clinical review nurse

Centene

<div><p>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.<br>
</p><b>Position Purpose:</b> Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member.<ul><li>
Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care</li>
<li>Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member</li>
<li>Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered</li>
<li>Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines</li>
<li>Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings</li>
<li>Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members</li>
<li>Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines</li>
<li>Reviews member&rsquo;s transfer or discharge plans to ensure a timely discharge between levels of care and facilities</li>
<li>Collaborates with care management on referral of members as appropriate</li><li>
Performs other duties as assigned.</li>
<li>Complies with all policies and standards.</li></ul><p><b>
We are seeking a Clinical Review Nurse - Concurrent Review to join our team!</b></p><p><b>
The ideal candidate will bring expertise in:</b></p><p>
IL Nursing License
<br>
Concurrent Review
<br>
Inpatient Authorizations<br>
Discharge Planning<br>
Acute and/or Critical Care
<br>
Computer Savvy
<br>
Excellent Customer Service and Communication Skills</p><p><b>
Education/Experience:</b> Requires Graduate from an Accredited School of Nursing or Bachelor&rsquo;s degree in Nursing and 2 &ndash; 4 years of related experience. 2+ years of acute care experience required.<br>
<br>
Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred.<br>
Knowledge of Medicare and Medicaid regulations preferred.<br>
Knowledge of utilization management processes preferred.<br>
<br>
<b>License/Certification:</b></p><ul><li>
LPN - Licensed Practical Nurse - State Licensure required</li></ul>
Pay Range: $27.02 - $48.55 per hour<p>
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.</p><p>
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.</p><p><br>
Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act</p></div>

Clinical Review Nurse - Concurrent Review

Palm Medical Centers

<div><b>Position Summary:</b><br>
The <b>Concurrent Review Nurse</b> is responsible for performing utilization management activities to ensure medical services are delivered effectively, efficiently, and appropriately. This includes reviewing inpatient admissions and ongoing hospital stays to determine medical necessity, appropriateness of care, and length of stay in accordance with clinical guidelines and payer requirements.<br>
<br>
<b>Key Responsibilities:</b><ul><li>
Conduct timely and accurate concurrent reviews of inpatient hospitalizations and other levels of care.</li><li>
Evaluate clinical documentation against evidence-based criteria (e.g., InterQual&reg;, MCG) to determine medical necessity and appropriate level of care.</li><li>
Collaborate with physicians, hospital staff, and insurance companies to coordinate patient care and discharge planning.</li><li>
Communicate utilization review decisions and recommendations to providers and payers.</li><li>
Document all reviews, decisions, and communications in accordance with regulatory and organizational standards.</li><li>
Identify cases requiring escalation or peer review and follow established procedures.</li><li>
Ensure compliance with CMS guidelines, accreditation standards (e.g., NCQA, URAC), and HIPAA.</li><li>
Participate in quality improvement initiatives and departmental meetings</li></ul><b>
Qualifications:</b><br>
<br>
<b>Education &amp; Licensure:</b><ul><li>
Registered Nurse (RN) license, active and in good standing, required.</li><li>
Associate or Bachelor&rsquo;s degree in nursing (BSN preferred).</li></ul><b>
Experience:</b><ul><li>
Minimum 2 years of clinical experience (e.g., med-surg, critical care).</li><li>
At least 1 year of utilization review, case management, or managed care experience preferred.</li></ul><b>
Skills &amp; Competencies:</b><ul><li>
Knowledge of InterQual&reg;, MCG, or other clinical review guidelines.</li><li>
Familiarity with Medicare/Medicaid and commercial insurance regulations.</li><li>
Strong analytical and clinical judgment skills.</li><li>
Effective communication and negotiation skills.</li><li>
Proficient with electronic medical records (EMRs) and utilization review platforms.</li><li>
Detail-oriented with excellent organizational skills.</li></ul><b>
Work Environment:</b><ul><li>
Remote</li></ul><p><br>
Palm Primary Care is an equal opportunity employer that is committed to diversity and inclusion in the workplace. We prohibit discrimination and harassment of any kind based on race, color, sex, religion, sexual orientation, national origin, disability, genetic information, pregnancy, or any other protected characteristic as outlined by federal, state, or local laws.<br>
<br>
This policy applies to all employment practices within our organization, including hiring, recruiting, promotion, termination, layoff, recall, leave of absence, compensation, benefits, training, and apprenticeship. Palm Primary Care makes hiring decisions based solely on qualifications, merit, and business needs at the time.</p><p>
</p><p>9cbfR8Lziz</p></div>

