clinical appeals nurse

clinical pharmacist

DataAnnotation

<div>
 We are looking for a
 
 Clinical Pharmacist
 
 to join our team to train AI models. You will measure the progress of these AI chatbots, evaluate their logic, and solve problems to improve the quality of each model.
 
 
 In this role, you will need to be an expert in healthcare. We are interested in a wide range of expertise, so relevant backgrounds include Clinical Documentation &amp; HIM, Medication Management (PharmD), Laboratory Medicine and Pathology Services (MLS, MD), Quality Improvement &amp; Patient Safety, Regulatory Compliance, Accreditation &amp; Medical Staff, Care Coordination &amp; Case Management, Population Health &amp; Value-Based Care, and Managed Care &amp; Utilization Management.
 
 
 
 Benefits
 
 
 
 <ul>
 <li>
 Full-time or part-time remote position
 </li>
 <li>
 Choose which projects you want to work on
 </li>
 <li>
 Flexible schedule
 </li>
 <li>
 Projects are paid hourly starting at $50+ per hour
 </li>
 <li>
 Bonuses available for high-quality and high-volume work
 
 
 </li>
 </ul>
 
 Responsibilities
 
 
 
 <ul>
 <li>
 Provide AI chatbots with diverse and complex healthcare-related problems
 </li>
 <li>
 Evaluate AI outputs for logic, accuracy, and performance
 </li>
 <li>
 Ensure the medical accuracy and overall quality of model responses
 
 
 </li>
 </ul>
 
 Qualifications
 
 
 
 <ul>
 <li>
 Fluency in English (native or bilingual level)
 </li>
 <li>
 A current or in-progress medical or healthcare-related degree
 
 
 </li>
 </ul>
 
 Notes:
 
 Payment is made via PayPal. We will never ask you for any money. PayPal will handle any currency conversions from USD. Only applicants in the United States will be considered for this role. This is an independent contractor position.
 
 
 
 #medicine
 
</div>

Clinical Pharmacist

CVS Health

<div>We&rsquo;re building a world of health around every individual &mdash; shaping a more connected, convenient and compassionate health experience. At CVS Health&reg;, you&rsquo;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 &ndash; helping to simplify health care one person, one family and one community at a time.
Position Summary:
Utilizes advanced clinical judgment and critical thinking skills to facilitate appropriate member physical health and behavioral healthcare through assessment and care planning, direct provider coordination/collaboration, and coordination of psychosocial wraparound services to promote effective utilization of available resources and optimal, cost-effective outcomes. 
Assessment of Members:<ul><li>
Through the use of clinical tools and information/data review, conducts comprehensive assessments of referred member&rsquo;s needs/eligibility and determines approach to case resolution and/or meeting needs by evaluating member&rsquo;s benefit plan and available internal and external programs/services.</li><li>
Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and address complex clinical indicators which impact care planning and resolution of member issues.</li><li>
Using advanced clinical skills, performs crisis intervention with members experiencing a behavioral health or medical crisis and refers them to the appropriate clinical providers for thorough assessment and treatment, as clinically indicated.</li><li>
Provides crisis follow up to members to help ensure they are receiving the appropriate treatment/services.</li></ul>
Enhancement of Medical Appropriateness and Quality of Care:<ul><li>
Application and/or interpretation of applicable criteria and clinical guidelines, standardized case management plans, policies, procedures, and regulatory standards while assessing benefits and/or member&rsquo;s needs to ensure appropriate administration of benefits</li><li>
Using holistic approach consults with supervisors, Medical Directors and/or other programs to overcome barriers to meeting goals and objectives; presents cases at case conferences to obtain multidisciplinary view in order to achieve optimal outcomes</li><li>
Identifies and escalates quality of care issues through established channels</li><li>
Ability to speak to medical and behavioral health professionals to influence appropriate member care.</li><li>
Utilizes influencing/motivational interviewing skills to ensure maximum member engagement and promotes lifestyle/behavior changes to achieve optimum level of health</li><li>
Provides coaching, information and support to empower the member to make ongoing independent medical and/or healthy lifestyle choices.</li><li>
Helps member actively and knowledgably participate with their provider in healthcare decision-making</li><li>
Analyzes all utilization, self-report and clinical data available to consolidate information and begin to identify comprehensive member needs.</li></ul> 
Monitoring, Evaluation and Documentation of Care<ul><li>
In collaboration with the member and their care team develops and monitors established plans of care to meet the member&rsquo;s goals</li><li>
Utilizes case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures.</li><li>
Ability to take and manage crisis calls.</li></ul> 
Required Qualifications:<ul><li>
Unencumbered Independent Behavioral Health clinical license in the state where they reside and work:</li></ul><h3 class="jobSectionHeader">
Licensed Mental Health Counselor (LMHC)</h3><h3 class="jobSectionHeader">
Licensed Clinical Social Worker (LCSW)</h3><h3 class="jobSectionHeader">
Licensed Independent Social Worker (LISW)</h3><h3 class="jobSectionHeader">
Licensed Marital and Family Therapist (LMFT)</h3><h3 class="jobSectionHeader">
Licensed Professional Counselor (LPC)</h3><ul><li>
3+ years of direct clinical practice experience post masters degree, e.g., hospital setting or alternative care setting such as ambulatory care or outpatient clinic/facility</li><li>
3+ years minimum of Behavioral Health experience</li><li>
Applicants must be willing to work standard business hours in EST or CST.</li></ul> 
Preferred Qualifications<ul><li>
Case management and discharge planning experience
</li><li>Crisis intervention skills
</li><li>Managed care/utilization review experience
</li><li>Ability to take and manage crisis calls</li></ul>
Education
Minimum of a Master&rsquo;s degree in Behavioral/Mental Health or related field
Anticipated Weekly Hours
40
Time Type
Full time
Pay Range
The typical pay range for this role is:
$54,095.00 - $142,576.00
This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. 
Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.
Great benefits for great people
We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families. 
This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility. 
Additional details about available benefits are provided during the application process and on Benefits Moments. 
We anticipate the application window for this opening will close on: 05/02/2026
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.</div>

