Clinical Care Reviewer - Utilization Management (RN/LPN)

Join Integrated Resources Inc. as a Clinical Care Reviewer in Utilization Management, where your expertise in patient care will make a significant impact. In this role, you will evaluate and assess clinical information to ensure quality healthcare services are provided efficiently and effectively. Collaborate with healthcare professionals to optimize patient…

Hello from Fabergent,We are currently seeking a qualified Clinical Care Reviewer to join our team. If you are actively seeking new opportunities, we would love to hear from you. Please take a moment to review the details of this position below and respond with your updated resume if you are interested.As a Clinical Care Reviewer, you will be responsible for evaluating requests for services to determine medical necessity and ensuring compliance with relevant guidelines. Your expertise will play a crucial role in the utilization management process, including pre-certifications for outpatient and inpatient services. You will also be involved in discharge planning and case management referrals.Key Responsibilities:• Conduct timely reviews of clinical information from providers against plan criteria and benefit guidelines.• Utilize professional judgment to assess the necessity of additional information before making decisions.• Document all relevant case details for approvals and denials, and refer cases for medical director review as needed.• Collaborate with providers to facilitate outpatient services and discharge planning needs for members.• Maintain monthly reports on inpatient activities and assist with various projects as assigned.Required Skills and Qualifications:• A minimum of 3 to 5 years of experience in a clinical setting.• Active RN or LPN license in Iowa is mandatory.• Knowledge of Utilization Management and Waiver processes (home and community-based) is preferred.• An Associate's degree in Nursing is required; a Bachelor's degree is preferred.• At least two years of experience in managed care quality assurance or utilization review.• RN candidates should have two years of experience in an acute care hospital setting.Join us and make a difference in the health care community!

Join our team as a Clinical Care Reviewer Registered Nurse, where you will play a crucial role in evaluating and enhancing patient care processes. Your expertise will directly impact the quality of care provided to patients, ensuring compliance with clinical standards and best practices.

Job SummaryAs a Senior Clinical Care Reviewer, you will play a pivotal role in evaluating medical necessity for inpatient and outpatient services. Under the supervision of the unit Supervisor, you will leverage your nursing experience and clinical expertise to assess provider requests. Your responsibilities will entail collaborating with providers and members to gather essential information for comprehensive reviews. You will have the authority to request additional data and clarifications as needed. Utilizing your professional judgment, you will ensure that appropriate services are authorized while identifying care coordination opportunities and referring cases as necessary. You will apply medical health benefit policies and management guidelines to grant service approvals and escalate cases to the Medical Director when required. Staying informed about relevant laws, regulations, and organizational policies will be crucial as you apply your clinical judgment effectively.

As a Clinical Care Reviewer at Integrated Resources Inc., you will play a vital role in evaluating and ensuring the quality of healthcare services. Your expertise will contribute to the overall improvement of patient care and the efficiency of clinical processes.

Utilization Management Assistant Location: Onsite in Dubuque, IA. Also accepting remote applicants. Are you passionate about enhancing patient care and thrive in a dynamic healthcare environment? We are in search of a committed Utilization Management Assistant to join our dedicated healthcare team. We welcome candidates with experience in medical settings, such as receptionists, schedulers, insurance verifiers, LPNs, CNAs, Medical Assistants, or those from customer service backgrounds looking to make a significant impact behind the scenes. If you desire a professional office atmosphere with daytime office hours and weekends/holidays off, this opportunity is for you! The Utilization Management Assistant will handle initial calls in Utilization Review for our Health & Wellness participants. Responsibilities include evaluating certification requests by reviewing group-specific requirements and determining if a Utilization Review Nurse’s expertise is required to assist with the call. You will also be responsible for reviewing medical records, coordinating with healthcare providers, and ensuring that patients receive appropriate, cost-effective care in alignment with clinical guidelines and insurance policies.

Primary Responsibilities:Screen incoming information and connect members with the appropriate providers, or reach out to providers on behalf of members.Facilitate the authorization process for requests that do not necessitate clinical judgment or criteria applications.Provide essential information to members and assist them with Plan-related inquiries in the absence of Member Services personnel.Serve as a resource for team members regarding the prior authorization process.Escalate unresolved questions about the prior authorization process to the Lead Intake Specialist.Assist the Lead Intake Specialist in developing, planning, and executing staff training initiatives.Identify and report educational opportunities for members and providers to the Lead Intake Specialist.Accurately respond to inquiries regarding Plan benefits and Utilization Management requirements for both members and providers.Conduct inquiries to assess potential coordination of benefits and communicate findings to the relevant provider and claims staff.Support Utilization Management nurses with data entry tasks.Perform additional duties as assigned.Adhere to the policies and procedures of Select Health and KMHP.Uphold and promote the mission and values of Select Health and Mercy.