Concurrent Review Nurse

HMSA

<div>
 <strong>
  Employment Type
  <br/>
  <br/>
 </strong>
 Full-time
 <br/>
 <br/>
 <strong>
  Exempt or Non-Exempt
  <br/>
  <br/>
 </strong>
 Exempt
 <br/>
 <br/>
 <strong>
  Job Summary
  <br/>
  <br/>
 </strong>
 <strong>
  Hybrid Work Environment - Must reside in Hawaii
  <br/>
  <br/>
 </strong>
 <strong>
  Pay Range:
 </strong>
 $59,000 to $116,000
 <br/>
 <br/>
 <strong>
  Note
 </strong>
 : Individuals typically begin between the minimum to middle of the pay range
 <br/>
 <br/>
 Under minimal supervision, conducts detailed analysis and review of precertification requests, post-service and suspended claims, by applying clinical expertise against HMSA medical and reimbursement policies, plan benefits and nationally accepted clinical guidelines to determine appropriateness of care for all HMSA lines of business.
 <br/>
 <br/>
 <strong>
  Minimum Qualifications
 </strong>
 <br/>
 <br/>
 <ul>
  <li>
   Associates degree in Nursing.
  </li>
  <li>
   Current, unrestricted Nursing License in the state of Hawaii as an RN or LPN.
  </li>
  <li>
   Two years clinical, case management or utilization management related experience.
  </li>
  <li>
   Knowledge of current standards of care to be followed for a given diagnosis and the normative values of medical tests and procedures.
  </li>
  <li>
   Strong organizational skills
  </li>
  <li>
   Good communication skills both verbally and written
  </li>
  <li>
   Analytical skills
  </li>
  <li>
   Basic knowledge of Microsoft Office applications. Including but not limited to Word, Excel, and Outlook.
  </li>
  <li>
   Currently licensed in Hawaii as an RN or LPN
  </li>
  <ul>
   <li>
    (if applicable upon hire, proof of licensure to be provided by employee or confirmed by Human Resources)
    <br/>
   </li>
  </ul>
 </ul>
 <strong>
  Duties And Responsibilities
 </strong>
 <br/>
 <br/>
 <ul>
  <li>
   Utilize medical necessity criteria from established medical policies and clinical practice guidelines to render precertification determinations as described in the Medical Management UM work plan. This detailed clinical judgment includes evaluating whether the requested service is a covered benefit under the member's health plan, is medically appropriate for the member's clinical condition or whether the request requires referral to a Medical Director for potential denial of the request. The Nurse Reviewer must follow each line of business' requirements and each accrediting body's (CMS, NCQA, HSAG) requirements for each request. Assists on inquiries from external parties such as the State Insurance Commissioner and from the Legal Department. Responsibilities include, but are not limited to:
  </li>
  <ul>
   <li>
    Demonstrate understanding and application of over 250 Guide to Benefits, Evidence of Coverage, Plan Brochure, and Member Handbook. HMSA annually updated medical and drug policies, medical protocols, National Comprehensive Cancer Network, Milliman Care Guidelines, Drugdex, etc. to determine the medical necessity of urgent and non-urgent precertification requests. Urgent requests must be completed within 72 hours and non-urgent requests within 15 calendar days.
   </li>
   <li>
    Use clinical judgment, medical necessity guidelines and plan benefits to determine approval, potential denial or alternative treatment of each urgent or non-urgent precertification request. Settings include inpatient, outpatient, in-state, out-of state and out-of country.
   </li>
   <li>
