/or private agencies, etc. to resolve discrepancies/problems.
Participates in compliance initiatives and other directed activities. Participates/oversees special projects as requested by management.
Required Education:

Associate Degree – Nursing OR
Graduate of Accredited School of Nursing.
Required Work Experience:

Four years of clinical, OR
Two years of clinical and two years of medical review/utilization review, OR
Combination of health plan, clinical, and business experience totaling four years.
Preferred requirements

ESRD/renal dialysis experience

Five or more years’ clinical, quality management, or leadership experience as a registered nurse in a Dialysis setting.

Three or more years’ education/training/consulting experience related to Dialysis services. (may be concurrent).
Three or more years’ experience in quality management coordination related to Dialysis services. (may be concurrent)
Required Skills and Abilities:

Working knowledge of managed care and various forms of health are delivery systems.
Strong clinical experience to include home health, rehabilitation, and/or broad medical surgical experience.
Knowledge of specific criteria/protocol sets and the use of the same.
Working knowledge of word processing and spreadsheet software.
Ability to work independently, prioritize effectively, and make sound decisions.  
Good judgment skills.
Demonstrated customer service, organizational, and presentation skills.
Demonstrated proficiency in spelling, punctuation, and grammar skills.
Demonstrated oral and written communication skills.
Ability to persuade, negotiate, or influence others.
Analytical or critical thinking skills.
Ability to handle confidential or sensitive information with discretion.
Ability to lead/direct/motivate others.
Required Software and Tools:

Microsoft Office.
Required License and Certificate:

Active, unrestricted RN licensure from the United States and in the state of hire, OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact NLC).
Equal Employment Opportunity Statement

BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.

We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company.

SPECIALTIES:

Case Management (CM)

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.  
This RN Call Center position supports Optum’s Women’s Health program, providing telephonic clinical support for high-risk obstetric patients enrolled in case management services. The role focuses on remotely monitoring pregnant patients with complex medical needs, including diabetic pregnancies and other high-risk conditions, while serving as a critical bridge between patients, case managers, and field-based nursing teams. Through proactive outreach, assessment, triage, and care coordination, the nurse helps ensure timely intervention and positive maternal and fetal outcomes.

This position is part-time (20 hours/week) and the schedule and hours are 7:30 PM – 12:30 AM EST on the days listed below.

Week 1: Sunday, Tuesday, Thursday and Friday
Week 2: Monday, Tuesday, Thursday, Saturday

You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.

Primary Responsibilities:

Monitor high-risk obstetric patients through remote patient monitoring systems, including blood glucose and blood pressure tracking
Review clinical alerts and conduct outbound outreach to patients when elevated blood sugar levels, blood pressure readings, or other concerns are identified
Assess patients’ health status and recommend appropriate care based on clinical judgment, established protocols, and evidence-based guidelines
Assess and triage immediate health concerns, determining the appropriate level of care and escalation when necessary
Provide nursing assessment, education, and support to high-risk pregnant patients, including those enrolled in nausea and vomiting infusion pump programs
Identify potential gaps in care, treatment plans, provider follow-up, or resource utilization
Coach patients on treatment options, self-management strategies, symptom monitoring, and available care alternatives
Coordinate services, referrals, and connections to case management, health programs, community resources, and other supportive services
Serve as an initial clinical point of contact for patients requiring assistance, helping address concerns and facilitating seamless transitions of care
Collaborate closely with case managers and field nurses who provide in-home assessments and ongoing care management
Ensure patients receive appropriate follow-up and continuity of care by bridging clinical needs to the assigned case management team

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

Current, unrestricted Compact RN licensure
2+ years of clinical experience
1+ years of experience working in obstetrics

Preferred Qualifications:

Bachelor’s degree in Nursing (BSN)  

*All employees working remotely 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 hourly pay for this role will range from $29.00 to $52.00 per hour based on full-time employment. We comply with all minimum wage laws as applicable.

Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.

