clinical appeals nurse

nurse

DataAnnotation

<div>
 We are looking for a 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.
 
 
 
 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>

Nurse

<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 Respiratory Therapist 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.
 
 
 
 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>

Respiratory Therapist

Blue Shield of California

<div>
 
 Job Description
 
 
 
 
 Your Role
 
 
 
 The Federal Employee Program (FEP) team performs integrated case management (CM) and disease management (DM) activities demonstrating clinical judgment and independent analysis, collaborating with members and those involved with members&rsquo; care including clinical nurses and treating physicians. The Triage Registered Nurse Case Manager will report to the FEP Care Manager Department Manager. In this role you will determine, develop, and implement a plan of care based on accurate and comprehensive assessment of the members&rsquo; needs.
 
 
 Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow &ndash; personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.
 
 
 
 Working hours for this role: Monday-Thursday, 10:30am-7:00pm; Friday- 9:30am-6:00pm
 
 
 
 
 In the future there could be Saturday shift hours.
 
 
 
 
 Responsibilities
 
 
 
 
 Your Work
 
 
 
 In this role, you will:
 
 
 <ul>
 <li>
 Conduct provider searches and assists members in accessing medically necessary services within the access network
 </li>
 <li>
 Triage referrals coming from the 24-hours Nurse Line to ensure members see providers in timely fashion and receive necessary education on their health conditions
 </li>
 <li>
 Work with providers and other internal departments to initiate the Letter of Agreement (LOA) and Exception process
 </li>
 <li>
 Outreach to members with HEDIS Care Gaps to assist with closure
 </li>
 <li>
 Research and design treatment/care plans to promote quality of care, cost effective health care services based on medical necessity complying with contract for each appropriate plan type
 </li>
 <li>
 Provide Referrals to Quality Management (QM), Disease Management (DM) and Appeals and Grievance department (AGD)
 </li>
 <li>
 Recognize the client&rsquo;s right to self-determination as it relates to the ethical principle of autonomy, including the client/family's right to make informed choices that may not promote the best outcomes, as determined by the healthcare team
 </li>
 <li>
 Design appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access and cost-effective outcomes
 </li>
 <li>
 Initiate and implement appropriate modifications in plan of care to adapt to changes occurring over time and through various settings
 </li>
 <li>
 Applies detailed knowledge of FEP PPO and Blue Shield of California's (BSC) established medical/departmental policies, clinical practice guidelines, community resources, contracting and community care standards to each case
 </li>
 <li>
 Performs effective discharge planning and collaborates with member support system and health care professionals involved in the continuum of care
 </li>
 <li>
 Coordinates Care for Lower Level of Care coordination such as Skilled Nursing Facility, Home Health, Home Infusion, Rehab, and other community program as appropriate
 </li>
 <li>
 Provides disease management education on core chronic conditions (Diabetes, Heart Failure, COPD, Asthma and Coronary Artery Disease)
 </li>
 <li>
 Determines, develops and implements a plan of care based on accurate and comprehensive assessment of the member's needs related to behavioral health
 </li>
 <li>
 Must be able to sit for extended periods of time and read information on one computer screen and apply that information on a second computer screen to complete documentation
 
 
 </li>
 </ul>
 
 Qualifications
 
 
 
 
 Your Knowledge and Experience
 
 
 
 <ul>
 <li>
 Requires a current CA RN License
 </li>
 <li>
 Certified Case Manager (CCM) Certification or is in process of completing certification when eligible based on CCM application requirements
 </li>
 <li>
 Requires at least 5 years of prior experience in nursing, healthcare or related field
 </li>
 <li>
 Bachelor of Science in Nursing or advanced degree preferred
 </li>
 <li>
 Comprehensive knowledge of case management, discharge planning, utilization management, disease management and community resources
 </li>
 <li>
 Able to operate PC-based software programs including proficiency in Word and Excel.
 </li>
 <li>
 Strong clinical documentation skills, independent problem identification and resolution skills
 </li>
 <li>
 Strong supervisory, communication, abstracting skills with strong verbal and written communication skills and negotiation skills
 </li>
 <li>
 Competent understanding of NCQA and federal regulatory requirements.
 </li>
 <li>
 Knowledge of coordination of care, prior authorization, level of care and length of stay criteria sets desirable
 </li>
 <li>
 Demonstrates professional judgment, and critical thinking, to promote the delivery of quality, cost-effective care. This judgment is based on medical necessity including intensity of service and severity of illness within contracted benefits and appropriate level of care
 </li>
 <li>
 Demonstrate leadership, project management and program evaluation skills and ability to interact with all levels including senior management and influence decision-making
 
 
 </li>
 </ul>
 
 Hybrid Virtual Work
 
 
 
 This role allows employees to work virtually full-time, however employees will be expected to come into the office based on business needs.
 
 
 
 About The Team
 
 
 
 
 About Blue Shield of California
 
 
 
 As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies.
 
 
 At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.
 
 
 To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.
 
 
 Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities &ndash; join us!
 
