CareHarmony’s Care Coordinators (LPN) (NLC) (LVN) work comprehensively with providers to deliver value-based care management initiatives for their patients. CareHarmony is seeking an experienced Licensed Practical Nurse – LPN Nurse (LPN) (NLC) (LVN) with at least 3 years of direct patient-facing work experience; that thrives in a fast-paced environment, is self-motivated, has impeccable attention to detail, and values the impact they can have on a patient’s healthcare journey. You will have experience identifying resources and coordinating needs for chronic care management patients. What's in it for you? - Fully remote position - Work from the comfort of your own home in cozy clothes without a commute. Score! - Consistent schedule - Full-Time Monday – Friday, no weekends, rotational on-call-once per year on average. - Career growth - Many of our team members move up in the company at a faster-than-average rate. We love to see our people succeed!

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description BHPS provides Utilization Review services to its clients. The UM Denials Coordinator supports the Utilization Management function by reviewing denied and partially denied authorizations and preparing denial correspondence within the Utilization Management system. This role is responsible for drafting, editing, and formatting denial and partial denial letters to ensure clarity, accuracy, completeness, and appropriate readability, while maintaining compliance with regulatory requirements and client-specific service level agreements. The position works closely with physicians and nursing staff and may require follow-up phone calls or email communication to clarify determinations, obtain additional information, or resolve discrepancies prior to letter release. The UM Denials Coordinator reports to the Clinical Services team and performs a range of moderately complex administrative and operational tasks in support of UM activities. This is a fast-paced, productivity-driven role that requires strong attention to detail, sound judgment, and the ability to manage competing priorities. Qualifications - LPN license required. - Two or more years of experience in Utilization Management or medical necessity Appeals. - Strong verbal and written communication skills. - Demonstrated customer service skills, including effective written and verbal communication. - Proficient in Microsoft Office applications, including Word, Excel, and Outlook, in a Windows-based environment. - Ability to adapt quickly to changing business needs and learn new processes and systems. Requirements - Review denied authorization cases within the Utilization Management system to understand the clinical determination and supporting rationale prior to letter creation or finalization. - Draft, edit, and format denial and partial denial letters based on authorization determinations, including creation of member friendly letter language, accurately copying and inserting approved clinical statements, criteria citations, and other information into correspondence templates. - Apply working knowledge of Utilization Management processes and sound judgment to ensure all written correspondence is clear, readable, complete, and accurate. - Ensure all letter content, data fields, and member, provider, and service details are accurately populated to prevent compliance risks or downstream operational issues. - Communicate with physicians and nursing staff as needed to clarify determinations, obtain missing information, or resolve discrepancies prior to letter release. - Prioritize and triage denied authorization cases in alignment with client-specific requirements and regulatory turnaround times. - Respond to and resolve member and provider inquiries related to denied authorizations and denial correspondence. - Responsible for pulling and analyzing reporting around denial processes and presenting analysis to leadership. - Perform other related duties as assigned. Benefits - Previous experience reviewing or writing UM denial letter language. - Proficient/Experienced with CPT4 and ICD-10 codes. - Working knowledge of URAC and NCQA documentation standards.

Join our growing organization in making a difference. We are seeking a Quality Nurse for our Onco360 Specialty Pharmacy in Louisville, KY. This will be a Full-Time position, Monday to Friday from 9am to 5:30pm EST. Role can be worked remotely but it is required that you live within a commutable distance to our pharmacy located in Louisville, KY. Onco360 Pharmacy is a unique oncology pharmacy model created to serve the needs of community, oncology and hematology physicians, patients, payers, and manufacturers. A career with us is more than just a job. It's an opportunity to connect and care for our patients, providers, communities and each other. We attract extraordinary people who have a strong desire to live our mission - to better the lives of those battling cancer and rare diseases. Compassion is more important than numbers. We value teamwork, respect, integrity, and passion. We succeed when you do, and our company and management team work hard to foster an environment that provides you with opportunities for both professional and personal growth. Starting salary from $80,000 annual and up We offer a variety of benefits including: - Medical; Dental; Vision - 401k with a match - Paid Time Off and Paid Holidays - Tuition Reimbursement - Company paid benefits – life; and short and long-term disability Quality Nurse Position Summary: The Quality Nurse works across the organization leveraging relationships with internal teams, patients, and providers to ensure the organization is providing quality patient care. The Quality Nurse provides expertise and participates in clinical and essential quality management activities within the Quality Department. Activities will include but are not limited to the quality audit process, medical record reviews, medical record documentation related to accreditation standards, and quality related events. When program opportunities or improvements are identified, provide escalation to the Director as appropriate. The Quality Nurse will work with the Director to provide recommendations, champion next steps, and obtain resolution as needed. Quality Nurse Major Responsibilities: - Performs medical record / chart audits and documents opportunities related to high quality, safe, and appropriate patient care. - Interacts telephonically with patients to counsel and assess when clinical intervention would be appropriate. - Demonstrates performance that improves the overall quality of care for our patients by thoroughly reviewing patient’s diagnosis, therapy line, adherence, co-morbidities, and information collected upon initial patient assessment leading to conducting and documenting the re-assessment. - Collaborate with the Director to develop auditing processes and training to ensure adherence to quality processes. - Tracks and trends quality results to inform continuous improvement opportunities. - Performs other tasks as assigned, maintains high attention to detail on all tasks and completes things in a timely, often independent, manner. - Works all projects that are assigned by the Director or Vice President of Pharmacy Operations. Quality Nurse Qualifications: Education/Learning Experience - Required - graduate from an accredited school with Bachelor of Science degree in Nursing Work Experience - Required: 2+ years in specialty pharmacy, quality process, patient care type of role Skills/Knowledge - Required: Caring clinical patient care, CPR+ knowledge, problem solving, patient education / intervention, and excellent communication skills (verbal and written). Self-starter who can work independently with little to no guidance. Licenses/Certifications - Required: Licensed Registered Nurse (RN) - License must be in good standing in the state of practice