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:

Triage

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.  
The Care Manager – Registered Nurse provides ongoing support and expertise through comprehensive assessment, planning, implementation, and overall evaluation of individual member needs.  The goal of this position is to enhance the quality of member management and satisfaction, to promote continuity of care and cost effectiveness through the integration and functions of care management and discharge planning.  It is the purpose of the Care Manager – Registered Nurse to ensure that the psychosocial and educational needs of the members are met. This position assists members and their families/significant others in making appropriate choices regarding the use of health care services. Care management services may be provided telephonically, in a provider office, or at the members’ home.  

You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.  

Primary Responsibilities:

Develop a comprehensive care management plan that will address members’ individual needs which include specific objectives, goals, and actions
Prioritizes member care needs upon initial interaction/assessment and address emerging issues
Assist members in the management of illness and treatment, monitor adherence, and proactively investigate and address problems that may contribute to non-adherence with the members and other members of the multidisciplinary team
Assesses reports, data, and other health plan information to identify potential members in need of care management intervention
Decrease healthcare costs of members by working collaboratively to assist members in managing visits to primary care, to decrease ER Utilization, number of inpatient hospitalizations, readmits to hospital, admissions to skilled nursing facilities and home health
Monitor the effectiveness of the care management plan and short/long term goals and adjust per member need
Assesses and prioritizes care referrals to assure program requirements for outreach and engagement are within expected time frames
Provides member and family education, support, and encouragement, especially to enhance adherence to treatment regimen and follow up care
Develops communication protocols with physicians in the network, clinic, and community so that early notification and intervention by the care management team occurs for members
Independently keeps current on areas of care management, quality management, utilization management, member education and preventive health guidelines
Provides recommendations in the development of policies and procedures that meet the requirements of NCQA, HEDIS, and State and Federal guidelines
Acts as liaison and members advocate with other care providers and programs
Participate in team meetings, multi-disciplinary meetings, care conferences and other collaboration via appropriate communication methods (teleconference, video conference, in-person conference)
Integrates, coordinates and advocates for complex mental and physical health care services from a variety of health care providers and settings, within the framework of planned health outcomes
Develop an effective support system within the family and community to manage emergency situations and to provide support and safety for the members
Acts to prevent suicide and homicide in accordance with state licensure requirements
Supports collection of information and other statistical data relevant to care loads, productivity and health care trends within member population
Potential for RN oversight of LNP/LVN. Provide clinical supervision and direction to LPN/LVN staff in accordance with state scope of practice and organizational policies
Maintain overall accountability for member care outcomes delivered by LPN/LVN
Review and validate care plans developed or supported by LPN/LVN staff
Provide real-time guidance, coaching and clinical support to LPN/LVN staff
Performs additional duties as assigned
Professional Competencies:

Working knowledge of health care delivery systems
Working knowledge of PC applications including MS Office Suite and other supportive technology
Ability to use written and oral communication skills
Ability to read and interpret data
Skill in writing clear, grammatically correct, easy to use instructional documentation
Ability to identify learning needs, set goals and seek educational opportunities
Ability to analyze problems and formulate appropriate plans, solutions, and courses of action
Knowledge of age specific communication needs with the ability to listen actively and respond to internal and external customers in a timely, competent manner both verbally and nonverbally
Ability to work with frequent interruptions
Ability to establish and maintain cooperative working relationships with individuals at all levels of the organization and affiliates
Ability to maintain confidentiality of patient and all related entity business matters of the organization and its partners
Ability to manage detail and work with accuracy
Ability to recognize and act appropriately in situations where patient care needs exceed scope of practice
Skill in working with a team and the ability to collaborate on projects with colleagues
Skill in working effectively under deadlines and changing priorities
Ability to effectively delegate action items appropriately to clinical and non-clinical staff in accordance with their role and scope of practice
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:

Degree in Nursing from an accredited school of nursing
Unrestricted RN licensure
CA license
CCM Certification within three years of employment
Preferred Qualifications:

Bachelor’s Degree
2+ years of clinical experience in a health care setting, care management for a health insurer
Skills:

