5,591 Nurse jobs

Position Purpose: Perform care management duties to assess, plan and coordinate all aspects of medical and supporting services across the continuum of care for select members to promote quality, cost effective care. Assess the member's current health status, resource utilization, past and present treatment plan and services, prognosis, short and long term goals, treatment and provider options Utilize assessment skills and discretionary judgment to develop plan of care based upon assessment with specific objectives, goals and interventions designed to meet member's needs and promote desired outcomes Coordinate services between Primary Care Physician (PCP), specialists, medical providers, and non-medical staff as necessary to meet the complete medical socio economic needs of clients Provide patient and provider education Facilitate member access to community based services Monitor referrals made to community based organizations, medical care and other services to support the...

Position Purpose: Perform care management duties to assess, plan and coordinate all aspects of medical and supporting services across the continuum of care for select members to promote quality, cost effective care. Assess the member's current health status, resource utilization, past and present treatment plan and services, prognosis, short and long term goals, treatment and provider options Utilize assessment skills and discretionary judgment to develop plan of care based upon assessment with specific objectives, goals and interventions designed to meet member's needs and promote desired outcomes Coordinate services between Primary Care Physician (PCP), specialists, medical providers, and non-medical staff as necessary to meet the complete medical socio economic needs of clients Provide patient and provider education Facilitate member access to community based services Monitor referrals made to community based organizations, medical care and other services to support the...

This position is a remote opportunity Position Purpose: The Utilization Review Nurse I provides first level clinical review for all outpatient and ancillary services requiring authorization. Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services. Answers Utilization Management directed telephone calls; managing them in a professional and competent manner. Processes all prior authorizations to completion utilizing appropriate review criteria. Identifies and refers all potential quality issues to the Clinical Quality Management Department, and suspected fraud and abuse cases to Program Integrity. Acts as liaison between the TRICARE beneficiary and the Network Provider. Provides first level RN review for all outpatient and ancillary prior authorization requests for medical appropriateness and medical necessity using appropriate criteria, referring those requests that fail review to the...

Position Purpose: Perform onsite review of emergent/urgent and continued stay requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician or Medical Director with recommendations for other determinations Complete medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Directors for review depending on case findings Collaborate with various staff within provider networks and discharge planning team electronically, telephonically, or onsite to coordinate member care Conduct discharge planning Educate providers on utilization and medical management processes Provide clinical knowledge and act as a clinical resource to non-clinical team staff Enter and maintain pertinent clinical information in various medical management systems Promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate...

Position Purpose: Determine needs and eligibility of members for various services through field-based collaboration with medical, behavioral, and social support staff. Conduct screening and risk assessment interventions per program guidelines. Conduct member assessments via telephonic outreach Document assessments and contacts, develop and approve service plans, and ensure authorizations are completed Conduct follow-up contacts or in-person visits to determine if services meet member's needs Assess member's medical, safety and support service needs and coordinate the delivery of services Provide education related to member's health condition and care Assist with modification and management of care plans under the direction of Registered Nurse in conjunction with member, medical consenter or caregiver, Department of Family and Protective Services caseworker and family, if applicable, as well as the managing physician Maintain case record documents and enter information in...

Position Purpose: Perform care management duties to assess, plan and coordinate all aspects of medical and supporting services across the continuum of care for select members to promote quality, cost effective care Develop, assess and adjust, as necessary, the care plan and promote desired outcome Assess the member's current health status, resource utilization, past and present treatment plan and services, prognosis, short and long term goals, treatment and provider options Coordinate services between Primary Care Physician (PCP), specialists, medical providers, and non-medical staff as necessary to meet the complete medical socio economic needs of clients Develop plan of care based upon assessment with specific objectives, goals and interventions designed to meet member's needs Provide patient and provider education Facilitate member access to community based services Monitor referrals made to community based organizations, medical care and other services to support the...

