managed care nurse

Elevance Health

<div>
 <strong>
  Nurse Appeals- Licensed Nurse
  <br/>
  <br/>
 </strong>
 <strong>
  Location:
 </strong>
 Virtual: This role enables associates to work virtually full-time, except for required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development.
 <br/>
 <br/>
 Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.
 <br/>
 <br/>
 <strong>
  Hours
 </strong>
 : The work schedule for this position is Tuesday through Saturday with Sunday rotation. Business hours are 8 am to 8 pm EST, and the selected candidate must be able to work an 8-hour shift between those hours, including holidays on a rotational basis.
 <br/>
 <br/>
 The
 <strong>
  Nurse Appeals
 </strong>
 is responsible for investigating and processing and medical necessity appeals requests from members and providers.
 <br/>
 <br/>
 <strong>
  How You Will Make An Impact
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Conducts investigations and reviews of member and provider medical necessity appeals.
  </li>
  <li>
   Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity.
  </li>
  <li>
   Extrapolates and summarizes medical information for medical director, consultants and other external review.
  </li>
  <li>
   Prepares recommendations to either uphold or deny appeal and forwards to Medical Director for approval.
  </li>
  <li>
   Ensures that appeals and grievances are resolved timely to meet regulatory timeframes.
  </li>
  <li>
   Documents and logs appeal/grievance information on relevant tracking systems and mainframe systems.
  </li>
  <li>
   Generates written correspondence to providers, members, and regulatory entities.
  </li>
  <li>
   Utilizes leadership skills and serves as a subject matter expert for appeals/grievances/quality of care issues and is a resource for clinical and non clinical team members in expediting the resolution of outstanding issues.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Minimum Requirements
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Requires a HS diploma or equivalent and a minimum of 2 years of experience in a managed care healthcare setting; or any combination of education and experience, which would provide an equivalent background. Current active unrestricted RN license to practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States required.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Preferred Skills, Capabilities And Experiences
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   AS or BS in Nursing preferred.
  </li>
  <li>
   Three to five years of clinical experience as a Registered Nurse strongly preferred.
  </li>
  <li>
   Have a current active unrestricted RN license to practice nursing within the scope of licensure in applicable state(s) or territory of the United States strongly preferred.
  </li>
  <li>
   Have two years in a managed care healthcare setting - reviewing medical records, investigation, and/or processing appeals within a managed care setting; or any combination of education and experience, which would provide an equivalent background strongly preferred.
  </li>
  <li>
   Experienced researching Medicare clinical guidelines: NCD, LCD; Medicare Benefit Policy and Milliman Care Guidelines is preferred.
  </li>
  <li>
   Experience reviewing claims and researching CPT codes or ICD-9 codes is preferred.
  </li>
  <li>
   Experience with Facets, Macess, and ACMP is preferred.
   <br/>
   <br/>
  </li>
 </ul>
 For candidates working in person or virtually in the below locations, the salary* range for this specific position is $72,492 to $108,738
 <br/>
 <br/>
 <strong>
  Locations: Latham, New York
  <br/>
  <br/>
 </strong>
 In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the company. The company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.
 <br/>
 <br/>
 <ul>
  <li>
   The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education, and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company&rsquo;s sole discretion, consistent with the law.
   <br/>
   <br/>
  </li>
 </ul>
 Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
 <br/>
 <br/>
 Who We Are
 <br/>
 <br/>
 Elevance Health is a health company dedicated to improving lives and communities &ndash; and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.
 <br/>
 <br/>
 How We Work
 <br/>
 <br/>
 At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.
 <br/>
 <br/>
 We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
 <br/>
 <br/>
 Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.
 <br/>
 <br/>
 The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.
 <br/>
 <br/>
 Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance.
 <br/>
 <br/>
 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.
</div>


