Summary Ensures that the Local Coverage Determination (LCD) process adheres to contract instructions. Creates, implements, and maintains educational tools to help providers reduce the submission of claims for non-covered services and reduce the claims payment error rate. The error rate is a factor in awarding and renewing Medicare/other contracts. Description Logistics This position is full time (40 hours/week) Monday-Friday 8:00-5:00 and will be W@H. Unrestricted RN license required What You Will Do: - Provides clinical expertise, research, and judgment to develop Local Coverage Determinations(LCDS) under the direction of medical director. Maintains LCDS once developed. - Educates providers and internal customers on LCDS. Communicates with other interdepartmental staff in appropriate coding and reimbursement guidelines to ensure coordination and compliance. - Provides clinical input for internal requests. Serves as reviewer to determine inter-rater reliability. To Qualify for This Position, You Will Need: - Bachelor's in a job related field OR Graduate of Accredited School of Licensed Practical Nursing or Licensed Vocational Nursing - Required Work Experience: 5 years clinical experience in medical insurance, managed care, case management, or claims management, or a combination of these areas. - Required Skills and Abilities: Knowledge of managed care or medical claims payment policy issues. Working knowledge of word processing, spreadsheet software. Excellent verbal and written communication skills. Excellent customer service, organizational, presentation, analytical or critical thinking skills. Ability to persuade, negotiate, or influence others. Ability to handle confidential or sensitive information with discretion. - Required Software and Tools: Microsoft Office. - Required License and Certificate: An active, unrestricted RN license from the United States and in the state of hire, OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC). For Division 33, Certified Genetic Counselor will be considered in lieu of RN License. What We Prefer: - Bachelor's degree- Nursing. - 7 years-clinical experience in medical insurance, managed care, case management, or claims management, or a combination of these areas. - Preferred Skills and Abilities: Working knowledge of database software. Knowledge of government/healthcare programs and contracts laws, regulations. Knowledge of government/healthcare programs and regulations, coding, and approval practices. Knowledge of corporate administrative/medical policy for all lines of business. Knowledge of guidelines, benefits, and coverage for all lines of business. Preferred Software and Tools: Working knowledge of Microsoft Access or other database software, DB2 and Easytrieve. - Preferred Licenses and Certificates: HIAA, Loma, and/or ACLI certification. MPH, MHA certifications. - Experience with molecular testing - Experience with policy work What We Can Do for You: - 401(k) retirement savings plan with company match. - Subsidized health plans and free vision coverage. - Life insurance. - Paid annual leave – the longer you work here, the more you earn. - Nine paid holidays. - On-site cafeterias and fitness centers in major locations. - Wellness programs and healthy lifestyle premium discount. - Tuition assistance. - Service recognition. - Incentive Plan. - Merit Plan. - Continuing education funds for additional certifications and certification renewal. Equal Employment Opportunity Statement BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations. We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company. If you need special assistance or an accommodation while seeking employment, please email mycareer.help@bcbssc.com or call 800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis. We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Here's more information. Some states have required notifications. Here's more information.

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description Performs medical record and claims review for Medicare, Medicaid, and/or other claims data in order to ensure that proper guidelines have been followed and assesses for potential overpayment, fraud, waste, and abuse with regards to Medicare, Medicaid, and/or other claims. - Reviews beneficiary, provider, and/or pharmacy cases for potential overpayment, fraud, waste, and abuse. - Completes desk review or field audits to meet applicable contract requirements and to identify evidence of potential overpayment or fraud. - Consults with benefit integrity investigation experts and pharmacists for advice and clarification. - Completes case summaries and provides results to investigators to support the investigative process. - Provides case specific or plan specific data entry and reporting. - Participates in internal and external focus groups, as required. - Participates in provider onsite visits and beneficiary interviews, as required, for field audits/investigations. - Testifies at various legal proceedings, as necessary. - Provides job-specific orientation and training, as needed. Helps develop training content, resources, and programs specific to job functions. Qualifications - Minimum Bachelor's Degree required. Requirements - 2 - 4 years of experience required; 5 - 7 years preferred. - Current, active and non-restricted RN licensure required. - Coding certification preferred.