    Document clinical case summary and review outcome of each review appropriately to meet regulatory and program requirements.
   </li>
   <li>
    Review various types of services, including but not limited to:
   </li>
   <li>
    Transplants
   </li>
   <li>
    Air Ambulance
   </li>
   <li>
    Chemotherapy
   </li>
   <li>
    Clinical trials
   </li>
   <li>
    Genetic testing
   </li>
   <li>
    Cancer treatments/radiation therapy
   </li>
   <li>
    Experimental/Investigational Services/Devices
   </li>
   <li>
    New Technology
   </li>
  </ul>
  <li>
   Utilize medical necessity criteria from established medical policies and clinical practice guidelines to render precertification determinations as described in the Medical Management UM work plan. This detailed clinical judgment includes evaluating whether the requested service is a covered benefit under the member's health plan, is medically appropriate for the member's clinical condition or whether the request requires referral to a Medical Director for potential denial of the request. The Nurse Reviewer must follow each line of business' requirements and each accrediting body's (CMS, NCQA, HSAG) requirements for each request. Assists on inquiries from external parties such as the State Insurance Commissioner and from the Legal Department. Responsibilities include, but are not limited to:
  </li>
  <ul>
   <li>
    Call providers when additional clinical information is required to clarify or complete a complex precertification determination.
   </li>
   <li>
    Approve precertification requests based on clinical judgment using criteria, medical record documentation and other information received from the provider.
   </li>
   <li>
    Consult with Medical Directors on requests which do not meet clinical criteria and offer alternative covered health care options as appropriate.
   </li>
   <li>
    Consult Medical Directors on potential quality issues identified during review of medical records. Refer cases to Integrated Health Management, Pharmacy Department or Benefits Integrity Department depending on the concern.
   </li>
  </ul>
  <li>
   Evaluate suspended claims against medical records to determine the medical necessity and appropriateness of medical services, identify irregularities such as over or under-utilization of services, potential up-coding, over billing, etc.
  </li>
  <li>
   Communicate timely, accurate information either verbally, electronically or in writing using clinical judgment, knowledge of medical/reimbursement policies and plan benefits to providers, members as well as internal MM staff and other internal departments (Claims Administration, Customer Relations, Provider Contracting, etc.). For denied services, ensure the denial, benefit and appeal language are accurate and consistent with department procedures, accreditation and regulatory guidelines.
  </li>
  <li>
   Identify and refer members with specific medical and/or behavioral health needs or complex case management and collaborate with medical and behavioral case management staff. Identify and refer quality of care issues and suspected fraud, waste or abuse to the appropriate departments.
  </li>
  <li>
   Perform pre-screening assessment of incoming pre-certification requests to ensure appropriateness of review. Advises non-clinical staff on clinical and coding questions to ensure correct system processes and entries.
  </li>
  <li>
   Performs all other miscellaneous responsibilities and duties as assigned or directed.
   <br/>
   <br/>
  </li>
 </ul>
</div>