 
 
 Our Values:
 
 
 
 <ul>
 <li>
 Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
 </li>
 <li>
 Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.
 </li>
 <li>
 Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.
 
 
 </li>
 </ul>
 
 Our Workplace Model
 
 
 
 We believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility - providing clear expectations while respecting the diverse needs of our workforce. Our workplace model is designed around intentional in-person interaction, collaboration, connection, creativity and flexibility:
 
 
 <ul>
 <li>
 For most teams, this means coming into the office two days per week.
 </li>
 <li>
 Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need.
 </li>
 <li>
 For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.
 
 
 </li>
 </ul>
 The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews.
 
 
 
 Physical Requirements:
 
 
 
 Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.
 
 
 Please click here for further physical requirement detail.
 
 
 
 Equal Employment Opportunity:
 
 
 
 External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.
</div>

RN - Complex Care Coordination Triage Case Manager, Sr.

Health Net

<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.
 
 
 
 Position Purpose
 
 Develops, assesses, and facilitates complex care management activities for primarily physical needs members to provide high quality, cost-effective healthcare outcomes including personalized care plans and education for members and their families.
 
 
 <ul>
 <li>
 Evaluates the needs of the member, barriers to accessing the appropriate care, social determinants of health needs, focusing on what the member identifies as priority and recommends and/or facilitates the plan for the best outcome
 </li>
 <li>
 Develops ongoing care plans / service plans and collaborates with providers to identify providers, specialists, and/or community resources to address member's unmet needs
 </li>
 <li>
 Identifies problems/barriers to care and provide appropriate care management interventions
 </li>
 <li>
 Coordinates as appropriate between the member and/or family/caregivers and the care provider team to ensure members are receiving adequate and appropriate person-centered care or services
 </li>
 <li>
 Provides ongoing follow up and monitoring of member status, change in condition, and progress towards care plan / service plan goals; collaborate with member, caregivers, and appropriate providers to revise or update care plan / service plan as necessary to meet the member's goals / unmet needs
 </li>
 <li>
 Provides resource support to members and care managers for local resources for various services (e.g., employment, housing, participant direction, independent living, justice, foster care) based on service assessment and plans, as appropriate
 </li>
 <li>
 Facilitate care management and collaborate with appropriate providers or specialists to ensure member has timely access to needed care or services
 </li>
 <li>
 May perform telephonic, digital, home and/or other site outreach to assess member needs and collaborate with resources
 </li>
 <li>
 Collects, documents, and maintains all member information and care management activities to ensure compliance with current state, federal, and third-party payer regulators
 </li>
 <li>
 Provides and/or facilitates education to members and their families/caregivers on disease processes, resolving care gaps, healthcare provider instructions, care options, referrals, and healthcare benefits
 </li>
 <li>
 Provides feedback to leadership on opportunities to improve and enhance care and quality delivery for members in a cost-effective manner
 </li>
 <li>
 Other duties or responsibilities as assigned by people leader to meet business needs
 </li>
 <li>
 Performs other duties as assigned.
 </li>
 <li>
 Complies with all policies and standards.
 
 
 </li>
 </ul>
 
 Education/Experience
 
 Requires a Degree from an Accredited School of Nursing or a Bachelor's degree in Nursing and 2 &ndash; 4 years of related experience.
 
 
 
 License/Certification
 
 
 
 <ul>
 <li>
 RN - Registered Nurse - State Licensure and/or Compact State Licensure required
 
 
 </li>
 </ul>
 
 Location Position is remote. Must live in CA.
 
 
 
 Pay Range $27.02 - $48.55 per hour
 
 
 Centene offers a comprehensive benefits package including competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.
 
 
 Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
 
 
 Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
</div>

Care Manager (RN)

Abridge

<div>
 
 About Abridge
 
 
 
 Abridge was founded in 2018 with the mission of powering deeper understanding in healthcare. Our AI-powered platform was purpose-built for medical conversations, improving clinical documentation efficiencies while enabling clinicians to focus on what matters most&mdash;their patients.
 
 
 Our enterprise-grade technology transforms patient-clinician conversations into structured clinical notes in real-time, with deep EMR integrations. Powered by Linked Evidence and our purpose-built, auditable AI, we are the only company that maps AI-generated summaries to ground truth, helping providers quickly trust and verify the output. As pioneers in generative AI for healthcare, we are setting the industry standards for the responsible deployment of AI across health systems.
 
 
 We are a growing team of practicing MDs, AI scientists, PhDs, creatives, technologists, and engineers working together to empower people and make care make more sense. We have offices located in the Mission District in San Francisco, the SoHo neighborhood of New York, and East Liberty in Pittsburgh.
 
 
 
 The Role
 
 
 
 As the Clinical Success Director - Nursing, you will be at the forefront of defining, launching, and growing our generative AI platform for nurses. Your work will directly contribute to improving the cognitive burden associated with clinical documentation. You will collaborate with clients, partners, product managers, designers, machine learners, and healthcare professionals to bring to life products that bridge the gap between clinical conversations and actionable data.
 