Clinical Case Manager, Behavioral Health

<div>
 We are looking for a
 
 Clinical Appeals Nurse
 
 to join our team to train AI models. You will measure the progress of these AI chatbots, evaluate their logic, and solve problems to improve the quality of each model.
 
 
 In this role, you will need to be an expert in healthcare. We are interested in a wide range of expertise, so relevant backgrounds include Clinical Documentation &amp; HIM, Medication Management (PharmD), Laboratory Medicine and Pathology Services (MLS, MD), Quality Improvement &amp; Patient Safety, Regulatory Compliance, Accreditation &amp; Medical Staff, Care Coordination &amp; Case Management, Population Health &amp; Value-Based Care, and Managed Care &amp; Utilization Management.
 
 
 
 Benefits
 
 
 
 <ul>
 <li>
 Full-time or part-time remote position
 </li>
 <li>
 Choose which projects you want to work on
 </li>
 <li>
 Flexible schedule
 </li>
 <li>
 Projects are paid hourly starting at $50+ per hour
 </li>
 <li>
 Bonuses available for high-quality and high-volume work
 
 
 </li>
 </ul>
 
 Responsibilities
 
 
 
 <ul>
 <li>
 Provide AI chatbots with diverse and complex healthcare-related problems
 </li>
 <li>
 Evaluate AI outputs for logic, accuracy, and performance
 </li>
 <li>
 Ensure the medical accuracy and overall quality of model responses
 
 
 </li>
 </ul>
 
 Qualifications
 
 
 
 <ul>
 <li>
 Fluency in English (native or bilingual level)
 </li>
 <li>
 A current or in-progress medical or healthcare-related degree
 
 
 </li>
 </ul>
 
 Notes:
 
 Payment is made via PayPal. We will never ask you for any money. PayPal will handle any currency conversions from USD. Only applicants in the United States will be considered for this role. This is an independent contractor position.
 
 
 
 #medicine
 
</div>

Clinical Appeals Nurse

<div>
 We are looking for a Physician Assistantto join our team to train AI models. You will measure the progress of these AI chatbots, evaluate their logic, and solve problems to improve the quality of each model.
 