All staff members are to promote a positive and productive work environment by acting maturely and responsibly, satisfactorily performing his or her job responsibilities and conducting themselves in a professional, courteous, and respectful manner toward fellow employees, physicians, and patients
Must hold relationships to a high standard- respectful approach to all people and interactions, listen to understand, take emotional accountability and exemplify balance of self with all interactions, be receptive to feedback and opportunities keeping an open mind towards growth
Integrates Lean principles, practices, and tools to improve operational efficiency, reduce costs and increase customer satisfaction
Follows written and oral instructions, completes routine tasks independently
Completes annual compliance training on HIPAA/Privacy/Confidentiality/Non-Discrimination/Harassment/Integrity Statement and signs Agreements
Ensures confidentiality of patient information following HIPAA guidelines and company policies
Attends training to meet the requirements of the job position and as needed or mandated by company policies and regulations
Has regular and predictable attendance
*All employees working remotely 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 range from $60,200 – $107,400 annually based on full-time employment. We comply with all minimum wage laws as applicable.

Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.

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:

Case Management (CM)

Optum Home & Community Care, part of the Optum family of businesses, is creating something new in health care. We are uniting industry-leading solutions to build an integrated care model that holistically addresses an individual’s physical, mental and social needs – helping patients access and navigate care anytime and anywhere. As a team member of our Optum HouseCalls team, together in an interdisciplinary care environment, we help patients navigate the health care system and connect them to key support services. This preventive care can help patients stay well at home. We’re connecting care to create a seamless health journey for patients across settings. Join us to start Caring. Connecting. Growing together.
The HouseCalls Clinical Support Team (HCCST) supports Advanced Practice Clinicians in the HouseCalls program by providing telephonic consultation to plan members post HouseCalls visit. This position is completely telephonic in a call center environment.

Goals of the program include providing a one-time outreach to members for follow up post HouseCalls visit to provide education and clarification on any concerns raised during their HouseCalls visit. The main objective of this program is to ensure successful transition of care from the HouseCalls Advanced Practice Clinician back to the members Primary Care Provider.  

This team includes nurse care managers and social workers. The Nurse Care Manager (NCM) will report directly to the Manager/or Director of Clinical Operations of HCCST. The NCM interacts via telephonic consult with members and providers to assist with education and clarification on any concerns raised during the HouseCalls visit and ensure the member has/or assist in obtaining an appointment with the provider to transition care. They work to ensure members receive quality customer service by answering questions, addressing concerns, providing education, providing resource information, and entering referrals.

The schedule is Monday through Friday from 9AM to 5:30PM Eastern or 9AM to 5:30PM Central respectively.

Primary Responsibilities:

Perform telephonic outreach to members identified by the Advance Practice Clinician for specific referral related issues
Ensure member has scheduled appointment with Primary Care Provider (PCP)/specialty provider; help scheduling appointment, if needed
Refer members to internal departments such as Social Work, or Clinical Help Desk when appropriate
Gather clinical information telephonically from patient/family
Assist patients/members with urgent needs requiring acute intervention that arise during the call
Identify triggers for hospitalization and barriers to meeting healthcare goals as they arise during the call
Complete required documentation in compliance with auditing standards and policies
Provide patient/family education on disease process and trigger management that arise during the call or are directly related to referral reasons
Assist with connections to appropriate community resources if needed
Understand and maintain confidentiality of legal and ethical issues
Maintain compliance with all HIPAA (Health Insurance Portability and Accountability Act) regulations
Enhance the experience of both internal and external customers by providing excellent customer service while maintaining production metrics
Serve as a clinical resource and consultant for other clinicians
Attend and participate in team huddles and staff meetings
Work with Supervisor to identify system improvements that could be made to drive operational advancements and efficiencies
Provide cross-coverage support across the team and assist with special projects, as needed
Assume other duties as assigned and directed by the Supervisor or Manager of Clinical Call Center Operations
You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