Nurse Appeals

Cahaba Medical Care Foundation

<div><div><b>Chronic Care Management Nurse/RN</b></div><div></div><div><i><br>
Reports to </i><b><i>Chief Quality Officer</i></b></div><div><b><br>
 Cahaba Medical Care Foundation</b></div><p><b>
 Supervised by: </b>Chief Quality Officer</p><h3 class="jobSectionHeader">
Position Overview:</h3><p>
The Chronic Care Management Nurse plays a pivotal role in providing personalized care for patients with chronic conditions, including but not limited to diabetes, hypertension, asthma, COPD, heart disease, and other long-term illnesses. This role involves monitoring patients' health status, educating them on their conditions, ensuring adherence to treatment plans, and promoting proactive measures to prevent complications. The Chronic Care Management Nurse collaborates closely with physicians, care teams, and patients to deliver high-quality care in a clinic setting.</p><h3 class="jobSectionHeader">
Working Environment:</h3><ul><li><p>
Clinic Hours: Monday to Friday, 8:00 AM &ndash; 5:00 PM (with occasional extended hours depending on patient needs).</p></li><li><div>
Environment: Fast-paced, team-oriented, and patient-focused clinic setting.</div></li><li><p>
Physical Demands: Standing, walking, and sitting for extended periods. Occasional lifting of patients or equipment may be required.</p></li></ul><h3 class="jobSectionHeader">
Key Responsibilities:</h3><h4 class="jobSectionHeader">
Patient Care &amp; Management:</h4><ul><li><p>
Chronic Disease Management:</p><ul><li><div><br>
Monitor and assess the health status of patients with chronic conditions, including vital signs, lab results, medications, and treatment adherence.</div></li><li><div>
Provide ongoing education and support to patients on managing their chronic conditions and improving health outcomes.</div></li><li><div>
Collaborate with physicians and other healthcare providers to develop and implement personalized care plans based on patient needs.</div></li><li><div>
Offer routine assessments for patients in both in-person and remote settings, such as phone calls or telehealth visits.</div></li></ul></li><li><div>
Medication Management:</div><ul><li><div><br>
Educate patients on the proper use of prescribed medications and monitor for adherence, side effects, and potential drug interactions.</div></li><li><div>
Coordinate medication refills and communicate with pharmacies/providers as necessary.</div></li><li><div>
Assist in adjusting medication regimens as ordered by the physician, in accordance with established protocols.</div></li></ul></li><li><div>
Care Coordination:</div><ul><li><div><br>
Act as a point of contact for patients with chronic conditions, ensuring that all aspects of care are coordinated, including referrals, tests, and specialist visits.</div></li><li><div>
Communicate and follow up with patients to ensure continuity of care and address any issues or concerns promptly.</div></li><li><p>
Monitor patients' progress and identify early signs of complications or deterioration in their condition.</p></li></ul></li></ul><h4 class="jobSectionHeader">
Education &amp; Support:</h4><ul><li><p>
Patient Education:</p><ul><li><div><br>
Provide education on managing chronic diseases, including self-management skills, lifestyle changes, diet, exercise, and coping strategies.</div></li><li><div>
Educate patients and their families on the importance of preventative care, such as routine screenings, immunizations, and other health-related behaviors.</div></li><li><div>
Use self management methods to ensure patients understand their treatment plans and health goals.</div></li></ul></li><li><div>
Health Promotion:</div><ul><li><div><br>
Help patients set realistic, measurable goals to improve their health and quality of life.</div></li><li><div>
Guide patients through disease-specific management strategies, including symptom monitoring, tracking triggers, and recognizing warning signs.</div></li><li><p>
Empower patients to take ownership of their health and become active participants in their care plans.</p></li></ul></li></ul><h4 class="jobSectionHeader">
Documentation &amp; Reporting:</h4><ul><li><p>
Patient Records:</p><ul><li><div><br>
Maintain accurate and up-to-date patient records in compliance with clinic policies and relevant regulations (e.g., HIPAA).</div></li><li><div>
Document patient assessments, care plans, interventions, progress notes, and any changes in condition or treatment in the electronic health record (EHR).</div></li><li><p>
Complete required reports related to chronic care management programs, including billing and outcome documentation.</p></li></ul></li></ul><h4 class="jobSectionHeader"><br>
Quality Improvement:</h4><ul><li><p>
Outcomes Monitoring:</p><ul><li><div><br>
Track and report on the effectiveness of chronic care management services, identifying areas for improvement in care delivery.</div></li><li><div>
Participate in quality improvement initiatives aimed at improving patient outcomes and enhancing the overall care process.</div></li><li><p>
Support the clinic&rsquo;s efforts to meet accreditation standards, quality measures, and performance benchmarks for chronic care management.</p></li></ul></li></ul><h3 class="jobSectionHeader">
Skills and Qualifications:</h3><ul><li><p>
Education and Certification:</p><ul><li><div><br>
Registered Nurse (RN) or Licensed Practical Nurse (LPN)with an active state license.</div></li><li><div>
BLS (Basic Life Support) certification</div></li></ul></li><li><div>
Experience:</div><ul><li><div><br>
Minimum of 2-3 years of nursing experience, with a focus on chronic disease management, geriatrics, or related areas.</div></li><li><div>
Experience working in a clinic or outpatient setting preferred.</div></li><li><div>
Knowledge and experience in patient education, health promotion, and care coordination.</div></li></ul></li><li><div>
Technical Skills:</div><ul><li><div><br>
Proficiency with Electronic Health Records (EHR) systems.</div></li><li><div>
Basic knowledge of chronic care management programs and healthcare regulations.</div></li><li><div>
Familiarity with telemedicine platforms and remote patient monitoring is a plus.</div></li></ul></li><li><div>
Interpersonal Skills:</div><ul><li><div><br>
Excellent communication skills, both verbal and written, to effectively interact with patients, families, and healthcare professionals.</div></li><li><div>
Ability to work collaboratively within a multidisciplinary team.</div></li><li><div>
Strong critical thinking and problem-solving skills, with the ability to assess complex situations and make sound clinical decisions.</div></li></ul></li><li><div>
Personal Attributes:</div><ul><li><div><br>
Empathy and compassion for patients with chronic conditions.</div></li><li><div>
Strong organizational skills and attention to detail.</div></li><li><div>
Ability to manage a high volume of patients and prioritize care effectively.</div></li></ul></li></ul><h3 class="jobSectionHeader">
Additional Information:</h3><p>
The Chronic Care Management Nurse is a critical member of our care team, dedicated to improving the health and quality of life of patients with chronic conditions. This role provides an opportunity to make a meaningful difference in the lives of patients, empowering them to manage their health and prevent complications associated with chronic diseases.</p></div>