Nurse Reviewer - Clinical Review Unit

VanderHouwen

<div>
 Our client is seeking a detail-oriented and clinically strong Registered Nurse who excels at applying sound judgment to complex healthcare scenarios. This individual will bring a balance of analytical thinking, regulatory awareness, and clear communication to ensure fair and accurate appeal outcomes. The ideal candidate is collaborative, adaptable, and confident navigating both clinical and non-clinical conversations in a remote environment.
 <br/>
 <br/>
 <em>
  This role is a Hybrid model in Idaho. Applicants must be able to maintain flexibility to occasionally support work outside of standard business hours may be required.
  <br/>
  <br/>
 </em>
 <strong>
  Clinical Appeals Nurse (RN) Responsibilities
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Conduct comprehensive clinical reviews of member and provider appeals, ensuring alignment with medical necessity, policies, and standards of care.
  </li>
  <li>
   Apply clinical expertise to interpret medical records, benefit plans, and contractual requirements to support accurate determinations.
  </li>
  <li>
   Collaborate with physician advisors when needed to validate complex or high-risk clinical decisions.
  </li>
  <li>
   Ensure all appeal decisions meet regulatory, accreditation, and organizational compliance requirements.
  </li>
  <li>
   Provide guidance and education to non-clinical team members on clinical aspects of appeals and case reviews.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Clinical Appeals Nurse (RN) Qualifications
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Must hold a current, unrestricted Registered Nurse (RN) license in Oregon, Washington, Idaho, or Utah; Bachelor&rsquo;s degree in Nursing preferred.
  </li>
  <li>
   Minimum of 2 years of experience in health insurance, utilization management, or clinical appeals review, plus at least 3 years of direct patient care experience.
  </li>
  <li>
   Strong knowledge of medical terminology, procedures, coding systems (CPT, ICD, HCPCS), and clinical guidelines (e.g., MCG).
  </li>
  <li>
   Proven ability to interpret medical records, claims, and benefit structures, and translate findings into clear, concise written determinations.
  </li>
  <li>
   Familiarity with regulatory and accreditation standards, along with proficiency in Microsoft Office tools and remote work environments.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Compensation: $28-$30/hr. (DOE)
 </strong>
 <strong>
  VanderHouwen Contractors Enjoy Exceptional Benefit Perks!
  <br/>
  <br/>
 </strong>
 As an eligible contract employee with VanderHouwen, you'll have access to a full suite of benefits designed with your well-being in mind. Our comprehensive package includes medical, dental, vision, life insurance, short- and long-term disability, and a matching 401(k) to help secure your future.
 <br/>
 <br/>
 <strong>
  Meet VanderHouwen
  <br/>
  <br/>
 </strong>
 What kind of recruiter do you see yourself working with? One who prioritizes your best interest, no matter what? VanderHouwen does, and we're in it for the long game! Our recruiters focus on YOU, building meaningful, long-term relationships while developing a deep understanding of companies' staffing needs and workplace cultures. This approach helps us find an ideal job match that aligns with your unique career aspirations and goals.
 <br/>
 <br/>
 VanderHouwen is an award-winning, Women &amp; Diversity-Owned, WBENC certified professional staffing firm. Founded in 1987, VanderHouwen places experienced professionals across the nation! Our recruitment teams specialize in either Technology and IT, Engineering, Human Resources, or Accounting and Finance career markets. Partner with us to land your next exciting career!
 <br/>
 <br/>
 VanderHouwen is an Equal Opportunity Employer and participates in E-Verify. VanderHouwen does not discriminate based on race, color, religion, sex, national origin, age, disability, or any other characteristic protected by applicable local, state, or federal civil rights laws.
 <br/>
 <br/>
</div>


Clinical Appeals Nurse (RN)