In the U.S., 60% of adults – more than 133 million people – live with at least one chronic condition. These patients need frequent, proactive support to stay healthy, yet our care system isn’t built for that level of attention. With rising clinician shortages, strained infrastructure, and reactive care models, patients too often end up in the ER or the hospital when those outcomes could have been prevented. At Cadence, we’re building a better system. Our mission is to deliver proactive care to one million seniors by 2030. Our technology and clinical care team extend the reach of primary care providers and support patients every day at home. In partnership with leading health systems, Cadence consistently monitors tens of thousands of patients to improve outcomes, reduce costs, and help patients live longer, healthier lives. *]:pointer-events-auto scroll-mt-[calc(var(--header-height)+min(200px,max(70px,20svh)))]" data-turn-id="request-6973a1b9-fbd8-8325-be36-66622ef94b91-23" data-testid="conversation-turn-60" data-scroll-anchor="true" data-turn="assistant"> The Cadence Health team is seeking a remote Licensed Practical Nurse (internally known as a Clinical Navigator) to provide virtual patient support across Cadence care programs. In this role, you will support Medicare patients living with chronic conditions by reinforcing care plans, encouraging adherence to medications and preventive care, and providing education that helps patients better manage their health. Clinical Navigators deliver proactive, patient-centered outreach and follow-through. Depending on program needs, your work may include structured patient check-ins, coaching and goal-setting, care coordination to close gaps in care, and addressing barriers such as access to resources, transportation, or medication refills. You will document patient interactions in the Cadence platform and collaborate closely with the clinical team to escalate concerns, coordinate next steps to ensure patients feel supported, informed, and engaged throughout their care journey. Schedule: This is a full-time, remote position based in the United States. Standard working hours are Monday through Friday, from 8:00 AM to 5:00 PM or 9:00 AM to 6:00 PM in the Hawaii time zone. What you'll do: - Conducting outbound telephonic patient outreach to support patients enrolled in Cadence care programs - Provide one-on-one coaching and support to patients managing chronic conditions, including but not limited to type 2 diabetes, hypertension, and cardiovascular disease - Help patients execute personalized care plans and achieve their goals by providing education and coaching focused on behavior modification, nutrition, physical activity, and self-management strategies using evidence-based techniques such as motivational interviewing and SMART goals - Conduct comprehensive assessments of patients' health status, lifestyle behaviors, nutritional habits, and readiness to change - Support patient care delivery by performing assigned tasks in accordance with Cadence clinical policies and established protocols, under appropriate clinical supervision - Educate patients on disease management, medication adherence, symptom recognition, and prevention strategies - Monitor patients' progress, adherence to treatment plans, and health outcomes through regular check-ins and remote monitoring tools - Documenting patient interactions, outcomes, and follow-up plans in the Cadence platform - Identifying barriers to care (including social needs) and connecting patients with resources or internal support pathways - Collaborating in real time with clinicians and patient support teams using tools such as our Cadence Platform, Google Workspace, and Slack - Contributing feedback to improve workflows in a fast-moving, change-oriented environment These responsibilities are intended to describe the general nature and level of work being performed by personnel assigned to this job classification. They are not to be construed as an exhaustive list of job duties performed by personnel in this classification. Other job related duties may be assigned by management. What you need: Education, licenses, and experiences required for this role: - Must be currently located in Hawaii - An active compact multi-state LPN/LVN license in the state where you currently reside is required - At least 5 years of clinical experience as a Licensed Practical Nurse is required - Remote work readiness (including stable high-speed WiFi) is required - An active CA state LVN license is highly preferred - Experience providing patient education and support to individuals managing chronic conditions is preferred Cadence Clinical Navigators also demonstrate: - Strong patient education, coaching, and care coordination skills - Skilled in supporting patients in managing their health and chronic conditions by meeting them where they are in life - considering their age, lifestyle, and diet - Strong documentation habits and attention to detail - Reliable attendance and strong schedule adherence - Exceptional written, verbal, and interpersonal communication skills - Ability to work independently in a remote, fast-paced environment with evolving workflows - Tech-savvy and comfortable navigating and/or troubleshooting multiple systems while engaging patients virtually The anticipated compensation range for this role is $26 - $31 per hour, which is based on role scope, level, and location. In addition to base compensation, this role may be eligible for incentive compensation as part of the overall total rewards package. This position is remote and based in the United States. Actual compensation will be determined based on factors including experience, skills, internal equity, and applicable law. Who we are Cadence Health was built around a simple promise: patients always come first. Our technology-enabled remote care model pairs continuous health insights with a highly skilled clinical Care Team, empowering seniors to stay healthier, avoid complications, and live more independent, fulfilling lives, all without the limits of a traditional office visit. Your expertise is the heart of our system. Nurse practitioners, registered nurses, medical assistants, patient-success coordinators, and other frontline clinicians are the face and beating heart of Cadence. You’ll bring warmth, clinical