Current, unrestricted Compact RN (Registered Nurse) license in the state of residence
Willing and able to obtain additional licensure in assigned states within 6 months of hire
3+ years of clinical experience in a hospital, acute care, home health / hospice, direct care, or case management position
Computer/typing proficiency to enter and retrieve data in electronic clinical records
Proficient with Microsoft Word, Outlook, and Excel
Proven solid problem-solving skills
Proven ability to communicate complex or technical information in a manner that others can understand and the ability to understand and interpret complex information from others
Proven ability to perform positively and efficiently in production driven environment
Dedicated, distraction-free space in home and access to company approved high-speed internet (Broadband Cable, DSL, Fiber)
Bilingual in Spanish
Preferred Qualifications:

Telephonic case management experience
Home care / field based case management
Medicaid, Medicare, or managed care experience
Experience working remotely from home
Experience working in a call center environment
Experience working in a metrics-driven environment
Demonstrated excellent customer service skills
Reside in the Central or Eastern time zone
*All employees working remotely 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 range from $60,200 to $107,400 annually based on full-time employment. We comply with all minimum wage laws as applicable.

OptumCare  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.

OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

SPECIALTIES:

Triage

Optum Home & Community Care, part of the Optum family of businesses, is creating something new in health care. We are uniting industry-leading solutions to build an integrated care model that holistically addresses an individual’s physical, mental and social needs – helping patients access and navigate care anytime and anywhere. As a team member of our Optum HouseCalls team, together in an interdisciplinary care environment, we help patients navigate the health care system and connect them to key support services. This preventive care can help patients stay well at home. We’re connecting care to create a seamless health journey for patients across settings. Join us to start Caring. Connecting. Growing together.
The HouseCalls Clinical Support Team (HCCST) supports Advanced Practice Clinicians in the HouseCalls program by providing telephonic consultation to plan members post HouseCalls visit. This position is completely telephonic in a call center environment.

Goals of the program include providing a one-time outreach to members for follow up post HouseCalls visit to provide education and clarification on any concerns raised during their HouseCalls visit. The main objective of this program is to ensure successful transition of care from the HouseCalls Advanced Practice Clinician back to the members Primary Care Provider.

This team includes nurse care managers and social workers. The Nurse Care Manager (NCM) will report directly to the Manager/or Director of Clinical Operations of HCCST. The NCM interacts via telephonic consult with members and providers to assist with education and clarification on any concerns raised during the HouseCalls visit and ensure the member has/or assist in obtaining an appointment with the provider to transition care. They work to ensure members receive quality customer service by answering questions, addressing concerns, providing education, providing resource information, and entering referrals.

You’ll enjoy the flexibility to work remotely * from the Central or Eastern time zones as you take on some tough challenges.

The schedule is Monday through Friday from 9AM to 5:30PM Eastern or 9AM to 5:30PM Central respectively.

Must live in either the Central or Eastern time zones

Primary Responsibilities:

Perform telephonic outreach to members identified by the Advance Practice Clinician for specific referral related issues
Ensure member has scheduled appointment with Primary Care Provider (PCP)/specialty provider; help scheduling appointment, if needed
Refer members to internal departments such as Social Work, or Clinical Help Desk when appropriate
Gather clinical information telephonically from patient/family
Assist patients/members with urgent needs requiring acute intervention that arise during the call
Identify triggers for hospitalization and barriers to meeting healthcare goals as they arise during the call
Complete required documentation in compliance with auditing standards and policies
Provide patient/family education on disease process and trigger management that arise during the call or are directly related to referral reasons
Assist with connections to appropriate community resources if needed
Understand and maintain confidentiality of legal and ethical issues
Maintain compliance with all HIPAA (Health Insurance Portability and Accountability Act) regulations
Enhance the experience of both internal and external customers by providing excellent customer service while maintaining production metrics
Serve as a clinical resource and consultant for other clinicians
Attend and participate in team huddles and staff meetings
Work with Supervisor to identify system improvements that could be made to drive operational advancements and efficiencies
Provide cross-coverage support across the team and assist with special projects, as needed
Assume other duties as assigned and directed by the Supervisor or Manager of Clinical Call Center Operations
You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

