You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. *Must be licensed in California Position Purpose: Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member. - Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care - Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member - Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered - Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines - Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings - Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members - Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines - Reviews member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities - Collaborates with care management on referral of members as appropriate - Performs other duties as assigned. - Complies with all policies and standards. Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience. 2+ years of acute care experience required. Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. License/Certification: - For Health Net of California: RN license required - **Must be licensed in California Location: Position is remote. Hours: 8:00-5:00 PST. 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

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By joining Sedgwick, you'll be part of something truly meaningful. It’s what our 33,000 colleagues do every day for people around the world who are facing the unexpected. We invite you to grow your career with us, experience our caring culture, and enjoy work-life balance. Here, there’s no limit to what you can achieve. Newsweek Recognizes Sedgwick as America’s Greatest Workplaces National Top Companies Certified as a Great Place to Work® Fortune Best Workplaces in Financial Services & Insurance RN Field Case Manager This Field Case Manger will cover our Raleigh, NC region and must live in this area in order to be considered. Must be and RN and have as least 1.5 years of prior Field Case Manager workers compensation experience. PRIMARY PURPOSE OF THE ROLE: Sedgwick Field Case Managers work face to face with their injured workers and medical providers to facilitate; though advocacy, progressive medical treatment, and timely return-to-work; while acting as a liaison and providing communication between all involved parties. While frequent travel is required, you will maintain a home-based office. ARE YOU AN IDEAL CANDIDATE? We are looking for enthusiastic candidates who thrive in a collaborative environment, who are driven to deliver great work. - Apply your medical/clinical or rehabilitation knowledge and experience to assist in the management of complex medical conditions, treatment planning and recovery from illness or injury. - Work in the best of both worlds - a rewarding career making an impact on the health and lives of others, and a remote work environment that allows face to face interaction with injured workers and medical professionals. - Enjoy flexibility and autonomy in your daily work, your location, and your career path while advocating for the most effective and efficient medical treatment for injured employees in a non-traditional setting. - Enable our Caring counts® mission supporting injured employees from some of the world’s best brands and organizations. - Be a part of a rapidly growing, industry-leading global company known for its excellence and customer service. - Celebrate your career achievements and each other through professional development opportunities, continuing education credits, team building initiatives and more. - Access diverse and comprehensive benefits to take care of your mental, physical, financial and professional needs. . ESSENTIAL RESPONSIBLITIES MAY INCLUDE - Serve as patient advocate to support, guide and coordinate care for injured workers, families and caregivers as they navigate through the recovery process. - Assist injured workers in achieving recovery and autonomy through advocacy, communication, education, identification of service resources and service facilitation. - Identify appropriate providers and facilities throughout the continuum of services, while ensuring that available resources are being used in a timely and cost-effective manner in order to obtain optimum value for both the client and the reimbursement source EDUCATION AND LICENSING RN licensure required. Valid driver’s license required. High speed internet required. TAKING CARE OF YOU BY - Offering a blended work environment. - Supporting meaningful work that promotes critical thinking and problem solving. - Providing on-going learning and professional growth opportunities. - Promoting a strong team environment and a culture of support. - Recognizing your successes and celebrating your achievements. - We offer a diverse and comprehensive benefits package including: - Three Medical, and two dental plans to choose from. - Tuition reimbursement eligible. - 401K plan that matches 50% on every $ you put in up to the first 6% you save. - 4 weeks PTO your first full year. NEXT STEPS If your application is selected to advance to the next round, a recruiter will be in touch. #nurse #fieldcasemanager Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace. If you're excited about this role but your experience doesn't align perfectly with every qualification in the job description, consider applying for it anyway! Sedgwick is building a diverse, equitable, and inclusive workplace and recognizes that each person possesses a unique combination of skills, knowledge, and experience. You may be just the right candidate for this or other roles.

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description We are seeking a Clinical Pharmacist to support medication adherence initiatives and chronic disease management for a large healthcare population. In this role, you will conduct targeted outreach to members, providers, and pharmacies to address medication-related barriers, improve adherence, and optimize treatment outcomes. The Clinical Pharmacist plays a critical role in helping improve outcomes for patients with chronic conditions such as diabetes, hypertension, and hyperlipidemia by performing medication therapy reviews, identifying care gaps, and collaborating with providers. This position requires strong clinical knowledge, excellent communication skills, and the ability to manage a high volume of outreach in a remote environment. Key Responsibilities - Member & Provider Outreach: - Conduct pharmacist-led outreach to members, providers, and pharmacies to identify and resolve medication-related barriers. - Perform 40+ outreach encounters per day with the goal of ensuring multiple member engagement points annually. - Provide education to members regarding medication use, adherence strategies, and chronic disease management. - Collaborate with providers to support medication access, therapy changes, and adherence solutions. - Clinical Review & Medication Management: - Perform Medication Therapy Reviews (MTRs) and provide clinical recommendations to optimize therapy. - Identify medication adherence issues and recommend interventions to improve outcomes. - Support the transition of members from uncontrolled to controlled chronic disease status through medication adherence strategies. - Utilize payer-approved population health tools and adherence platforms to prioritize outreach. - Documentation & Reporting: - Accurately document outreach, interventions, and clinical recommendations in required systems and tracking tools. - Maintain timely and compliant documentation aligned with quality reporting requirements. - Monitor progress toward performance and quality goals. - Collaboration & Quality Improvement: - Participate in scheduled performance and quality review meetings. - Work collaboratively with population health teams, providers, and operations to address medication access and adherence barriers. - Support initiatives aimed at improving healthcare quality measures and closing care gaps. Qualifications - Doctor of Pharmacy (PharmD) degree. - Active, unrestricted California Pharmacist license. - Strong clinical knowledge of chronic disease management including diabetes, hypertension, and hyperlipidemia. - Experience with medication therapy management (MTM), adherence strategies, and barrier assessments. - Ability to manage high-volume outreach (40+ encounters daily) in a remote environment. - Excellent communication and interpersonal skills when engaging with patients, providers, and care teams. - Strong organizational and documentation skills. Preferred Qualifications - Board Certification (e.g., BCPS, BCGP). - Experience working with Medicare Advantage, Medicaid, or Stars quality programs. - Background in population health, care gap closure, or medication adherence programs. - Familiarity with clinical guidelines related to diabetes, hypertension, and lipid management. - Experience using population health or quality reporting platforms (e.g., Cozeva or similar systems). Work Environment - 100% Remote position. - Must be available during Pacific Standard Time business hours (8:00 AM – 5:00 PM PST). - High-volume outreach role requiring strong time management and documentation accuracy.