precision, and the empathy that turns a virtual touchpoint into a human connection. Every chat, phone call, and care plan you deliver shapes how patients experience “what healthcare should be.” A modern toolkit to practice top-of-license care We’ve replaced reactive visits with real-time data, intelligent workflows, and seamless collaboration tools. That means you can spend less time on busywork and more time practicing at the top of your license, coaching patients, spotting risks early, and coordinating with physicians to keep care proactive and personal. Thriving in a fast-moving, mission-driven culture. Change excites us. Innovation fuels us. If you’re energized by technology, eager to re-imagine care delivery, and motivated to improve outcomes for both patients and the providers who serve them, you’ll feel at home here. We invest in continuous learning, clinical mentorship, and transparent growth paths so you can advance your skills while making a measurable impact every day. Join us in redefining healthy aging. If you’re passionate about compassionate care and ready to transform how seniors across the country manage chronic conditions, recover after hospitalization, and age with confidence, let’s talk. Together, we’ll build a future where exceptional care is consistent, connected, and just a call away. What You'll Get: Cadence full-time employees are eligible for the benefits described below. Part-time employees may qualify for benefits mandated by state or local law. Cadence recognizes the unique needs of its diverse, distributed workforce and seeks to provide an inclusive work environment for its world-class clinicians and technologists. - Company culture all about impact, shared growth mindset, empowerment, and integrity - An opportunity to help improve the quality of life of millions of Americans - Unique chance to support the development of an amazing product; Cadence’s in-house clinicians are our super users and beta testers - Competitive salaries and quarterly incentives - Medical, dental, and vision insurance - Competitive PTO - 401K and 401K match - National and local discounts powered by TriNet - Onboarding stipend for remote equipment and home office setup - Paid Parental Leave - Charitable Donation Match program We are committed to equal opportunity and fairness regardless of race, color, religion, sex, gender identity, sexual orientation, nation of origin, ancestry, age, physical or mental disability, country of citizenship, medical condition, marital or domestic partner status, family status, family care status, military or veteran status or any other basis protected by local, state or federal laws. Candidates must be willing to comply with all pre-employment drug screening requirements and, where applicable, comply with additional drug screening requirements as a condition of continued employment in accordance with company policy and applicable law. *A notice to Cadence applicants: Our Talent team only directs candidates to apply through our official careers page at https://www.cadence.care/our-team. Cadence will never refer you to external websites, ask for payment or personal information, or conduct interviews via messaging apps. We receive all applications through our website and anyone suggesting otherwise is not with Cadence.

In the U.S., 60% of adults – more than 133 million people – live with at least one chronic condition. These patients need frequent, proactive support to stay healthy, yet our care system isn’t built for that level of attention. With rising clinician shortages, strained infrastructure, and reactive care models, patients too often end up in the ER or the hospital when those outcomes could have been prevented. At Cadence, we’re building a better system. Our mission is to deliver proactive care to one million seniors by 2030. Our technology and clinical care team extend the reach of primary care providers and support patients every day at home. In partnership with leading health systems, Cadence consistently monitors tens of thousands of patients to improve outcomes, reduce costs, and help patients live longer, healthier lives. The Cadence Health team is seeking a remote Licensed Practical Nurse (internally known as a Clinical Navigator) to provide virtual patient support across Cadence care programs. In this role, you will support Medicare patients living with chronic conditions by reinforcing care plans, encouraging adherence to medications and preventive care, and providing education that helps patients better manage their health. Clinical Navigators deliver proactive, patient-centered outreach and follow-through. Depending on program needs, your work may include structured patient check-ins, coaching and goal-setting, care coordination to close gaps in care, and addressing barriers such as access to resources, transportation, or medication refills. You will document patient interactions in the Cadence platform and collaborate closely with the clinical team to escalate concerns, coordinate next steps to ensure patients feel supported, informed, and engaged throughout their care journey. Schedule: This is a full-time, remote position based in the United States. Standard working hours are Monday through Friday, from 8:00 AM to 5:00 PM or 9:00 AM to 6:00 PM in the Pacific time zone. What you'll do: - Conducting outbound telephonic patient outreach to support patients enrolled in Cadence care programs - Provide one-on-one coaching and support to patients managing chronic conditions, including but not limited to type 2 diabetes, hypertension, and cardiovascular disease - Help patients execute personalized care plans and achieve their goals by providing education and coaching focused on behavior modification, nutrition, physical activity, and self-management strategies using evidence-based techniques such as motivational interviewing and SMART goals - Conduct comprehensive assessments of patients' health status, lifestyle behaviors, nutritional habits, and readiness to change - Support patient care delivery by performing assigned tasks in accordance with Cadence clinical policies and established protocols, under appropriate clinical supervision - Educate patients on disease management, medication adherence, symptom recognition, and prevention strategies - Monitor patients' progress, adherence to treatment