Current, unrestricted Compact RN (Registered Nurse) license in the state of residence
Willing and able to obtain additional licensure in assigned states within 6 months of hire
3+ years of clinical experience in a hospital, acute care, home health / hospice, direct care, or case management position
Computer/typing proficiency to enter and retrieve data in electronic clinical records
Proficient with Microsoft Word, Outlook, and Excel
Proven ability to communicate complex or technical information in a manner that others can understand and the ability to understand and interpret complex information from others
Proven ability to perform positively and efficiently in production driven environment
Dedicated, distraction-free space in home and access to company approved high-speed internet (Broadband Cable, DSL, Fiber)
Reside in the Central or Eastern time zone
Preferred Qualifications:

Telephonic case management experience
Home care / field based case management
Medicaid, Medicare, or managed care experience
Experience working remotely from home
Experience working in a call center environment
Experience working in a metrics-driven environment
Demonstrated excellent customer service skills

Proven solid problem-solving skills
*All employees working remotely 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 range from $60,200 to $107,400 annually based on full-time employment. We comply with all minimum wage laws as applicable.

Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.

OptumCare 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.

OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

SPECIALTIES:

Triage

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: Clinical Call Center Triage Nurse

Company: Oak Street Health

Location: Remote

Role Description:

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.

SPECIALTIES:

Triage

This position is full time (40 hours/week) Monday-Friday from 8:00am – 5:00pm and will be fully remote.
What You’ll Do:

Documents the basis of the appeal or retrospective review in an accurate and timely manner and in accordance with applicable regulations or standards.

Performs thorough research of the substance of service appeals by both member and provider based on clinical documentation, contractual requirements, governing agencies, policies and procedures, while adhering to confidentiality regulations regarding protected health information.

Performs appeal and retrospective reviews demonstrating ability to define and determine precedence of pertinent issues in application of policies and procedures to clinical information and or application to benefit or policy provisions.

Performs special projects including reviews of clinical information to identify quality of care issues.

To Qualify for This Position, You’ll Need the Following:

Required Education:  Associate’s in a job-related field  

Degree Equivalency: Graduate of Accredited School of Nursing

Required Work Experience: 2 years clinical experience plus 1 year utilization/medical review, quality assurance, or home health, OR, 3 years clinical. FOR PALMETTO GBA (CO. 033) ONLY: 2 years clinical experience plus 2 years utilization/medical review, quality assurance, or home health experience or a combination of experience in clinical, utilization/medical review, quality assurance or home health experience totaling four years.

Required Skills and Abilities: Working knowledge of word processing software.  Ability to work independently, prioritize effectively, and make sound decisions.  Working knowledge of managed care and various forms of health care delivery systems. Strong clinical experience to include home health, rehabilitation, and/or broad medical surgical experience.  Knowledge of specific criteria/protocol sets and the use of the same.  Good judgment skills.  Demonstrated customer service, organizational, oral and written communication skills.  Ability to persuade, negotiate, or influence others.  Analytical or critical thinking skills.  Ability to handle confidential or sensitive information with discretion.  

Required Software and Tools:  Microsoft Office.                                                                                                                                                                        

Required License and Certificate:  An active, unrestricted RN license from the United States and in the state of hire, OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC).

We Prefer That You Have the Following:

Preferred Education: Bachelor’s degree- Nursing.

Preferred Work Experience:  3 years-utilization/medical review, quality assurance, or home health, plus 5 years clinical.

Preferred Skills and Abilities:  Administrative Law Judge (ALJ) process.

Knowledge of statistical principles.

Knowledge of the National Committee for Quality Assurance (NCAG).

Knowledge of Utilization Review Accreditation Commission (URAC).

Knowledge of South Carolina Department of Insurance (SCDOI).

Knowledge of US DOL and Health Insurance Portability/Accountability Act (HIPAA) standards/regulations.

Excellent organizational and time management skills. Knowledge of claims systems. Presentation skills.