Advanced Health Coordinated Care Organization

<div>
 We are currently hiring a
 <strong>
  Part-time
 </strong>
 <strong>
  REMOTE Utilization Review Nurse!
 </strong>
 If you are a licensed nurse with excellent critical thinking skills, have experience in acute care settings and utilization review, and value being part of a team that makes a difference, you may be the right person for the position!
 <strong>
  Apply today!
  <br/>
  <br/>
 </strong>
 <strong>
  Classification:
 </strong>
 NON-EXEMPT |
 <strong>
  Status &amp; Schedule:
 </strong>
 PART-TIME, 20-HRS/WEEK, GENERALLY MONDAY &ndash; FRIDAY, BUT MAY INCLUDE ADDITIONAL HOURS TO MEET THE NEEDS OF THE POSITION
 <br/>
 <br/>
 <strong>
  Location:
 </strong>
 REMOTE, LOCAL TO OREGON STRONGLY PREFERRED
 <br/>
 <br/>
 <strong>
  Work Location:
 </strong>
 OR, CA, AZ, TX, FL
 <br/>
 <br/>
 <strong>
  Salary:
 </strong>
 $35.29 - $47.37/HOURLY
 <br/>
 <br/>
 <strong>
  Department:
 </strong>
 MEDICAL SERVICES/UTILIZATION REVIEW |
 <strong>
  Reports to:
 </strong>
 DIRECTOR OF MEDICAL SERVICES |
 <strong>
  Supervision Exercised:
 </strong>
 NON-SUPERVISORY
 <br/>
 <br/>
 <strong>
  JOB PURPOSE: Utilization Review Nurse
  <br/>
  <br/>
 </strong>
 The Clinical Review Nurse is responsible for providing clinically efficient and effective utilization management. Reviews prior authorization requests for appropriate care and setting by following evidence based clinical guidelines, medical necessity criteria and health plan guidelines. Reviews and applies hierarchy of criteria to all referral and preauthorization requests from the PCP's and specialists that require a medical necessity determination. Is involved in assuring that the patient receives high-quality cost-effective care. Uses sound clinical judgement and managed care principles in the coordination of care. Prepares any case that does not meet medical necessity guidelines for medical appropriateness of procedure, service, or treatment for review with the Physician Reviewer for a decision.
 <br/>
 <br/>
 <strong>
  QUALIFICATIONS, EDUCATION, And EXPERIENCE
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Nursing degree from an accredited nursing program
  </li>
  <li>
   Unrestricted Oregon RN license
  </li>
  <li>
   Experience with a similar population in health plans or managed care
  </li>
  <li>
   Experience administering OHP, Medicare benefits or utilization review highly preferred.
   <br/>
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  ESSENTIAL RESPONSIBILITIES: Licensed Utilization Review
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Maintains clinical expertise and knowledge of scientific progress in nursing and medical arena and incorporates this information into the clinical review and care coordination processes
  </li>
  <li>
   Performs clinical review for appropriate utilization of medical services by applying appropriate medical necessity criteria guidelines
  </li>
  <li>
   Authorizes healthcare services in compliance with contractual agreements, Health Plan guidelines and appropriate medical necessity criteria
  </li>
  <li>
   Provides accurate and timely documentation within internal system supporting rational of decision based on clinical review
  </li>
  <li>
   Identifies members who are appropriate for care coordination programs and collaborates with the Medical Management team for care coordination of the member's needs along the continuum of care
  </li>
  <li>
   Meets timeliness standards for referral and prior authorization activities
  </li>
  <li>
   Sends appropriate notifications for Third Party Liability (TPL) and/or possible Stop Loss
  </li>
  <li>
   Forward relevant information of members requiring special interventions to Advanced Health
  </li>
  <li>
   Participate in quality and organizational process improvement activities and teams when requested
  </li>
  <li>
   Assist in audit preparation as directed
  </li>
  <li>
   Ensure compliance with company policies and procedures as applicable to area(s) of responsibility
  </li>
  <li>
   Handle confidential information and materials appropriately and maintains a secure work area
  </li>
  <li>
   Maintains the confidentiality of all company procedures, results, and information about patients, contracts, and all other proprietary information regarding company business.
  </li>
  <li>
   Ensure compliance with company policies and procedures as applicable to area(s) of responsibility
  </li>
  <li>
   Handle confidential information and materials appropriately and maintain a secure work area
  </li>
  <li>
   Other duties as assigned
   <br/>
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  ESSENTIAL RESPONSIBILITIES: ORGANIZATIONAL TEAM MEMBER
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Participate in quality and organizational process improvement activities and teams when requested
  </li>
  <li>
   Support and contribute to effective safety, quality, and risk management efforts by adhering to established; policies and procedures, maintaining a safe environment, promoting accident prevention, and identifying and reporting potential liabilities
  </li>
  <li>
   Openly, clearly, and respectfully share and receive information, opinions, concerns, and feedback in a supportive manner
  </li>
  <li>