plans, and health outcomes through regular check-ins and remote monitoring tools - Documenting patient interactions, outcomes, and follow-up plans in the Cadence platform - Identifying barriers to care (including social needs) and connecting patients with resources or internal support pathways - Collaborating in real time with clinicians and patient support teams using tools such as our Cadence Platform, Google Workspace, and Slack - Contributing feedback to improve workflows in a fast-moving, change-oriented environment These responsibilities are intended to describe the general nature and level of work being performed by personnel assigned to this job classification. They are not to be construed as an exhaustive list of job duties performed by personnel in this classification. Other job related duties may be assigned by management. What you need: Education, licenses, and experiences required for this role: - An active compact multi-state LPN/LVN license in the state where you currently reside is required - At least 5 years of clinical experience as a Licensed Practical Nurse is required - Remote work readiness (including stable high-speed WiFi) is required - An active CA state LVN license is required - Fluency in Spanish is preferred - Experience providing patient education and support to individuals managing chronic conditions is preferred Cadence Clinical Navigators also demonstrate: - Strong patient education, coaching, and care coordination skills - Skilled in supporting patients in managing their health and chronic conditions by meeting them where they are in life - considering their age, lifestyle, and diet - Strong documentation habits and attention to detail - Reliable attendance and strong schedule adherence - Exceptional written, verbal, and interpersonal communication skills - Ability to work independently in a remote, fast-paced environment with evolving workflows - Tech-savvy and comfortable navigating and/or troubleshooting multiple systems while engaging patients virtually The anticipated compensation range for this role is $26 - $31 per hour, which is based on role scope, level, and location. In addition to base compensation, this role may be eligible for incentive compensation as part of the overall total rewards package. This position is remote and based in the United States. Actual compensation will be determined based on factors including experience, skills, internal equity, and applicable law. Who we are Cadence Health was built around a simple promise: patients always come first. Our technology-enabled remote care model pairs continuous health insights with a highly skilled clinical Care Team, empowering seniors to stay healthier, avoid complications, and live more independent, fulfilling lives, all without the limits of a traditional office visit. Your expertise is the heart of our system. Nurse practitioners, registered nurses, medical assistants, patient-success coordinators, and other frontline clinicians are the face and beating heart of Cadence. You’ll bring warmth, clinical precision, and the empathy that turns a virtual touchpoint into a human connection. Every chat, phone call, and care plan you deliver shapes how patients experience “what healthcare should be.” A modern toolkit to practice top-of-license care We’ve replaced reactive visits with real-time data, intelligent workflows, and seamless collaboration tools. That means you can spend less time on busywork and more time practicing at the top of your license, coaching patients, spotting risks early, and coordinating with physicians to keep care proactive and personal. Thriving in a fast-moving, mission-driven culture. Change excites us. Innovation fuels us. If you’re energized by technology, eager to re-imagine care delivery, and motivated to improve outcomes for both patients and the providers who serve them, you’ll feel at home here. We invest in continuous learning, clinical mentorship, and transparent growth paths so you can advance your skills while making a measurable impact every day. Join us in redefining healthy aging. If you’re passionate about compassionate care and ready to transform how seniors across the country manage chronic conditions, recover after hospitalization, and age with confidence, let’s talk. Together, we’ll build a future where exceptional care is consistent, connected, and just a call away. What You'll Get: Cadence full-time employees are eligible for the benefits described below. Part-time employees may qualify for benefits mandated by state or local law. Cadence recognizes the unique needs of its diverse, distributed workforce and seeks to provide an inclusive work environment for its world-class clinicians and technologists. - Company culture all about impact, shared growth mindset, empowerment, and integrity - An opportunity to help improve the quality of life of millions of Americans - Unique chance to support the development of an amazing product; Cadence’s in-house clinicians are our super users and beta testers - Competitive salaries and quarterly incentives - Medical, dental, and vision insurance - Competitive PTO - 401K and 401K match - National and local discounts powered by TriNet - Onboarding stipend for remote equipment and home office setup - Paid Parental Leave - Charitable Donation Match program We are committed to equal opportunity and fairness regardless of race, color, religion, sex, gender identity, sexual orientation, nation of origin, ancestry, age, physical or mental disability, country of citizenship, medical condition, marital or domestic partner status, family status, family care status, military or veteran status or any other basis protected by local, state or federal laws. Candidates must be willing to comply with all pre-employment drug screening requirements and, where applicable, comply with additional drug screening requirements as a condition of continued employment in accordance with company policy and applicable law. *A notice to Cadence applicants: Our Talent team only directs candidates to apply through our official careers page at https://www.cadence.care/our-team. Cadence will never refer you to external websites, ask for payment or personal information, or conduct interviews via messaging apps. We receive all applications through our website and anyone suggesting otherwise is not with Cadence.