Preferred Software and Other Tools:  Excel or other spreadsheet software. Ability to effectively use Microsoft Office applications, such as Word, Power point and Excel.

Our Comprehensive Benefits Package Includes the Following:

We offer our employees great benefits and rewards.  You will be eligible to participate in the benefits the first of the month following 28 days of employment.

Subsidized health plans, dental and vision coverage

401k retirement savings plan with company match

Life Insurance

Paid Time Off (PTO)

On-site cafeterias and fitness centers in major locations

Education Assistance

Service Recognition

National discounts to movies, theaters, zoos, theme parks and more

Equal Employment Opportunity Statement

BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.

We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company.

SPECIALTIES:

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

The Clinical Clearance Specialist is a fully remote 1099 contractor role within Charlie Health’s Clinical Operations / Admissions function. This RN serves as the dedicated clinical reviewer for escalated admissions cases involving eating disorder (ED) and substance use disorder (SUD) presentations — cases that require nursing-level clinical expertise beyond the independent decision-making scope of the CAT team, but that do not require physician review.
You will own the clearance review queue, interpret labs, vitals, and EKGs, issue timely admission determinations, and serve as the primary clinical bridge between the admissions team and medical leadership.

Responsibilities

Receive, triage, and independently review escalated clinical clearance requests submitted by the CAT/CAA team
Apply nursing clinical judgment to determine admission appropriateness for complex ED and SUD presentations
Review and interpret ED medical clearance labs (electrolytes, CBC, prealbumin, phosphorous, liver function) and integrate findings into clearance determinations
Evaluate EKG findings relevant to ED presentations — bradycardia, QTc prolongation, ST/T wave changes — in context of nutritional and electrolyte status
Assess orthostatic vital signs and recognize hemodynamic instability
Issue timely clearance outcomes (clear for admission or refer out for HLOC) and communicate directly to CATs
Serve as clinical liaison between the CAT team and medical leadership; prepare organized case summaries for physician-level escalations
Track and follow up on pending lab results; coordinate with clients and providers to eliminate admission delays
Maintain the clinical clearance queue in Salesforce; ensure all ‘Admission Pending — Clinical Clearance’ cases are reviewed promptly
Coordinate MAT-related clearances per state/insurance eligibility criteria; escalate to medical leadership as needed
Identify process gaps and recommend updates to decision trees, templates, and SOPs
Contribute to CAT team training on clinical clearance expectations and escalation criteria
Requirements

Active Registered Nurse (RN) license in good standing; unrestricted licensure required
Minimum 2–3 years of nursing experience; behavioral health, medical-surgical, or eating disorder/SUD-adjacent settings strongly preferred
Working knowledge of ED medical stability criteria: %IBW, percent weight change, BMI thresholds, and refeeding syndrome risk
Ability to review and interpret ED lab panels and identify clinically significant flags: electrolyte abnormalities, CBC deviations, nutritional markers, and liver function
Comfort reviewing EKGs for ED-relevant findings in the context of electrolyte status and nutritional presentation
Working knowledge of SUD presentations including withdrawal risk, MAT, and SUD level-of-care criteria
Strong knowledge of level-of-care frameworks (IOP, PHP, residential, inpatient) and LOCUS criteria
Excellent written communication; ability to document clinical reasoning clearly and concisely
Proficiency with or ability to quickly learn Salesforce or similar CRM/admissions platforms
Familiarity with ASAM criteria preferred; experience in virtual/telehealth behavioral health settings preferred
Bilingual (English/Spanish) a plus
Work authorized in the United States
Compensation & Benefits

This is a 1099 independent contractor role. Hourly compensation is commensurate with experience and credentials.

The total target hourly compensation for this role will be between $48 and $52 per hour at the commencement of engagement. Please note, pay will be determined on an individualized basis and will be impacted by location, experience, expertise, and other relevant business considerations.

Our Values
Connection: Care deeply & inspire hope.
Congruence: Stay curious & heed the evidence.
Commitment: Act with urgency & don’t give up.
Please do not call our public clinical admissions line in regard to this or any other job posting.