   Work collaboratively by mentoring new and existing co-workers, building bridges, and creating rapport with team members across the organization
  </li>
  <li>
   Provide excellent customer service to all internal and external customers, which includes team members, members, students, visitors, and vendors, by consistently exceeding the customer&rsquo;s expectations
  </li>
  <li>
   Recognize new developments and remain current in [position&rsquo;s expertise] best practice standards and anticipate organizational modifications
  </li>
  <li>
   Advance personal knowledge base by pursuing continuing education to enhance professional competence
  </li>
  <li>
   Promote individual and organizational integrity by exhibiting ethical behavior to maintain high standards
  </li>
  <li>
   Represent organization at meetings and conferences as applicable
   <br/>
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  KNOWLEDGE, SKILLS, And ABILITIES
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Knowledge of OHP program requirements, benefit package, eligibility categories, and Oregon Division of Medical Assistance Program (MAP) rules and regulations preferred
  </li>
  <li>
   Knowledge of ICD, CPT, and HCPCS codes
  </li>
  <li>
   Proficient in Milliman Clinical Guidelines (MCG)
  </li>
  <li>
   Strong attention to detail
  </li>
  <li>
   Ability to think and work independently with minimum supervision
  </li>
  <li>
   Provide critical attention to detail for accuracy and timeliness
  </li>
  <li>
   Ability to manage multiple tasks and remain flexible in a dynamic work environment
  </li>
  <li>
   Ability to report to work as scheduled, and willingness to work a flexible schedule when needed
  </li>
  <li>
   Proficient in Microsoft Office Suite and Windows Operating System (OS)
  </li>
  <li>
   Training in or awareness of Health Literacy, Poverty Informed, Systemic Oppression, language access and the use of healthcare interpreters, uses of data to drive health equity, Cultural Awareness, Trauma-Informed Care, Adverse Childhood Experiences (ACEs), Culturally and Linguistically Appropriate Service (CLAS) Standards, and universal access
  </li>
  <li>
   Knowledge and understanding of how the positions&rsquo; responsibilities contribute to the department and company goals and mission
  </li>
  <li>
   Knowledge of federal and state laws including OSHA, HIPAA, Waste Fraud and Abuse
  </li>
  <li>
   Awareness and understanding of equity, diversity, inclusion, and the equity lens: ability to analyze the unfair benefits and/or burdens within a society or population by understanding the social, political, and environmental contexts of policies, programs, and practices
  </li>
  <li>
   Excellent people skills and friendly demeanor
  </li>
  <li>
   Critical thinking skills of using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems
  </li>
  <li>
   Attention to detail and organization skills
  </li>
  <li>
   Ability to handle stress and sensitive situations effectively while projecting a professional attitude
  </li>
  <li>
   Ability to communicate professionally, both conversing and written
  </li>
  <li>
   Ability to work with diverse populations and interact with people of differing personalities and backgrounds
  </li>
  <li>
   Sensitive to economic considerations, human needs and aware of how one&rsquo;s actions may affect others
  </li>
  <li>
   Ability to organize and work in a sensitive manner with people from other cultures
  </li>
  <li>
   Poised; maintains composure and sense of purpose
   <br/>
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  WORKING CONDITIONS
  <br/>
  <br/>
 </strong>
 This position must have the ability to remain in a stationary position, occasionally move about inside the office to access office machinery, printer, etc., frequently communicate and exchange accurate information.
 <br/>
 <br/>
 <strong>
  Work Condition:
 </strong>
 Remote Work Environment
 <br/>
 <br/>
 <ul>
  <li>
   Employee generally works within a remote work from home environment.
  </li>
  <li>
   Travel may be required on occasion.
  </li>
  <li>
   Hours of operations and specific staff scheduling may vary based on operational need.
   <br/>
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Exposed to:
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Employee is responsible for maintaining a safe work environment that is conducive to successful productivity and work output.
  </li>
  <li>
   Machines, equipment, tools, and supplies used: Constantly operates a computer or other office productivity machinery or software, such as fax, copier, calculator, multi-line telephone system, or scanner.
  </li>
  <li>
   May answer a high volume of telephone calls, complete documentation, and use computer programs to either obtain or record information.
   <br/>
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Multiple Duties:
 </strong>
 Must be able to work under conditions of frequent interruption and be able to stay on task.
 <br/>
 <br/>
 This job description is intended to provide only basic guidelines for meeting job requirements. This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of DOCS Management Services employees. Other duties, responsibilities and activities may change or be assigned at any time with or without notice.
</div>