CareHarmony is seeking a Remote Intake Coordinator who holds an active Licensed Practical Nurse (LPN) license. This fully remote position supports patients across value-based care management programs and helps shape positive healthcare outcomes from your own home. Role overview This role centers on coordinating care for patients with chronic conditions. Intake Coordinators work closely with providers to identify resources and ensure patients receive the support they need. Each day brings opportunities to engage with new patients and make a meaningful difference in their healthcare journeys. What you will do Collaborate with healthcare providers to enhance patient experience and outcomes Coordinate care and identify resources for patients managing chronic health issues Engage with new patients daily as part of a dedicated care team Requirements Active Licensed Practical Nurse (LPN) license At least 3 years of direct patient interaction experience Strong attention to detail and self-motivation Comfort working in a changing, collaborative environment Benefits Fully remote work with no commute and casual dress Consistent full-time schedule: Monday to Friday, no weekends Minimal on-call duty (average once per year) Opportunities for career advancement within CareHarmony Compensation This position offers $21 per hour.

Bilingual RN Case Manager Location: Remote. Join our dedicated team at HealthCheck360 as a compassionate and detail-oriented Bilingual RN Case Manager. In this vital role, you will provide comprehensive case management services throughout the continuum of care. You will assess, plan, implement, coordinate, monitor, and evaluate care for assigned consumers, ensuring optimal outcomes and cost-effective treatment solutions. Key Responsibilities: Conduct telephonic case management and utilization reviews for assigned consumers. Design, implement, and supervise individualized care plans to achieve quality and cost-effective outcomes. Collaborate effectively with healthcare providers, payors, and internal teams to ensure seamless care coordination. Act as a liaison between consumers and benefit administrators, providing clear communication and support. Track and report case outcomes, including cost savings and quality improvements. Qualifications: Bilingual: Proficient in Spanish. Education: Must possess RN licensure in the State of Iowa; BSN or higher preferred. Experience: Minimum of 2 years in clinical practice; case management or utilization review experience highly preferred. Skills: Exceptional communication, problem-solving, and computer skills; ability to work independently. Full-Time Benefits - Most benefits commence on day one Medical, Dental, and Vision Insurance Flexible Spending Account or Health Savings Account 401(k) with company matching Profit-Sharing/Defined Contribution (1-year waiting period) Paid Time Off and Paid Holidays Company-paid Short-Term and Long-Term Disability Maternity Leave and Parental Leave Subsidized Parking Company-paid Term Life and Accidental Death Insurance About HealthCheck360 At HealthCheck360, we are committed to meeting the needs of employers while enhancing participant experiences. Our focus is on reducing medical costs and improving employee engagement and productivity through onsite biometric screenings, innovative technology, tailored communications, and comprehensive support.

Join our dedicated team as a Telephonic Care Manager, utilizing your nursing expertise to provide exceptional care management services over the phone. In this role, you will assess patient needs, develop care plans, and collaborate with healthcare professionals to ensure optimal patient outcomes.

Role overview The Associate Clinical Oncology Specialist position at Natera is based in Des Moines, IA. This role centers on supporting clinical oncology practices and working alongside healthcare professionals. The goal is to help deliver consistent and high-quality care to patients, contributing to Natera’s broader mission of improving outcomes through advanced diagnostics. What you will do Support clinical oncology settings by assisting with daily operations and patient care activities Work collaboratively with physicians, nurses, and other healthcare staff to address patient needs Help uphold high standards for patient care and service within the oncology practice About Natera Natera develops diagnostic solutions aimed at improving outcomes for patients dealing with cancer and other complex conditions.

Join Wellmark Inc. as a Clinical Pharmacy Analyst specializing in Pharmacoeconomics, where you will play a crucial role in evaluating and improving the cost-effectiveness of pharmaceutical therapies. You will work closely with clinical teams to analyze drug utilization and outcomes, providing insights that drive clinical decision-making.

Join Michels Trenchless, Inc. as an Assistant Project Manager and contribute to innovative projects across various locations. In this dynamic role, you will support project managers in planning, executing, and finalizing projects according to strict deadlines and budget constraints. Your expertise will be crucial in coordinating project schedules, resources, and communication among stakeholders.