Please be cautious of potential recruitment fraud. If you are interested in exploring opportunities at Charlie Health, please go directly to our Careers Page: https://www.charliehealth.com/careers/current-openings. Charlie Health will never ask you to pay a fee or download software as part of the interview process with our company. In addition, Charlie Health will not ask for your personal banking information until you have signed an offer of employment and completed onboarding paperwork that is provided by our People Operations team. All communications with Charlie Health Talent and People Operations professionals will only be sent from @charliehealth.com email addresses. Legitimate emails will never originate from gmail.com, yahoo.com, or other commercial email services.

Recruiting agencies, please do not submit unsolicited referrals for this or any open role. We have a roster of agencies with whom we partner, and we will not pay any fee associated with unsolicited referrals.

At Charlie Health, we value being an Equal Opportunity Employer. We strive to cultivate an environment where individuals can be their authentic selves. Being an Equal Opportunity Employer means every member of our team feels as though they are supported and belong. We value diverse perspectives to help us provide essential mental health and substance use disorder treatments to all young people.

Charlie Health applicants are assessed solely on their qualifications for the role, without regard to disability or need for accommodation.

SPECIALTIES:

Case Management (CM), Triage

This is a full-time, fully remote position with a Sunday-Thursday 3:30PM- 12:00AM Central Time (CT).
As a 24/7 call center operation, our Triage Clinician department offers various shift options including mornings, mid-days, evenings, and overnights; most schedules include one weekend day.

Qualified candidates must be located in a Compact state and hold a Compact RN License in the state in which you reside.

Bilingual Spanish/English language skills are preferred.

The Worker’s Compensation Telephone Triage Clinician position provides inbound telephone triage services remotely to injured workers while following the individual state Worker Compensation rules and regulations. Uses clinical expertise and communication skills to triage, consult, and provide recommendations for emergent and non-emergent situations. Focuses on conveying compassion and ensuring service excellence is centered on the injured worker.

Position Responsibilities:

• Make safe decisions for appropriate care using critical thinking skills
• Use departmental evidence-based protocols to triage patients
• Build and maintain solid interdependent relationships within the team
• Maintain up-to-date knowledge and skill in professional, clinical, and system areas
• Demonstrate effective written and verbal communication skills

Qualifications

Unencumbered RN License in state of residence required, compact state strongly preferred
Minimum of three years’ recent RN experience in one of the following adult clinical areas: Telephone Triage, ER, Urgent Care, Medical Surgical Unit, Occupational Medicine
Bilingual in Spanish Preferred
Ability to obtain other state licenses as required with fees reimbursed
Ability to function independently and learn in a virtual work environment
Experience using Microsoft Office Suite
24 hour work week, schedules and shifts available dependent on the needs of the business, and schedules may include working every Saturday OR every Sunday
This is a remote position and the successful candidate must have a safe and HIPAA compliant home office with high speed internet connection, verified by speed test.

Benefits

We’re committed to supporting your ultimate well-being through our total compensation package offerings that support your health, wealth and self. These offerings include Medical, Dental, Vision, Health Savings Accounts / Flexible Spending Accounts, Life and AD&D Insurance, 401(k), Tuition Reimbursement, and an array of resources that encourage a lifetime of healthier living. Benefits eligibility may differ depending on full-time or part-time status. Compensation depends on the applicable US geographic market. The expected base pay for this position ranges from $35.00 –  $38.00 hourly, and will be based on a number of additional factors including skills, experience, and education.  

The Company is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability.  

Don’t meet every single requirement? Studies have shown that women and underrepresented minorities are less likely to apply to jobs unless they meet every single qualification. We are dedicated to building a diverse, inclusive, and authentic workplace, so if you’re excited about this role but your past experience doesn’t align perfectly with every qualification in the job description, we encourage you to apply anyway. You may be just the right candidate for this or other roles.