Chronic Care Management Nurse

Butler Memorial Hospital

<div><p>Job Summary:<br>
The Case Managers are experienced Registered Nurses who interact with the patient, families, physicians and other members of the<br>
interdisciplinary team to facilitate quality and cost effective care. An essential component to all roles includes the evaluation of medical<br>
necessity and intensity of service of each admission to arrive at decisions regarding medical appropriateness for the requested level of<br>
care. Communicates with the various payers/insurance companies to authorize services and ensure appropriate reimbursement to the<br>
facility. Actively promotes collaboration among all interdisciplinary care providers, including physicians to effectively identify needs for<br>
continued inpatient care or appropriate alternate levels of care. There is coordination to affect an appropriate discharge plan with the<br>
Case Managers ensuring arrangements of placement/services upon discharge. Assist to identify and make efforts to correct delays in<br>
services, fragmentation of care and gaps in communication. Patient outcome monitoring and participation in continuous performance<br>
improvement are also requirements in this role.<br>
Education<br>
Minimum:<br>
Graduate of a Registered Nurse Program<br>
Preferred:<br>
Bachelor Degree in Nursing<br>
Registration/Certification/Licensure:<br>
Current PA RN license<br>
Preferred: Healthcare Provider CPR<br>
Experience<br>
Minimum:<br>
Three years recent clinical experience.<br>
Preferred:<br>
Managed care or previous Case Management/Utilization Review experience.<br>
Other Requirements:<br>
Excellent communication skills and skills in customer service. Demonstrates leadership ability. Commitment to the delivery of quality<br>
patient care with the ability to develop and maintain effective, professional relationships with all members of the health care team.<br>
Status:<br>
Non-Exempt</p>
<p>
Physical Requirements:<br>
The following frequency definitions apply to all Physical Requirements unless otherwise noted:<br>
Occasional: (0-1/3 of day , 0 - 2.5 hrs/day, 1 - 4 reps/hr)<br>
Frequent: (1/3 -2/3 of day , 2.5 - 5.5 hrs/day, 5 -24 reps/hr)<br>
Constant: (&gt; 2/3rd of day , &gt; 5.5 hrs/day, &gt; 24 reps/hr)<br>
First Name xxxxx<br>
Middle Name xxxxx<br>
Last Name xxxxx<br>
Position Code 10.5070000.0000.236<br>
Position Name CASE MANAGER<br>
Department Name BMH Case Management<br>
Facility Name Butler Memorial Hospital<br>
Employee Number xxxxx<br>
NOTE: An asterisk (*) indicates that the item is an essential function.<br>
Non-Material Handling<br>
Standing* - Remaining on one's feet in an upright position remaining stationary. -FREQUENT<br>
Walking* - Remaining upright on one's feet, and moving about. -FREQUENT<br>
Sitting * - Body remains in a seated position. -FREQUENT<br>
Stooping - To bend the body downward and forward by bending the spine at the waist. - OCCASIONAL<br>
Bending - To flex the upper body forward. - OCCASIONAL<br>
Twisting - To rotate the upper body forward. - OCCASIONAL<br>
Climbing - To move the body in any direction on equipment or structures that do not include stairs or ladders. - N/A<br>
Ladders - To ascend and descend ladders. - N/A<br>
Stairs - To ascend and descend stairs. - FREQUENT<br>
Kneeling - To move the body downwards and come to rest on both hands and both knees - OCCASIONAL<br>
Squatting - To move the body downwards by bending both knees. - OCCASIONAL<br>
Crouching - To bend the body forward and downward by bending the spine and the legs. - OCCASIONAL<br>
Crawling - To move the body forward or backwards on hands and knees. - N/A<br>
Reaching Horizontal - To extend the arms and hands outward, remaining under shoulder height - OCCASIONAL<br>
Reaching Overhead - To extend the arms and hands up and out over shoulder height. - OCCASIONAL<br>
Grasping - Using functional gripping of the hand to handle an object. - CONSTANT<br>
Finger Manipulation - To manipulate objects with the use of fingers. - CONSTANT<br>
Seeing - Using visual feedback to accomplish a task or activity. - CONSTANT<br>
Hearing - Using sound feedback to accomplish a task or activity - CONSTANT<br>
Repetitive Upper Extremity Use - Using the arms and/or hands continuously or more than 2/3 of the total time. - CONSTANT<br>
Repetitive Lower Extremity Use - Using the legs and/or feet continuously or more than 2/3 of the total time. - CONSTANT<br>
Material Handling<br>
Pushing* - To exert a force upon an object in order to move it in a certain direction. Pushing refers to moving an object away from the<br>
person.<br>
CONSTANT<br>