 
 
 Physicians &amp; Advanced Practice Clinicians
 
 
 
 In this role you will need to be an expert in healthcare. We are interested in a wide range of expertise, so relevant backgrounds include:
 
 
 Physicians of all specialties (e.g., Internists, Cardiologists, Oncologists), Physician Assistants, Nurse Practitioners, Certified Nurse-Midwives, Certified Registered Nurse Anesthetists, Clinical Nurse Specialists, Registered Nurses.
 
 
 
 Therapists
 
 
 
 Physical Therapists, Occupational Therapists, Speech-Language Pathologists, Respiratory Therapists, Athletic Trainers, Massage/Recreational Therapists.
 
 
 
 Diagnostic &amp; Laboratory Professionals
 
 
 
 Radiologic Technologists, Sonographers, MRI &amp; Nuclear Medicine Technologists, Medical Laboratory Scientists, Phlebotomists, Histology &amp; Genetics Technicians.
 
 
 
 Public Health &amp; Specialized Roles
 
 
 
 Dietitians/Nutritionists, Genetic Counselors, Epidemiologists, Public Health Nurses.
 
 
 
 Benefits
 
 
 
 <ul>
 <li>
 This is a full-time or part-time REMOTE position
 </li>
 <li>
 You&rsquo;ll be able to choose which projects you want to work on
 </li>
 <li>
 You can work on your own schedule
 </li>
 <li>
 Projects are paid hourly starting at $50-$60 USD per hour, with bonuses on high-quality and high-volume work
 
 
 </li>
 </ul>
 
 Responsibilities
 
 
 
 <ul>
 <li>
 Give AI chatbots diverse and complex healthcare related problems and evaluate their outputs
 </li>
 <li>
 Evaluate the quality produced by AI models for correctness and performance
 </li>
 <li>
 Ensure the medical accuracy of model performance
 
 
 </li>
 </ul>
 
 Qualifications
 
 
 
 <ul>
 <li>
 Fluency in English (native or bilingual level)
 </li>
 <li>
 A current or in progress medical degree
 
 
 </li>
 </ul>
 Notes: Payment is made via PayPal. We will never ask for any money from you. PayPal will handle any currency conversions from USD. Only applicants in the United States will be considered for this role. This is an independent contract position.
 