SPECIALTIES:

Triage

For those who want to invent the future of health care, here’s your opportunity. We’re going beyond basic care to health programs integrated across the entire continuum of care. Join us to start Caring. Connecting. Growing together.
Under general supervision, organizes, supervises and leads the operation of the team, assuring the continuity and quality of patient care by following appropriate clinic/department protocols and the supervision and evaluation of staff. The RN Clinical Support Supervisor will articulate program status proactively and routinely to internal committees, advising leadership on key strategic initiatives, risks and opportunities related to telephonic nurse triage. Collect, analyze, maintain and report data on the utilization of medical services, department results and resource use.

If you have an OR Registered Nurse License, you will have the flexibility to work remotely* as you take on some tough challenges.

Primary Responsibilities:

Supervise and develop team consisting of diverse clinical and related positions and skill sets. Actively works with all members of the department health care team to manage patient care, ensuring quality and safety of nursing care and smooth patient flow within department. Collaborates with leadership and other business functions in enhancements to clinical care model and operational flow. Articulate program status proactively and routinely to internal committees, advising leadership on key strategic initiatives, risks and opportunities related to hospital and readmission rates. Collect, analyze, maintain and report data on the utilization of medical services, department results and resource use
Provides regular performance feedback and conducts performance appraisals to ensure performance standards are met.  Monitors skill development and performance of the staff. Directs the work of staff, including supervision, hiring, and terminations; determine staffing needs, and ensure efficient utilization of staff and resources. Monitors attendance and time off.
Meets regularly with leadership.  Perform other duties including resolving variances, researching and resolving patient complaints with staff
Develops clinical policy and procedures in conjunction with education and training department. Assists with development of protocols and other related written resource materials appropriate to the needs of the team
Assists in conducting staff meetings and huddles. Researches and resolves clinical quality issues
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:

Graduation from an accredited school of nursing
Active Registered Nurse license in Oregon and if located outside of Oregon, Active Registered Nurse license in state of hire also
3+ years of experience in clinical setting
Preferred Qualifications:

Bachelor’s degree in nursing
1+ years of leadership experience
*All employees working remotely 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 range from $72,800 – $130,000 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.  

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 optimized. Ready to make a difference? Join us to start Caring. Connecting. Growing together
As the new Clinical Grievances Nurse, you will be responsible for reviewing incoming member cases to determine if the appropriate care was given.

In providing consumer – oriented health benefit plans to millions of people; our goal is to create higher quality care, lower costs and greater access to health care. Join us and you will be empowered to achieve new levels of excellence and make a profound and personal impact as you contribute to new innovations in a vital and complex system.

If you are located within PST, CST, MST time zones, you will have the flexibility to work remotely* as you take on some tough challenges.  

Primary Responsibilities:

Perform clinical assessment of healthcare services provided to our members for appropriateness
Understand relevant state and federal grievance and peer review requirements and accreditation standards applicable for processes supported
Facilitate telephonic discussion with health care providers and/or members to obtain additional clinical information
Provide timely, quality service to members and providers while upholding UnitedHealthcare culture values
Act as a resource for others with less experience
Work independently and collaborating with Medical Directors and non-clinical partners
Function as a member of a self-directed team to meet specific individual and team performance metrics
Manage and maintain quality and productivity metrics
You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

Current, unrestricted RN license in the state of residency
3+ years of total RN experience including clinical experience in an inpatient / acute setting
Demonstrated clinical documentation skills and critical thinking skills
Demonstrated proficiency in computer skills – Windows, Instant Messaging, Clinical Platforms, Microsoft Suite including Word, Excel, and Outlook
Designated workspace and access to install secure high speed internet via cable / DSL in home
Live in PST, CST, or MST and work 8-5 in their time zone
Preferred Qualifications:

Bachelor’s in Nursing or higher
Experience with Managed Care Clinical Quality Programs
Case management experience
Clinical appeals and grievances experience
Audit / chart review experience
Experience in a telecommuting role
Demonstrated ability to effectively utilize UHG applications, including but not limited to authorization applications, auto correspondence, and member & provider demographic systems
*All employees working remotely 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 range from $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.

SPECIALTIES:

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