Up to 20#<br>
Pulling* - To exert a force upon an object in order to move it in a certain direction. Pulling refers to moving an object towards the<br>
person.<br>
CONSTANT<br>
Up to 20#<br>
Lift - Floor to waist<br>
CONSTANT<br>
Up to 20#<br>
Lift - Waist to shoulder<br>
CONSTANT<br>
Up to 20#<br>
Lift - Shoulder to overhead<br>
CONSTANT<br>
Up to 20#<br>
Carrying - To transport an object or article using the arms or hands (&gt; 10 feet)<br>
CONSTANT<br>
Up to 20#</p><br>
<p>
Environmental Factors<br>
Working alone - OCCASIONAL<br>
Working in cramped quarters - FREQUENT<br>
Constant interruptions * - CONSTANT<br>
Working with hands in water - N/A<br>
Use of power tools - N/A<br>
Working on ladders/scaffolding - N/A<br>
Exposure to vibration - N/A<br>
Exposure to dust - N/A<br>
Exposure to noise (constant) - N/A<br>
Exposure to electrical energy (outlets, etc) - N/A<br>
Exposure to termperature changes (heat, cold, humidity), that require special clothing - N/A<br>
Exposure to slippery walking surfaces - N/A<br>
Exposure to solvents, grease, oils - N/A<br>
Exposure to radiant energy, i.e. computer terminal (more than 4 hours per shift) * - CONSTANT<br>
Working with bloodborne pathogens - N/A<br>
Cardiovascular Energy Requirements - Physical Demand<br>
Physical<br>
Demand<br>
Met<br>
Level<br>
Examples of similar activity intensity<br>
Sedentary to<br>
Light<br>
0 - 3.5 Light house cleaning, washing dishes, serving food, food shopping, sitting, standing, computer work.<br>
Medium 3.6 - 6.3<br>
House work (mopping, scrubbing), health club exercising, treadmill work, stretching, yoga, walk/run-play<br>
with children, aerobic class, dancing, carrying bucket/wood, auto body repair, shoveling snow, golf<br>
(carrying clubs).<br>
Heavy to Very<br>
Heavy<br>
&gt; 6.4<br>
Calisthenics (push up, pull up, sit up, vigorous effort), carrying groceries upstairs, shoveling coal, bailing<br>
hay, fire fighting, sawing by hand, splitting wood.<br>
As relates to this position:<br>
Sedentary to Light - CONSTANT<br>
Medium - N/A<br>
Heavy to Very Heavy - N/A</p>
<p>
. Specific Job Responsibilities (Essential Functions):<br>
1. Performs admission as well as continued stay review of designated cases through established decision support criteria (Interqual) accurately<br>
identifying Severity of Illness/Intensity of Service to determine appropriateness of admission and ensure appropriate reimbursement. Focuses on<br>
Observation cases to determine appropriate action/follow up necessary in relationship to medical necessity; i.e. discharge/transition to inpatient<br>
status. Demonstrates understanding and efficiency in physician referrals/tasking to EHR.<br>
2. Provides clear documentation of selected medical necessity criteria as well as interventions and obtained authorizations. Demonstrates the ability<br>
to navigate the Navinet On Line Highmark process, the Allscripts case management module, Meditech and EMR.<br>
3. Understands and applies the many reimbursement strategies of the various payers and makes appropriate decisions relevant to this information<br>
(i.e. per diem/DRG, case Rate, observation, etc). Completes all required authorizations/pre-certifications to ensure appropriate reimbursement to<br>
the facility.<br>
4. Serves as an organizational collaborator for the patient to promote appropriate, efficient quality care. Collaborates with the Social Worker and<br>
health care team to ensure timely discharge planning; demonstrating efficiency in arranging for patient Post Discharge Needs: home infusion<br>
therapy, medications, DME, placement, transportation etc.<br>
5. Remains knowledgeable and participates in ongoing performance improvement activities within the department as well as on an organizational<br>
level; CoP (Conditions of Participation); MEIM, Freedom of Choice; Delay Days, LOS/Readmission Reduction initiatives, HF clinic referrals, identifying<br>
barriers to discharge, fragmentation in patient care, etc.<br>
II. Organizational Responsibilities:<br>
1. Completed mandatory education, annual competencies and department specific education within established timeframes.<br>
2. Completed annual employee health requirements within established timeframes.<br>
3. Maintained license/certification, registration in good standing throughout fiscal year.<br>
4. Consistently utilizes appropriate universal precautions, protective equipment, and ergonomic techniques to protect patient and self. Identifies and<br>
works to reduce potentially unsafe patient care or other safety practices.<br>
5. Adheres to regulatory agency requirements, survey process and compliance.</p></div>

