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Job Summary This position is responsible for ensuring compliance with Utilization Management (UM) and Quality Review (QR) functions performed by the health plan. The role supports clinical review activities requiring 5+ years of...

Supports the values of service excellence, teamwork, and integrity while managing patient care. Acts as a liaison among patients, caregivers, multidisciplinary teams, and payers. Qualifications: Requires a...

Ensemble Health Partners is seeking a Virtual Utilization Review Specialist to join our remote team. You will perform medical necessity reviews, manage denials, and coordinate with FCC and care management to optimize patient care while controlling...

Who We Are: Since 1985, BHCHP's mission has been to provide or assure access to the highest quality health care for all individuals and families experiencing homelessness in greater Boston. We care for over 11,000 homeless individuals each...

JOB DESCRIPTION Job Summary Provides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and...

About HCSC At HCSC, our employees are the cornerstone of our business and the foundation to our success. We empower employees with curated development plans that foster growth and promote rewarding, fulfilling careers. Join HCSC and be...

Centene Corporation is seeking a Licensed Practical Nurse (LPN) or Registered Nurse (RN) for a remote case management role in Pennsylvania. The selected candidate will perform concurrent reviews, determine appropriate care levels, and assist with...

Ethos Risk Services is seeking a full-time Clinical Recruiter (REMOTE) to lead hiring for the Case Management division. You will own full-cycle recruiting for nurse case managers and other clinical pros, from posting to onboarding, ensuring a...

Yoh is seeking a Utilization Management Nurse Coordinator (RN or LVN) for a 6+ month remote contract with a managed care client based in Northern California. Training occurs onsite in Fairfield or Redding for three weeks, then transitions to fully...

Our client, a mutual benefit corporation and health plan provider, seeks an accomplished Registered Nurse (Utilization Management). *** Candidate must be authorized to work in USA without requiring sponsorship...

A global talent management firm is seeking a Utilization Review Nurse for a contract role based in Pennington, NJ. The role involves performing utilization management, reviewing medical records, and coordinating discharge planning. Candidates must...

Job Title: Nurse, Clinical Medical Review Location: Columbia, MD (Primarily remote, but hybrid) Duration: 6 Months Contract PURPOSE: We are seeking a qualified RN or LPN with experience supporting HEDIS reporting and abstraction processes in a...

Spectraforce Technologies, Inc. is seeking a Clinical Review Nurse for remote concurrent review responsibilities. The role assesses member health status, medical necessity, and appropriate care levels, contributing to discharge planning within...

Molina Healthcare is hiring a remote RN Care Manager. Preference for candidates in Washington State. This role will be working Pacific Standard Time hours. This role supports Medicare members through telephonic case management and...

IQVIA is seeking a Flex Nurse Educator to deliver remote patient education and in-field support during territory vacancies, supporting adherence and disease management. This is a non-clinical, educational role requiring an active RN...

Ensemble Health Partners seeks a Manager for Utilization Review to lead the centralized Virtual Utilization Management program, coordinating clinical and operational excellence in authorizations, denials, and appeals for inpatient, observation,...

Brighton Health Plan Solutions is seeking an experienced Utilization Management Nurse to perform medical necessity and benefit reviews remotely, supporting both inpatient and outpatient cases. The role requires an active LPN license, strong...

Amerit Consulting is seeking an experienced Utilization Management Nurse (RN) in California for a remote 6-month contract. The incumbent will support inpatient utilization review, medical necessity determinations, and facility claims compliance,...

Centene Management Company LLC is seeking a Licensed Practical Nurse to analyze prior authorization requests and determine medical necessity in New York. You will work with healthcare providers and the authorization team to ensure timely,...

Exceptional care starts with exceptional people. For us, this is more than a job– it's a calling. It's waking up each day, looking for ways to make a difference with a compassionate, inclusive and talented team. Ochsner empowers you...

Bring clinical insight, nursing expertise, and data-driven precision to a Hybrid/Remote Clinical Documentation Improvement Nurse Specialist career that combines meaningful patient impact, supportive leadership, modern healthcare technology,...

Sentara Health Plans seeks an RN Clinician to perform utilization management and claim reviews across inpatient and outpatient settings. The role supports pre/post payment reviews and authorization assessments, ensuring compliance with policy and...

Centene Corporation is seeking a Nurse Reviewer for remote work in the United States. The role involves performing concurrent reviews to determine appropriate level of care and discharge planning, with emphasis on medical necessity and care...

CVS Health is hiring a full-time RN for healthcare services and utilization management. The role emphasizes assessing and coordinating care, applying clinical criteria, and communicating with providers to optimize member outcomes. The...

WORK REMOTELY after training! CANDIDATE MUST RESIDE IN THE METROPOLITAN NEW YORK AREA! !! Process all requests for services in accordance with Medicare and NYS Medicaid guidelines as well as departmental criteria and...