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description HealthPartners is hiring a Clinical Review Pharmacist. Service excellence is to be centered on patient care and patient relationships and is the responsibility of all employees. Teamwork is the norm and all employees will be held accountable to work as effective team members. The role involves: - Reviewing, approving, and denying prior authorization requests in compliance with pharmacy policies, procedures, and standards. - Providing support to physicians and pharmacy staff regarding prior authorization questions. - Reviewing prior authorization requests for medical policy drugs and pharmacy benefit drugs; making coverage determinations for drug products according to member benefits and coverage criteria. - Contributing to the development, maintenance, and communication of utilization management and exception criteria. - Providing clinical guidance and support to the Pharmacy Customer Service Assistants and other Pharmacy staff when requested. - Conducting research and analysis of coverage determinations and appeals on an ad hoc basis. - Providing support and follow-up for escalated clinical issues. - Researching drug information to maintain drug knowledge and disease state understanding for application to drug coverage reviews. - Applying drug knowledge and evidence from literature to specific case situations, discussions with Medical Directors, and other peer review groups. - Providing effective drug information and consultation to professional staff, providers, patients, and members. - Ensuring strict adherence to the requirements of CMS, DHS, MDH, and other regulatory agencies. - Supporting and cooperating with other departments’ operation initiatives. - Maintaining a professional image. - Adhering to the established Group Health, Inc., patient-service standards. - Performing other duties as assigned. Qualifications - Must be a graduate from an accredited college of pharmacy and licensed as a pharmacist in the state of Minnesota. - Must maintain this license in good standing as required by Minnesota law. - Must meet one of the following: - Pharm.D. - One year of recent experience in a managed care pharmacy setting. - One year of recent clinical pharmacy experience that includes prior authorization experience. - Demonstrated knowledge of pharmacodynamics, pharmacokinetics, pathophysiology, and therapeutic disease states commonly found in ambulatory patients. - Demonstrated competency in all professional aspects of pharmacy. - Strong leadership and organizational skills; maturity and dependability are essential. - Ability to organize and function under stress with many interruptions. - Ability to establish and maintain effective, friendly, and courteous working relationships with coworkers, physicians, and patients. - Strong communication/listening skills and good telephone etiquette. - Ability to accept and implement change. - Ability to tactfully resolve complaints. Requirements - Experience working with pharmacy technicians (preferred). - Experience working with Microsoft suite of products (preferred). - Knowledgeable in CMS and DHS regulations as well as other compliance-related rules and entities (preferred). Benefits - Comprehensive range of benefits to support every aspect of your life, including health, time off, retirement planning, and continuous learning opportunities. - Commitment to nurturing diverse talents and valuing dedication. - Support for work-life balance. - Goal to help you thrive physically, mentally, emotionally, and financially. Company Description At HealthPartners, we believe in the power of good – good deeds and good people working together. We’re a nonprofit, integrated health care organization, providing health insurance in six states and high-quality care at more than 90 locations, including hospitals and clinics in Minnesota and Wisconsin. We bring together research and education through HealthPartners Institute, training medical professionals across the region and conducting innovative research that improves lives around the world. At HealthPartners, everyone is welcome, included, and valued. We’re working together to increase diversity and inclusion in our workplace, advance health equity in care and coverage, and partner with the community as advocates for change.