CASE MANAGER

Cambia Health Solutions

<div>
 <strong>
  Remote Care Management Nurse (Future Opportunities)
  <br/>
  <br/>
 </strong>
 <strong>
  Work from home within Oregon, Washington, Idaho or Utah
  <br/>
  <br/>
 </strong>
 <strong>
  *
 </strong>
 Please be advised that this role is part of our candidate pool, which allows us to identify and attract exceptional talent for future opportunities. Although we may not have immediate openings, we invite you to submit your resume for consideration. By doing so, you will be included in our database and considered for all suitable positions as they become available, ensuring that you are among the first to be notified of new opportunities that match your skills and experience.*
 <br/>
 <br/>
 <strong>
  Build a career with purpose. Join our
 </strong>
 <strong>
  Cause
 </strong>
 <strong>
  to create a person-focused and economically sustainable health care system.
  <br/>
  <br/>
 </strong>
 <strong>
  Who We Are Looking For
  <br/>
  <br/>
 </strong>
 Every day, Cambia&rsquo;s dedicated team of Care Management RN's are living our mission to make health care easier and lives better. As a member of the Clinical Services team, our Care Management RN's provide clinical care management (such as case management, disease management, and/or care coordination) to best meet the member&rsquo;s specific healthcare needs and to promote quality and cost-effective outcomes. Oversees a collaborative process with the member and those involved in the member&rsquo;s care to assess, plan, implement, coordinate, monitor and evaluate care as needed - all in service of creating a person-focused health care experience.
 <br/>
 <br/>
 Are you a Registered Nurse looking to transition out of bedside care and into a role that still utilizes your clinical expertise, but offers a fresh challenge? Is your goal to promote quality, cost-effective outcomes and improve overall health and wellbeing? Then this role may be the perfect fit.
 <br/>
 <br/>
 <strong>
  Qualifications
  <br/>
  <br/>
 </strong>
 <strong>
  What You Bring to Cambia:
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Nursing or health/human services degree (Associate's or Bachelor's minimum), or equivalent experience in lieu of a degree
  </li>
  <li>
   At least 3 years of direct clinical care or experience in case management, utilization management, disease management, auditing, or retrospective review
  </li>
  <li>
   Active, unrestricted licensure or certification in a U.S. state or territory that allows you to independently conduct assessments within your scope of practice &mdash; RN license required for medical care management
  </li>
  <li>
   Must be eligible for licensure in Idaho, Oregon, Utah, and Washington
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Skills And Attributes
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Knowledge of health insurance industry trends, technology and contractual arrangements.
  </li>
  <li>
   General computer skills (including use of Microsoft Office, Outlook, internet search).
  </li>
  <li>
   Familiarity with health care documentation systems.
  </li>
  <li>
   Strong oral, written and interpersonal communication and customer service skills.
  </li>
  <li>
   Ability to interpret policies and procedures, make decisions, and communicate complex topics effectively.
  </li>
  <li>
   Strong organization and time management skills with the ability to manage workload independently.
  </li>
  <li>
   Ability to think critically and make decision within individual role and responsibility.
  </li>
  <li>
   Experience with AI tools and technologies to enhance productivity and decision-making in professional settings highly desired
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  What You Will Do At Cambia
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Conducts case management activities, including assessment, planning, implementation, coordination, monitoring, and evaluation to identify and meet member needs.
  </li>
  <li>
   Applies clinical expertise and judgment to ensure compliance with medical policy, medical necessity guidelines, and accepted standards of care, utilizing evidence-based criteria and practicing within the scope of their license.
  </li>
  <li>
   Collaborates with physician advisors, internal and external customers, and other departments to resolve claims, quality of care, member or provider issues, and identifies problems or needed changes, recommending resolutions and participating in quality improvement efforts.
  </li>
  <li>
   Serves as a resource to internal and external customers, responding to inquiries in a professional manner while protecting confidentiality of sensitive documents and issues.