 
 
 *To be hired you must be based in the Mountain or Pacific time zone
 
 *
 
 
 
 What You&rsquo;ll Do
 
 
 
 <ul>
 <li>
 Evaluate new product offerings and provide subject matter expertise to our product teams.
 </li>
 <li>
 Build and maintain relationships across customers, including onboarding users, listening to customer feedback, optimizing nursing workflows, and identifying opportunities for improved engagement and success.
 </li>
 <li>
 Design and recruit a council of trusted nurse advisors to guide product strategy and roadmap.
 </li>
 <li>
 Develop a use case-specific end-user survey and a set of success metrics to help communicate impact and value.
 </li>
 <li>
 Evangelize product capabilities and direction to prospective customers by creating sales collateral, conducting product demos, training, and more.
 
 
 </li>
 </ul>
 
 What You&rsquo;ll Bring
 
 
 
 <ul>
 <li>
 5+ years of experience as an RN, preferably in the inpatient setting
 </li>
 <li>
 Experience with electronic record systems (Epic is a definite plus)
 </li>
 <li>
 Passion for deeply understanding nursing workflows and improving inefficiencies
 </li>
 <li>
 Proven track record of leading successful initiatives from conception through launch
 </li>
 <li>
 Ability to build relationships with different layers of an organization, from front-line staff to executives
 </li>
 <li>
 Strong understanding of the healthcare industry, specifically clinical workflows and regulatory requirements
 </li>
 <li>
 Experience working with cross-functional teams in a fast-paced, startup environment
 </li>
 <li>
 This role requires 25% travel***
 
 
 </li>
 </ul>
 
 Why Work at Abridge?
 
 
 
 At Abridge, we&rsquo;re transforming healthcare delivery experiences with generative AI, enabling clinicians and patients to connect in deeper, more meaningful ways. Our mission is clear: to power deeper understanding in healthcare. We&rsquo;re driving real, lasting change, with millions of medical conversations processed each month.
 
 
 Joining Abridge means stepping into a fast-paced, high-growth startup where your contributions truly make a difference. Our culture requires extreme ownership&mdash;every employee has the ability to (and is expected to) make an impact on our customers and our business.
 
 
 Beyond individual impact, you will have the opportunity to work alongside a team of curious, high-achieving people in a supportive environment where success is shared, growth is constant, and feedback fuels progress. At Abridge, it&rsquo;s not just what we do&mdash;it&rsquo;s how we do it. Every decision is rooted in empathy, always prioritizing the needs of clinicians and patients.
 
 
 We&rsquo;re committed to supporting your growth, both professionally and personally. Whether it's flexible work hours, an inclusive culture, or ongoing learning opportunities, we are here to help you thrive and do the best work of your life.
 
 
 If you are ready to make a meaningful impact alongside passionate people who care deeply about what they do, Abridge is the place for you.
 
 
 
 How we take care of Abridgers:
 
 
 
 <ul>
 <li>
 Generous Time Off: 14 paid holidays, flexible PTO for salaried employees, and accrued time off for hourly employees
 </li>
 <li>
 Comprehensive Health Plans: Medical, Dental, and Vision coverage for all full-time employees and their families.
 </li>
 <li>
 Generous HSA Contribution: If you choose a High Deductible Health Plan, Abridge makes monthly contributions to your HSA.
 </li>
 <li>
 Paid Parental Leave: Generous paid parental leave for all full-time employees.
 </li>
 <li>
 Family Forming Benefits: Resources and financial support to help you build your family.
 </li>
 <li>
 401(k) Matching: Contribution matching to help invest in your future.
 </li>
 <li>
 Personal Device Allowance: Tax free funds for personal device usage.
 </li>
 <li>
 Pre-tax Benefits: Access to Flexible Spending Accounts (FSA) and Commuter Benefits.
 </li>
 <li>
 Lifestyle Wallet: Monthly contributions for fitness, professional development, coworking, and more.
 </li>
 <li>
 Mental Health Support: Dedicated access to therapy and coaching to help you reach your goals.
 </li>
 <li>
 Sabbatical Leave: Paid Sabbatical Leave after 5 years of employment.
 </li>
 <li>
 Compensation and Equity: Competitive compensation and equity grants for full time employees.
 </li>
 <li>
 ... and much more!
 
 
 </li>
 </ul>
 
 Equal Opportunity Employer
 
 
 
 Abridge is an equal opportunity employer and considers all qualified applicants equally without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, or disability.
 
 
 
 Staying safe - Protect yourself from recruitment fraud
 
 
 
 We are aware of individuals and entities fraudulently representing themselves as Abridge recruiters and/or hiring managers. Abridge will never ask for financial information or payment, or for personal information such as bank account number or social security number during the job application or interview process. Any emails from the Abridge recruiting team will come from an @abridge.com email address. You can learn more about how to protect yourself from these types of fraud by referring to this article. Please exercise caution and cease communications if something feels suspicious about your interactions.
 
 
 Compensation Range: $143,650 - $198,000
 
 
</div>

Clinical Success Director - Nursing