Position Purpose: Promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to prior authorization requests. Perform telephonic review of prior authorization requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician or Medical Director with recommendations for other determinations Complete medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Directors for review depending on case findings Collaborate with various staff within provider networks and case management team electronically or telephonically to coordinate member care Educate providers on utilization and medical management processes Provide clinical knowledge and act as a clinical resource to non-clinical team staff Enter and maintain pertinent clinical information in various medical...

Position Purpose: Perform onsite review of emergent/urgent and continued stay requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician or Medical Director with recommendations for other determinations Complete medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Directors for review depending on case findings Collaborate with various staff within provider networks and discharge planning team electronically, telephonically, or onsite to coordinate member care Conduct discharge planning Educate providers on utilization and medical management processes Provide clinical knowledge and act as a clinical resource to non-clinical team staff Enter and maintain pertinent clinical information in various medical management systems For New Hampshire and Massachusetts - home visits requiredPromote the quality and cost effectiveness of...

Position Purpose: Perform care management duties to assess, plan and coordinate all aspects of medical and supporting services across the continuum of care for select members to promote quality, cost effective care Develop, assess and adjust, as necessary, the care plan and promote desired outcome Assess the member's current health status, resource utilization, past and present treatment plan and services, prognosis, short and long term goals, treatment and provider options Coordinate services between Primary Care Physician (PCP), specialists, medical providers, and non-medical staff as necessary to meet the complete medical socio economic needs of clients Develop plan of care based upon assessment with specific objectives, goals and interventions designed to meet member's needs Provide patient and provider education Facilitate member access to community based services Monitor referrals made to community based organizations, medical care and other services to support the...

Position Purpose : Serve as a liaison for external groups and providers regarding clinical information from the Operations and Medical Management teams Implement and manage procedures for tracking, identifying and problem-solving operational issues Interpret and present program results and develop data-driven analysis and metrics used to measure effectiveness and ROI of all current and new products Act as the clinical representative in various meetings Collaborate with staff to identify internal and external opportunities and initiate process changes to increase quality and improve staff, provider and member satisfaction Serve as a resource and liaison on utilization, quality improvement, and case management activities Partner with various staff, along with internal and external departments on provider education and outreach Partner with regional leadership for providers requiring a clinical interpretation of results related to health plan reporting, data, and quality...

YOUR TASKS AND RESPONSIBILITIES The primary responsibilities of this role, Oncology Nurse Educator - Midwest, are to: Focus primary on high priority customers in area hospitals and large oncology and urology accounts; Contribute to strategic plan and implementation of area growth strategy; Educate sales consultants and regional managers on emerging concepts in Oncology and Urology; Serve as disease and product expert to sales training; Build productive work relationships externally; Cultivate strategic, long term, productive relationships with nurse Key Opinion Leaders (KOLs) and mid-level practitioners within the oncology and urology communities; Develop strategies and pull through educational opportunities for targeted hospitals and large accounts; Exhibit strong communication skills and persuasive abilities; Serve as a liaison, educator, and promotional conduit to Oncology and Urology health care professionals; Educate, persuade, and articulate...

Position Purpose: Promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to prior authorization requests. Perform telephonic review of prior authorization requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician or Medical Director with recommendations for other determinations Complete medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Directors for review depending on case findings Collaborate with various staff within provider networks and case management team electronically or telephonically to coordinate member care Educate providers on utilization and medical management processes Provide clinical knowledge and act as a clinical resource to non-clinical team staff Enter and maintain pertinent clinical information in various medical...

Position Purpose: Perform onsite review of emergent/urgent and continued stay requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician or Medical Director with recommendations for other determinations Complete medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Directors for review depending on case findings Collaborate with various staff within provider networks and discharge planning team electronically, telephonically, or onsite to coordinate member care Conduct discharge planning Educate providers on utilization and medical management processes Provide clinical knowledge and act as a clinical resource to non-clinical team staff Enter and maintain pertinent clinical information in various medical management systems For New Hampshire and Massachusetts - home visits required Promote the quality and cost effectiveness of...