  </li>
  <li>
   Provides consistent and accurate documentation, ensuring compliance with performance standards, corporate goals, and established timelines.
  </li>
  <li>
   Coordinates resources, organizes, and prioritizes assignments to meet goals and timelines.
  </li>
  <li>
   Monitors and evaluates the effectiveness of case management plans, gathering sufficient information to determine the plan's effectiveness and making adjustments as needed.
   <br/>
   <br/>
  </li>
 </ul>
 The expected hiring range for a Care Management Nurse is $36.80 &ndash; $49.80 per hour, depending on skills, experience, education, and training; relevant licensure/certifications; and performance history. The bonus target for this position is 10%. The current full salary range for this role is $34.20 &ndash; $55.70 per hour. Please let me know if you have any questions.
 <br/>
 <br/>
 <strong>
  About Cambia
  <br/>
  <br/>
 </strong>
 Working at Cambia means being part of a purpose-driven, award-winning culture built on trust and innovation anchored in our 100+ year history. Our caring and supportive colleagues are some of the best and brightest in the industry, innovating together toward sustainable, person-focused health care. Whether we're helping members, lending a hand to a colleague or volunteering in our communities, our compassion, empathy and team spirit always shine through.
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 <strong>
  Why Join the Cambia Team?
  <br/>
  <br/>
 </strong>
 <strong>
  At Cambia, You Can
  <br/>
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 </strong>
 <ul>
  <li>
   Work alongside diverse teams building cutting-edge solutions to transform health care.
  </li>
  <li>
   Earn a competitive salary and enjoy generous benefits while doing work that changes lives.
  </li>
  <li>
   Grow your career with a company committed to helping you succeed.
  </li>
  <li>
   Give back to your community by participating in Cambia-supported outreach programs.
  </li>
  <li>
   Connect with colleagues who share similar interests and backgrounds through our employee resource groups.
   <br/>
   <br/>
  </li>
 </ul>
 We believe a career at Cambia is more than just a paycheck &ndash; and your compensation should be too. Our compensation package includes competitive base pay as well as a market-leading 401(k) with a significant company match, bonus opportunities and more.
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 <strong>
  Benefits
  <br/>
  <br/>
 </strong>
 In exchange for helping members live healthy lives, we offer benefits that empower you to do the same. Just a few highlights include:
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 <ul>
  <li>
   Medical, dental and vision coverage for employees and their eligible family members, including mental health benefits.
  </li>
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   Annual employer contribution to a health savings account.
  </li>
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   Generous paid time off varying by role and tenure in addition to 10 company-paid holidays.
  </li>
  <li>
   Market-leading retirement plan including a company match on employee 401(k) contributions, with a potential discretionary contribution based on company performance (no vesting period).
  </li>
  <li>
   Up to 12 weeks of paid parental time off (eligibility requires 12 months of continuous service with Cambia immediately preceding leave).
  </li>
  <li>
   Award-winning wellness programs that reward you for participation.
  </li>
  <li>
   Employee Assistance Fund for those in need.
  </li>
  <li>
   Commute and parking benefits.
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   <br/>
  </li>
 </ul>
 <strong>
  Learn More About Our Benefits.
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 </strong>
 We are happy to offer work from home options for most of our roles. To take advantage of this flexible option, we require employees to have a wired internet connection that is not satellite or cellular and internet service with a minimum upload speed of 5Mb and a minimum download speed of 10 Mb.
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 We are an Equal Opportunity employer dedicated to a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A background check is required.
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 <br/>
 If you need accommodation for any part of the application process because of a medical condition or disability, please email CambiaCareers@cambiahealth.com. Information about how Cambia Health Solutions collects, uses, and discloses information is available in our Privacy Policy.
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</div>