 
 #medicine
</div>

Physician Assistant

<div>We&rsquo;re building a world of health around every individual &mdash; shaping a more connected, convenient and compassionate health experience. At CVS Health&reg;, you&rsquo;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 &ndash; helping to simplify health care one person, one family and one community at a time.
Position Summary
We are seeking a highly motivated and strategic professional to serve as the Medicaid Market Manager for our Risk Adjustment programs. This is a high-visibility role responsible for driving market level engagement, delivering insights, and demonstrating the value of Medicaid risk adjustment performance to senior leaders and market partners.
The Medicaid Market Manager will serve as the key connector between national Risk Adjustment strategy and market execution, ensuring alignment, accountability, and measurable impact. The individual in this role will lead monthly market meetings, translate performance data into actionable insights, and collaborate with cross functional partners to enhance provider engagement and member outcomes. 
1. Market Lead &amp; Performance Management<ul><li>
Function as a face of Revenue Integrity across internal market teams.</li><li>
Develop and deliver executive level presentations highlighting key performance drivers, challenges, and solutions.</li><li>
Investigates operational issues that impact market performance &ndash; work with business partners to implement solutions.</li><li>
Track deliverables and identify barriers in market engagement in conjunction with implementing resolutions.</li><li>
Assist with development of educational material to support market intelligence.</li><li>
Engage with market clinical team, care management team, member services team; attend market level meetings as appropriate.</li><li>
Apply project management skills to coordinate deliverables, track timelines, and manage competing priorities.</li></ul>
2.Data Analysis &amp; Reporting<ul><li>
Work closely with the Informatics team to review requirements, dashboards, reports including any enhancements.</li><li>
Utilize data analyses using national tools in conjunction with the corporate lead to identify areas of opportunity.</li><li>
Produce and present market specific performance specific to Medicaid Revenue Integrity efforts at various governance, market, and executive leadership meetings.</li></ul>
3. Strategy &amp; Execution<ul><li>
Monitors program or programs that are jointly accountable for risk adjustment strategy, performance, and results within a designated market(s).</li><li>
Responsible for identifying and recommending nuanced market risk adjustment strategies and collaboratively executing tactics to focus, maximize and achieve market success, including market referrals.</li><li>
Coordinate with local markets to drive correctness, completeness, accuracy, and timeliness of risk score performance.</li><li>
Collaborate on market specific strategies that drive member engagement in risk adjustment programs.</li><li>
Stay abreast of regulatory changes and leading risk adjustment practices and tools to maximize the effectiveness and efficiency of the team.</li><li>
Partner with segment product, sales, network, clinical teams to implement processes aimed at strengthening member and provider engagement of Revenue Integrity programs resulting in improved outcomes.</li></ul>
Required Qualifications
5+ years of progressive experience in healthcare operations, risk adjustment or related fields
2+ years analyzing performance data and building executive-ready narratives and materials that translate findings into clear recommendations (KPIs, trends, variance drivers, and actions).
3+ years leading cross-function projects, managing project plans/timelines and routing status reporting.
Strong presentation skills with ability to clearly communicate complex information to diverse audiences, including senior leadership
Proven track record of leading and supporting meetings by capturing detailed, accurate notes, key decisions and action items.
Advanced proficiency in Microsoft PowerPoint; including ability to create clear, visually compelling, executive-level presentations.
Strong working knowledge of Microsoft Excel, with experience building tables, charts and dashboard to synthesize and communicate data effectively
Ability to translate complex data into concise actionable insights using visuals and structured storytelling.
Rigorous follow up on takeaways, driving accountability and timely completion of next steps across stakeholders.
Knowledge of insurance regulatory and contractual requirements.
Self-starter who demonstrates initiative and displays a high energy level.
Intellectual curiosity and tenacity: strong ability to learn on the fly; to understand and solve complex problems.
Proven ability to lead projects end to end.
Preferred Qualifications
Experience delivering presentations to Senior Executives and Provider groups
Master&rsquo;s degree or management development program preferred.
2+ years of experience in Medicaid operations, risk adjustment, or medical coding and documentation
Deep knowledge of local markets across Aetna Medicaid. 
Education
Bachelor&rsquo;s Degree or equivalent work experience
Anticipated Weekly Hours
40
Time Type
Full time
Pay Range
The typical pay range for this role is:
$54,300.00 - $145,860.00
This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. 
Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.
Great benefits for great people
We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families. 
This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility. 
Additional details about available benefits are provided during the application process and on Benefits Moments. 
We anticipate the application window for this opening will close on: 05/31/2026
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.</div>

Medicaid Risk Adjustment Market Manager

Centene

<div>You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you&rsquo;ll have access to competitive benefits including a fresh perspective on workplace flexibility. 
**Applicants for this role have the flexibility to work remotely from their home anywhere within the state of Iowa**
Position Purpose: Supervises the care management team and the care coordination of behavioral health members to promote quality and efficacy of care management delivery related to mental and behavioral health needs. Supervises day-to-day escalations and care management issues related to members or providers.<ul><li>
Monitors and reviews care management required documentation to maintain compliance with federal and state regulations and contractual agreements</li><li>
Assigns caseloads to care management staff based on state requirements, care management staff experience, and member needs</li><li>
Works with senior management on escalated and complex care cases related to BH and provides guidance to junior team members to address member concerns</li><li>
Educates and provides resources for care management team on key initiatives and member outreach</li><li>
Evaluates care management team performance and provides feedback regarding performance, goals, and career milestones</li><li>
Provides coaching and guidance to care management team and providers to ensure members are receiving high quality care and information regarding service / care plan options, procedures, referrals, and healthcare benefits</li><li>
Monitors and review reports on a regular basis ensuring quality and productivity metrics are met and for case assignments, and may perform audits of staff on a regular basis</li><li>
Assists with onboarding, hiring, and training care management team members</li><li>
Performs other duties as assigned.</li><li>
Complies with all policies and standards.</li></ul>
Education/Experience: Requires a Master's degree or Graduate from an Accredited School of Nursing and 4+ years of related experience. 
 
License/Certification:<ul><li>
Licensed Clinical Behavioral Health Professional or RN based on state contract requirements e.g., LCSW, LMSW, LMFT, LMHC, and RN with BH experience required</li></ul>
Pay Range: $87,000.00 - $161,300.00 per year
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</div>

Supervisor, Care Management