Position Purpose: Supervise nurses in a highly regulated department responsible for performing medical necessity case reviews for appropriateness of medical care and service. Supervise the day to day clinical operations and functions within the department, ensuring productivity and quality metrics are met. Ensure that the Clinical Appeals and Grievances unit processes all appeals in accordance with referred time frames and other contractual legal requirements. Ensure that clinical team is reviewing the appeals in accordance with clinical policies and using appropriate NDL and LDL to make appropriate decisions Monitor appeals and provide senior management with monthly reporting on trends Confer with staff to review new projects, status of work in progress, problems encountered, and ensure compliance with departmental policies and procedures. Work with various external constituencies, i.e., state, local and federal governments, local community and the public related to grievance...

Position Purpose: Perform care management duties to assess, plan and coordinate all aspects of medical and supporting services across the continuum of care for select members to promote quality, cost effective care Develop, assess and adjust, as necessary, the care plan and promote desired outcome Assess the member's current health status, resource utilization, past and present treatment plan and services, prognosis, short and long term goals, treatment and provider options Coordinate services between Primary Care Physician (PCP), specialists, medical providers, and non-medical staff as necessary to meet the complete medical socio economic needs of clients Develop plan of care based upon assessment with specific objectives, goals and interventions designed to meet member's needs Provide patient and provider education Facilitate member access to community based services Monitor referrals made to community based organizations, medical care and other services to support the members'...

Position Purpose: Facilitate medical necessity appeals and denials including disposition of denials notification letters, review of clinical information to determine if medical necessity criteria are met Review clinical data to determine claim payment based on company policies and National Committee for Quality Assurance (NCQA) guidelines, including overturning denied claims, upholding the denials and submitting cases to the Medical Director for review Prepare case review for the Medical Director in cases where criteria are not met based on the additional clinical information received Generate appropriate appeal resolution communication to the member and provider in accordance with company policies and NCQA guidelines. Create system authorization events for overturned denial decisions Request additional information, as appropriate from provider(s) to facilitate timely appeals resolution Gather and prepare case information for Administrative Law Hearings Maintain appeals...

Position Purpose: Perform onsite review of emergent/urgent and continued stay requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician or Medical Director with recommendations for other determinations Complete medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Directors for review depending on case findings Collaborate with various staff within provider networks and discharge planning team electronically, telephonically, or onsite to coordinate member care Conduct discharge planning Educate providers on utilization and medical management processes Provide clinical knowledge and act as a clinical resource to non-clinical team staff Enter and maintain pertinent clinical information in various medical management systems For New Hampshire and Massachusetts - home visits required Promote the quality and cost effectiveness of...

Transforming the health of our community, one person at a time. We're Carolina Complete Health, a subsidiary of Centene Corporation, and we're on a mission to impact the health of our communities by making healthcare accessible to everyone. As a diversified, multi-national Fortune 50 and rapidly growing organization, our mission is fueled by exceptional talent. We need people driven to make a difference. People like you. People who could change everything for over 25 million people. Join our family today and take advantage of our generous benefits: $5,000 sign-on bonus Comprehensive insurance coverage Tuition reimbursement About You: You are a highly collaborative, strategic risk-taker driven to make a difference and change the face of healthcare. You thrive in a supportive, result-oriented community and are committed to the relentless pursuit of continuous growth. Delivering patient-focused care while making a real impact is important to you - it is what sets you...

Position Purpose: Perform care management duties to assess, plan and coordinate all aspects of medical and supporting services across the continuum of care for select members to promote quality, cost effective care. Assess the member's current health status, resource utilization, past and present treatment plan and services, prognosis, short and long term goals, treatment and provider options Utilize assessment skills and discretionary judgment to develop plan of care based upon assessment with specific objectives, goals and interventions designed to meet member's needs and promote desired outcomes Coordinate services between Primary Care Physician (PCP), specialists, medical providers, and non-medical staff as necessary to meet the complete medical socio economic needs of clients Provide patient and provider education Facilitate member access to community based services Monitor referrals made to community based organizations, medical care and other services to support the...