REMOTE Utilization Review Nurse - Managed Care

Vitae Health Systems

<div><p><b>Company:</b> Vitae Health Systems<br>
<b>Location:</b> Remote &ndash; Georgia<br>
<b>Compensation:</b> $700 per Nurse Practitioner per month<br>
<b>Commitment:</b> Part-time / Contract</p><h2 class="jobSectionHeader"><b>
About Vitae Health Systems</b></h2><p>
Vitae Health Systems is a leading provider of behavioral health and internal medicine services in post-acute and long-term care settings. Our team partners with skilled nursing and rehabilitation facilities across multiple states to deliver high-quality psychiatric care to underserved populations.</p><p>
We are seeking a <b>Georgia-licensed Psychiatrist</b> to serve as a <b>Collaborating Physician</b> for our Psychiatric Nurse Practitioners practicing in Georgia. This is a flexible, low-time-commitment opportunity ideal for psychiatrists interested in supporting high-quality NP-led behavioral health care.</p><h2 class="jobSectionHeader"><b>
Position Overview</b></h2><p>
The Collaborating Psychiatrist will provide clinical collaboration and oversight to Psychiatric Nurse Practitioners in accordance with Georgia state regulations and protocol agreements. The role primarily involves periodic chart review, protocol oversight, and clinical consultation as needed.</p><h2 class="jobSectionHeader"><b>
Responsibilities</b></h2><ul><li><p>
Enter into and maintain a <b>Collaborative Practice Agreement / Nurse Protocol Agreement</b> with Psychiatric Nurse Practitioners.</p></li><li><p>
Conduct <b>periodic chart reviews and co-sign documentation</b> as required by Georgia regulations.</p></li><li><p>
Review and sign off on medication management and prescribing documentation when applicable.</p></li><li><p>
Be <b>available for clinical consultation</b> regarding patient care and treatment planning.</p></li><li><p>
Provide general oversight and feedback to ensure high standards of psychiatric care.</p></li><li><p>
Participate in periodic protocol review and quality assurance activities as required by state guidelines.</p></li></ul><h2 class="jobSectionHeader"><b>
Qualifications</b></h2><ul><li><p>
MD or DO with <b>board certification or board eligibility in Psychiatry</b></p></li><li><p><b>
Active and unrestricted Georgia medical license</b></p></li><li><p>
DEA registration preferred</p></li><li><p>
Reside within 50 miles of Georgia</p></li><li><p>
Ability to enter into collaborative agreements with Psychiatric Nurse Practitioners under Georgia law</p></li><li><p>
Interest in supporting team-based psychiatric care</p></li><li><p>
Prior experience working with NPs or in collaborative care settings preferred</p></li></ul><h2 class="jobSectionHeader"><b>
Compensation</b></h2><ul><li><p><b>
$700 per NP supervisee per month</b></p></li><li><p>
Flexible and minimal time commitment</p></li><li><p>
Remote collaboration allowed in accordance with Georgia regulations</p></li></ul><h2 class="jobSectionHeader"><b>
Why Work With Vitae</b></h2><ul><li><p>
Established behavioral health organization with multi-state presence</p></li><li><p>
Structured clinical protocols and administrative support</p></li><li><p>
Flexible collaboration model</p></li><li><p>
Opportunity to support access to psychiatric care in underserved settings</p></li></ul></div>