Remote Care Management Nurse

Blue Cross Blue Shield of Arizona

<div>
 Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy. AZ Blue offers a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions.
 <br/>
 <br/>
 At AZ Blue, we have a hybrid workforce strategy, called Workability, that offers flexibility with how and where employees work. Our positions are classified as hybrid, onsite or remote. While the majority of our employees are hybrid, the following classifications drive our current minimum onsite requirements:
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 <ul>
  <li>
   Hybrid People Leaders: must reside in AZ, required to be onsite at least twice per week
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   Hybrid Individual Contributors: must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per week
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  <li>
   Hybrid 2 (Operational Roles such as but not limited to: Customer Service, Claims Processors, and Correspondence positions): must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per month
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  <li>
   Onsite: daily onsite requirement based on the essential functions of the job
  </li>
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   Remote: not held to onsite requirements, however, leadership can request presence onsite for business reasons including but not limited to staff meetings, one-on-ones, training, and team building
   <br/>
   <br/>
  </li>
 </ul>
 Please note that onsite requirements may change in the future, based on business need, and job responsibilities. Most employees should expect onsite requirements and at a minimum of once per week.
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 <strong>
  This remote work opportunity requires residency, and work to be performed, within the State of Arizona.
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  PURPOSE OF THE JOB
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 Ensures accuracy and timeliness in the completion of prior authorization (PA) requests to meet contractual requirements and ensures all reviews utilize nationally recognized and evidence-based standards for the Medicaid Segment which includes Medicaid and Medicare Advantage / Dual Eligible Special Needs Plan (D-SNP), and Affordable Care Act (ACA) members. Ensures the completion, accuracy, and timeliness in the Notice of Action (NOA) process.
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 <strong>
  Qualifications
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  REQUIRED QUALIFICATIONS
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 <strong>
  Required Work Experience
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 </strong>
 <ul>
  <li>
   3 years of clinical experience
  </li>
  <li>
   1 year of Medicaid/Medicare experience
  </li>
  <li>
   1 year prior authorization and member and provider notification (NOA) experience
  </li>
  <li>
   1 year experience with National Committee for Quality Assurance (NCQA) standards
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Required Education
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 </strong>
 <ul>
  <li>
   Associate degree in Nursing
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  </li>
 </ul>
 <strong>
  Required Licenses
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 </strong>
 <ul>
  <li>
   Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) as a health professional, including RN or LPN.
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   <br/>
  </li>
 </ul>
 <strong>
  Required Certifications
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 </strong>
 <ul>
  <li>
   N/A
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   <br/>
  </li>
 </ul>
 <strong>
  Preferred Qualifications
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 </strong>
 <strong>
  Preferred Work Experience
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 <ul>
  <li>
   3+ years of experience in managed care
  </li>
  <li>
   3+years of experience in prior authorization/utilization review
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  </li>
 </ul>
 <strong>
  Preferred Education
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 </strong>
 <ul>
  <li>
   Bachelor of Science in Nursing
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   <br/>
  </li>
 </ul>
 <strong>
  Preferred Licenses
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  <br/>
 </strong>
 <ul>
  <li>
   N/A
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Preferred Certifications
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   N/A
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Essential Job Functions And Responsibilities
  <br/>
  <br/>
 </strong>
 <strong>
  ALL LEVELS
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  <br/>
 </strong>
 <ul>
  <li>
   Ensures the accuracy and timeliness of prior authorization requests to meet contractual requirements.
  </li>
  <li>
   Coordinates and manages the established preauthorization review process for pre-service requests.
  </li>
  <li>
   Ensures the use of nationally recognized and evidence-based standards in the completion of all pre-service reviews.
  </li>
  <li>
   Utilize clinical skills, chart review, physician communication and appropriate criteria for approval of pre-service requests; escalate pre-service request(s) to the medical director for determination when criteria not met.
  </li>
  <li>
   Clearly define and document review rationale to support approval, Medical Director Review and/or Notice of Action document.
  </li>
  <li>
   Initiates interdepartmental coordination to ensure quality and timely care for members.
  </li>
  <li>
   Participates in Quality Improvement Projects as directed.
  </li>
  <li>
   Participate in department audits and other regulatory activities.
  </li>
  <li>
   Engage cross-functionally and participate in special projects as needed.
  </li>
  <li>
   Performs Notice of Action (NOA) process.
  </li>
  <li>
   Participate in annual policy and procedure review and revision.
  </li>
  <li>
   Perform all other duties as assigned.
  </li>
  <li>
   The position requires a full-time work schedule,40 hours per week, plus any additional hours as requested or as needed to meet business requirements.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  COMPETENCIES
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 </strong>
 <strong>
  Required Competencies
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 </strong>
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  Required Job Skills
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 <ul>
  <li>
   Computer skills to include Microsoft Office applications, Word, Excel, and Outlook
  </li>
  <li>
   Ability to use electronic medical management systems
  </li>
  <li>
   Analytical problem solving skills
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Required Professional Competencies
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  <br/>
 </strong>
 <ul>
  <li>
   N/A
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Required Leadership Experience And Competencies
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   N/A
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Preferred Competencies
  <br/>
  <br/>
 </strong>
 <strong>
  Preferred Job Skills
  <br/>
  <br/>
 </strong>
 N/A
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 <br/>
 <strong>
  Preferred Professional Competencies
  <br/>
  <br/>
 </strong>
 N/A
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 <strong>
  Preferred Leadership Experience And Competencies
  <br/>
  <br/>
 </strong>
 N/A
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 <strong>
  Our Commitment
  <br/>
  <br/>
 </strong>
 AZ Blue does not discriminate in hiring or employment on the basis of race, ethnicity, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status or any other protected group.
 <br/>
 <br/>
 Thank you for your interest in Blue Cross Blue Shield of Arizona. For more information on our company, see azblue.com. If interested in this position, please apply.
</div>