As a Care Connector at Integrated Resources Inc., you will play a pivotal role in bridging the gap between patients and healthcare services. Your primary responsibilities will include facilitating communication between healthcare providers and patients, ensuring that individuals receive timely and appropriate care. You will utilize your interpersonal skills to foster positive relationships and support patients in navigating their healthcare journeys.

Join our dynamic team at Integrated Resources, Inc. as a Care Connector. In this pivotal role, you will serve as a liaison between patients and healthcare providers, ensuring seamless communication and support. Your expertise will be essential in guiding patients through their healthcare journeys, addressing inquiries, and facilitating access to necessary services.

Join our dedicated team at Covista as a Part-Time Clinical Nursing Faculty member in Des Moines. This role is essential in guiding the next generation of nursing professionals through practical, hands-on experience. You will be responsible for teaching and mentoring students in clinical settings, ensuring they gain the skills and knowledge necessary to excel in their careers.

Join the Wellmark Inc. team as a Clinical Pharmacist where you will play a pivotal role in enhancing patient care through effective medication management and clinical support. You will collaborate with healthcare professionals to optimize therapeutic outcomes and provide expert guidance on medication therapy. This position is ideal for someone with a passion for improving health outcomes and a drive to work in a dynamic healthcare environment.

Join Our National Wound Physician Group as an Urgent Care Physician Enjoy clinical satisfaction, autonomy, and a healthy work-life balance. Experience a role with no night shifts, no on-call duties, and no weekend responsibilities. Become a Specialist in Wound Management by learning from highly experienced, wound-certified physician trainers and Fellowship Directors. Leverage advanced clinical technologies and the latest wound care techniques. • Our physicians provide bedside wound care in over 3,200 facilities across 28 states.• We offer comprehensive physician-level wound management training and a specialized fellowship, equipping you with the expertise necessary for clinical excellence.• W2 physicians can expect an average earning of $300,000 annually plus benefits for a 30-hour work week (part-time options are also available).• Enjoy paid training opportunities. Practice Overview: • Full-time work typically occurs Monday to Friday from 7 am to 4 pm, with part-time roles available.• No on-call or weekend clinical obligations.• Physicians deliver modern wound management at the bedside within post-acute care settings: Skilled Nursing Facilities and Long-Term Acute Care Hospitals.• Weekly wound rounds will be conducted at each facility.• Minimum part-time work is expected to be 3 days per week, while full-time requires 4-5 days.• This is a mobile practice, where physicians visit facilities within a 40-60 mile radius of the practice location.• Physicians typically visit 2-3 facilities per day, treating approximately 20-30 patients daily.• Clinical documentation occurs in real-time at the point of care using our proprietary wound-specific EMR.• Paid training is included during onboarding, plus a 6-month wound care fellowship.

Join a Leading National Wound Physician Group as a Wound Care Physician Enjoy unparalleled clinical satisfaction, autonomy, and a healthy work-life balance. Experience a practice structure with no nights, no call, and no weekend clinical responsibilities. Advance Your Expertise in Wound Management, guided by distinguished wound-certified physician trainers and Fellowship Directors. Leverage state-of-the-art clinical technologies and innovative wound care modalities. • Our physicians provide bedside wound care across over 3,200 facilities in 28 states.• Benefit from comprehensive physician-level wound management training and a dedicated wound fellowship designed to equip you with the skills for clinical excellence.• W2 physicians earn an average of $300,000 per year, plus benefits, for a 30-hour work week (Part-time opportunities also available).• Enjoy paid training as part of your onboarding process. Practice Overview: • Full-time schedule: Monday - Friday (7 am - 4 pm), with part-time options available.• No call or weekend responsibilities.• Deliver modern wound management at the bedside in skilled nursing facilities and long-term acute care hospitals.• Conduct weekly wound rounds at each facility.• Part-time roles require a minimum commitment of 3 days per week; full-time roles require 4-5 days per week.• This is a mobile practice; physicians visit facilities within a 40-60 mile radius of the practice location.• Treat approximately 20-30 patients daily across 2-3 facilities each day.• Real-time clinical documentation is performed at the point of care using our proprietary wound-specific EMR system.• Paid training includes onboarding and a 6-month wound care fellowship. W2 employment contract (No work...

Important Notice:This position is NOT a remote or traditional classroom teaching role.Applicants must be prepared to travel up to 100% across various locations in their designated region within the United States, including Western (AK, HI, Pacific, Mountain), Central, and Eastern Time Zones. Nightingale faculty are expected to actively participate throughout all three 15-week semesters (spring, summer, fall), with clinical rotations scheduled for a minimum of 11 weeks during this period. Although we strive to maintain placements within the assigned region, operational demands may necessitate occasional travel outside of this area.