Collaborating Psychiatrist (Psych NP Supervision) – Remote | Georgia

Trillium Health Resources

<div><div><b>Pay Plan Title: </b>Registered Nurse</div><div><b>
Working Title: </b>Registered Nurse, UM &ndash; Physical Health</div><div><b>
FLSA Status: </b>Exempt</div><div><b>
Posting Salary Range: </b>$66,240 - $88,595</div><div><b>
Office Location: </b>Remote within North Carolina.</div><div></div><div><b><br>
POSTING DETAILS:</b></div><div></div><div><b><br>
Make an Impact</b></div><div></div><div><br>
Trillium Health Resources is a Tailored Plan and Managed Care Organization (MCO) serving 46 counties across North Carolina. We manage services for individuals with serious mental health needs, substance use disorders, traumatic brain injuries, and intellectual/development (IDD) disabilities. Our mission is to help individuals and families build strong foundations for healthy, fulfilling lives.</div><div></div><div><b><br>
Why Work for Us</b>?</div><div></div><div><br>
Trillium believes that empowering others begins with supporting our team. We offer our employees:</div><div></div><div><br>
<ul><li>
A collaborative, mission-driven work environment</li><li>
Competitive benefits and work-from-home options for most positions</li><li>
Opportunities for professional growth in a diverse inclusive culture</li></ul></div><div></div><div><br>
Every day, our work changes lives &ndash; from children thriving through early intervention and school-based therapies, to adults with severe mental illness living independently and contributing to their communities.</div><div></div><div><br>
If you are looking for a unique opportunity to make a tangible impact on the lives of others, apply today!</div><div></div><div><b><br>
What We&rsquo;re Looking For</b></div><div></div><div><br>
Trillium Health Resources has a career opening for a Registered Nurse to join our Utilization Management team! The Registered Nurse, UM &ndash; Physical Health, is responsible for ensuring timely and accurate determination and notification of reviews and reconsiderations based on the review determination status. The Registered Nurse, UM &ndash; Physical Health, will generate approval, modifications, and denials communications, to include member and provider notification of review determination. This position also facilitates, coordinates, and approves medically necessary reviews that meet established criteria.</div><div></div><div><b><br>
On a typical day, you might:</b></div><div></div><div><br>
<ul><li>
Perform prospective/preservice, concurrent, post-service, and retrospective claims medical review processes. Utilizing considerable clinical judgement, independent analysis, critical-thinking skills, and detailed knowledge of clinical coverage policies, clinical practice guidelines, and benefit plans to complete reviews and determinations within required turnaround times specific to the case type. Identify cases needing Medical Director review or input. Present cases to Medical Director for potential review or determinations when needed.</li><li>
Perform telephonic admission and concurrent review, and collaborate with on-site facility staff, physicians, providers, care management, the member, and significant others to develop and implement a successful discharge plan, if contracted by client.</li><li>
Maintain accurate records in the designated medical management system and/or claims systems.</li><li>
Generate appropriate member and provider communication for all determinations within the required timelines as defined by the most current department policy.</li></ul></div><div></div><div><b><br>
Employee Benefits:</b></div><div></div><div><br>
Trillium knows that work/life balance is essential. That&rsquo;s why we offer:</div><div></div><div><br>
<ul><li>
Typical working hours: 8:30 am &ndash; 5:00 pm; flexible work schedules with some roles with management approval.</li><li>
Work-from-home options available for most positions</li><li>
Health Insurance with no premium for employee coverage</li><li>
Flexible Spending Accounts</li><li>
24 days of Paid Time Off (PTO) plus 12 paid holidays in your first year</li><li>
NC Local Government Retirement Pension (defined-benefit plan) https://www.myncretirement.gov/systems-funds/local-governmental-employees-retirement-system-lgers/lgers-handbook</li><li>
401k with 5% employer match and immediate vesting</li><li>
Public Service Loan Forgiveness (PSLF) qualifying employer</li><li>
Quarterly stipend for remote work supplies</li></ul></div><div></div><div><b><br>
Qualifications</b></div><div></div><div><br>
Required:</div><div><ul><li>
Fully licensed by the North Carolina State Board of Nursing as an RN.</li><li>
Minimum two (2) years of Utilization Management/Review experience, to include clinical acute inpatient care (ER, ICU, Med-Surg), behavioral health, compliance, or evidence-based clinical decision support tools (ex: MCG/InterQual).</li><li>
Must have a valid driver&rsquo;s license.</li><li>
Must reside within North Carolina.</li><li>
Must be able to travel within catchment as required.</li></ul></div><div></div><div><br>
Preferred:</div><div><ul><li>
Clinical experience in a managed care organization, health plan or hospital setting.</li><li>
Utilization Management certification.</li></ul></div><div></div><div><b><br>
Deadline for Application:</b> Monday, May 18, 2026 at 11:59pm</div><div></div><div><b><br>
How to Apply</b></div><div></div><div><br>
To be considered, submit your application and resume through our ADP Career Center. Your resume must include:</div><div></div><div><br>
<ul><li>
Employer name, dates of service (month/year), average hours worked per week, and essential job duties</li><li>
Education details (degree type, date awarded, institution, field of study)</li><li>
Licensure/certification information, if applicable</li></ul></div><div></div><div><br>
After submission, your resume will be reviewed to ensure it meets the essential criteria for the position. You&rsquo;ll be notified by HR regarding your application status as appropriate. All applicants will receive a final update once the recruitment cycle closes.</div><div></div><div><br>
Join our Talent Community through ADP to stay informed about future opportunities. Be sure to keep your resume updated in your profile.</div><div></div><div><b><br>
Trillium Health Resources is an Equal Employment Opportunity (EEO) employer and a drug-free workplace. All candidates must pass a drug test as a condition of employment.</b></div><div></div><div><i><br>
#Innovation #Technology #Careers #NorthCarolina #BehavioralHealth</i></div></div>

Registered Nurse, UM – Physical Health

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