Prior Authorization Nurse - Remote - AZ

The Oaks at Radford Hills

<div>Description:
<p>
The Clinical Case Manager (CCM) is a licensed nurse responsible for coordinating and certifying the Resident Assessment Instrument (RAI) and Minimum Data Set (MDS) in compliance with federal and state regulations. The CCM collaborates with the interdisciplinary team to ensure accurate assessments, individualized care planning, PDPM compliance, and proper Medicare and Medicaid reimbursement while supporting quality, cost-effective resident care.</p><p><b>
Essential Duties and Responsibilities:</b></p><ul><li>
Manage the RAI process from admission through discharge to ensure clinical compliance and appropriate Medicare, Medicaid, and Managed Care reimbursement.</li><li>
Complete and submit accurate, timely, and documentation-supported MDS assessments in accordance with the RAI 3.0 User&rsquo;s Manual.</li><li>
Review MDS analytics with the interdisciplinary team prior to submission; monitor validation reports and correct/re-submit rejected assessments within required timeframes.</li><li>
Conduct daily rounds on all Medicare Part A and Managed Care residents; identify changes in condition, initiate Significant Change MDS assessments, and update care plans with IDT input.</li><li>
Ensure completion of daily skilled documentation and nursing observation notes for all Medicare Part A and Managed Care residents.</li><li>
Assign appropriate ICD-10-CM codes to support skilled services.</li><li>
Coordinate physician certification and re-certification for Medicare Part A and Managed Care residents.</li><li>
Collaborate with the interdisciplinary team and Business Office Manager to support care planning, managed care authorizations, and clinical justifications.</li><li>
Attend required PPS, care plan, quality, and reimbursement meetings to identify changes impacting resident status or reimbursement.</li><li>
Issue Notices of Medicare Non-Coverage (NOMNC) as required.</li><li>
Ensure PASRR (PL1) compliance for all admissions per State of Texas guidelines.</li><li>
Provide training and support to nursing staff on ADLs and clinical case management responsibilities.</li><li>
Attend required training, meetings, and seminars.</li><li>
Performs other duties as assigned.</li></ul>
Requirements:
<ul><li>Must be a Registered Nurse (RN) or Licensed Vocational Nurse (LVN) in good standing and currently licensed by the state.</li><li>
Demonstrated proficiency in computer applications, including Microsoft Office and Outlook, with the ability to learn new systems.</li><li>
Minimum Data Set (MDS) and care planning experience preferred and working knowledge of Medicare and Medicaid programs preferred.</li><li>
Minimum of one (1) year of geriatric experience, preferably with supervisory experience.</li><li>
Must be able to interact positively with residents, families, and regulatory agencies, and work collaboratively with employees at all levels.</li><li>
Must be able to maintain consistent attendance and be willing to work long or irregular hours, often under pressure.</li></ul><p><b>
Physical Requirements:</b></p><ul><li>
Must comply with all local health regulations and successfully complete a post-offer health assessment.</li><li>
Must be able to perform the essential functions of the position with or without reasonable accommodation.</li><li>
Physical and Sensory Requirements (with or without the use of mechanical devices):</li><li>
Ability to read, write, and speak fluent English to communicate effectively with residents, families, staff, and community agencies.</li><li>
Ability to perform physical activities such as walking, reaching, bending, stretching, pulling, and lifting.</li><li>
Adequate fine and gross motor coordination to carry out required tasks.</li></ul><p><b>
Work Environment:</b></p><ul><li>
Long-term care facility setting.</li><li>
Exposure to residents with varying levels of care needs.</li><li>
May include evenings, weekends, holidays, and on-call shifts.</li></ul><p><b>
Core Competencies:</b></p><ul><li>
Resident-centered care</li><li>
Professionalism and ethical conduct</li><li>
Team collaboration</li><li>
Problem-solving</li><li>
Cultural sensitivity and respect</li></ul><p><b>
Employer Statement:</b></p><p>
The facility is an equal opportunity employer. Duties and responsibilities may change based on business needs.</p></div>

Clinical Case Manager (CCM)

Harborview Health Systems

<div><h1 class="jobSectionHeader"><b>Wound Care Nurse - RN/LPN</b></h1><p></p><p><b>
Top pay and benefits!</b></p><p></p><p><b>
Who we are</b></p><p>
As a faith-based organization, our mission is simple but powerful: to care for the caregiver so they can in turn care for our residents.</p><p></p><p>
We offer top pay and benefits in a positive work environment.</p><p></p><p><b>
The Opportunity</b></p><p>
We are currently seeking a dedicated <b>Wound Care Nurse - RN/LPN</b></p><p></p><p><b>
What You Will Do</b></p><ul><li><p>
Perform comprehensive wound assessments and develop individualized care plans</p></li><li><p>
Administer appropriate wound care treatments, including dressing changes, debridement, and wound irrigation</p></li><li><p>
Monitor and evaluate the progress of wound healing</p></li><li><p>
Educate patients and their families on proper wound care techniques and prevention strategies</p></li><li><p>
Document all assessments, interventions, and outcomes accurately and timely</p></li><li><p>
Adhere to infection control protocols and maintain a clean and safe environment for patients</p></li><li><p>
Duties as assigned</p></li></ul><p></p><p><b>
What You Must Have</b></p><ul><li><p>
Active RN/LPN license in good standing in the state of practice.</p></li><li><p>
Experience as a Wound Care Nurse or in a similar role</p></li></ul><p></p><p><b>
Benefits - Things we want you to know</b></p><ul><li><p>
We offer a comprehensive benefits package, including:</p><ul><li><p>
401(k) managed by Merrill Lynch</p></li><li><p>
DailyPay</p></li><li><p>
Health Insurance with Anthem Blue Cross or Cigna</p></li><li><p>
Dental, Life, Vision, and Disability Insurance</p></li><li><p>
Paid Time Off</p></li><li><p>
Continuing Education Credits</p></li><li><p>
Career advancement opportunities!</p></li></ul></li></ul></div><p></p>

Wound Care Nurse

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