At Cleveland Clinic Health System, we believe in a better future for healthcare. And each of us is responsible for honoring our commitment to excellence, pushing the boundaries and transforming the patient experience, every day. We all have the power to help, heal and change lives — beginning with our own. That’s the power of the Cleveland Clinic Health System team, and The Power of Every One. Job Title Concurrent Denial Nurse BU - Utilization Management Location Cleveland Facility Remote Location Department Nursing Administrative Supervisors-Indian River Hospital Job Code 0019IR Shift Days Schedule 9:00am-5:00pm Job Summary Job Details CCIR Bidding Period: 12/9/2025 - 12/16/2025 Join the Cleveland Clinic team where you will work alongside passionate caregivers and provide patient-first healthcare. You will work alongside dedicated caregivers, receive endless support and appreciation, and build a rewarding career with one of the most respected healthcare organizations in the world. As a Concurrent Denial Nurse, you will support the Utilization Management Department by reviewing concurrent and retrospective clinical inpatient denials to ensure medical necessity criteria is met. We are looking for a Registered Nurse who is a subject matter expert in utilization management, has experience with MCG criteria, and is comfortable educating Caregivers and Physicians. In this role, you will get to work with a dynamic team of like-minded professionals and gain experience at an elite healthcare organization. A caregiver in this position works days from 7:30AM – 4:30PM. A caregiver who excels in this role will: - Serve as the expert in Utilization Management functions and be a resource to the department in general and the hospital. - Review and analyze concurrent and retrospective clinical denials and follow the specific payer processes. - Serve as an expert in payer specific process and communicate between payer and CCIRH to identify/resolve denial process issues. - Work in collaboration with the local physician advisor team and support the peer-to-peer process. - Perform the routine activities of a UM Specialist when needed while taking a leadership role. - Utilize knowledge of medical terminology, anatomy and physiology, diagnosis, surgical procedures and basic disease processes. - Utilize knowledge and experience with Care Guidelines and /or other UM criteria sets. - Utilize advanced interpersonal and communication written and verbal skills necessary to gather and exchange data (both internally and externally) with members of the health care team. - Recommend resource utilization when needed - Utilize analytical skills to gather data, identify problems and facilitate resolution. - Prioritize and organize work to meet changing priorities. - Utilize knowledge of multiple hospital information systems and department’s software. - Assist with education and monitoring of UM specialist's reviews. - Participate in payer specific p2p calls or local meetings as needed. Minimum qualifications for the ideal future caregiver include: - Bachelor’s Degree in Nursing or related field - Current Florida Resident with active Florida License - Completion of an accredited Registered Nursing Program (RN) - Current valid license in the State of Florida as a Registered Nurse (RN) - Basic Life Support (BLS) certification through the American Heart Association (AHA) or American Red Cross - Three years of full-time Utilization Management experience - Demonstrated above average competence in Utilization Management Processes Preferred qualifications for the ideal future caregiver include: - Case Management certification (CCM or ACM) Physical Requirements: - Requires extensive reading, telephone , computer use - Must be able to work well under pressure and maintain professional demeanor under adverse conditions Personal Protective Equipment: - Follows Standard Precautions using personal protective equipment as required The policy of Cleveland Clinic Health System and its system hospitals (Cleveland Clinic Health System) is to provide equal opportunity to all of our caregivers and applicants for employment in our drug free environment. All offers of employment are followed by testing for controlled substances. Cleveland Clinic Health System administers an influenza prevention program. You will be required to comply with this program, which will include obtaining an influenza vaccination on an annual basis or obtaining an approved exemption. Decisions concerning employment, transfers and promotions are made upon the basis of the best qualified candidate without regard to color, race, religion, national origin, age, sex, sexual orientation, marital status, ancestry, status as a disabled or Vietnam era veteran or any other characteristic protected by law. Information provided on this application may be shared with any Cleveland Clinic Health System facility. If applying for a Florida position, please see the following website for more information on the background screening requirements required by the Agency of Health Care Administration: https://info.flclearinghouse.com/ Please review the Equal Employment Opportunity poster. Cleveland Clinic is pleased to be an equal employment opportunity employer.

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 an experienced Care Navigation RN to provide direct, patient-centered support to our members. In this role, you will be the primary point of contact for members navigating complex health journeys. You will utilize your clinical expertise to improve health outcomes, reduce barriers to care, reduce costs, and provide compassionate advocacy within a high-performance, virtual environment. - Deliver coordinated, patient-centered virtual Care Navigation by telephone and digital channels to improve member health outcomes and satisfaction. - Lead proactive outreach efforts to identify high-risk individuals; complete comprehensive clinical assessments and develop tailored care plans for enrolled members. - Utilize the Nursing Process and a holistic "whole person" approach—including pharmacy interventions, crisis support, and disease-specific education—to support members. - Assist members in navigating the complexities of the healthcare system, providing education and empowerment to help them meet their healthcare goals. - Provide longitudinal Care Navigation during acute episodes, such as hospitalizations and rehabilitation stays, supporting both the member and their family through the transition of care. - Identify clinical or social barriers to health and provide targeted interventions, connecting members to relevant health benefit resources and social determinants of health (SDOH) support. - Work alongside other stakeholders and partners on co-managed cases and collaborate with internal teams to resolve complex benefit and claims questions. - Build supportive, trusting relationships through passionate follow-up care and consistent advocacy. - Maintain strict compliance with all regulatory, accreditation, and internal policy standards. - Demonstrate an understanding of the functions of other departments, communicate with other departments appropriately and maintain positive working relationships. Qualifications - Active RN license in a compact state with the ability to obtain licensure in other states as needed. - 2+ years of experience in case management for a health plan or TPA and 2+ years of experience in a hospital or clinical setting. - Experience across multiple specialties, including med/surg, oncology, behavioral health, maternity, critical care/emergency, pediatrics, or community care. - Strong competence in using multiple computer/medical record systems (EMRs), preferably Salesforce, and Google Workspace. - Ability to talk, type, and navigate an electronic chart simultaneously in a remote setting. - Proven ability to prioritize assignments, manage a busy caseload, and meet daily goals independently. - Experience in telephonic care management with no direct/face-to-face patient contact. - A drive for identifying and implementing clinical best practices. Requirements - Knowledge of Managed Care Programs. - Knowledge or certification in Motivational Interviewing. - Case Manager Certification. Benefits - Great overall employee experience with opportunities for career growth. - Meaningful mission-driven work. - Above average total rewards package. - Salary range for this position is $71,400 - $118,000 annually. - Numerous factors including education, skills, work experience, certifications, etc. will be considered when determining compensation. - Alternative medicine coverage. - Generous PTO. - Up to 16 weeks paid parental leave. - Paid holidays. - 401k program. - Transportation perks. - Education reimbursement. - Paid paw-ternity leave.

Description Dermatologist – Independent Clinical Reviewer (New Jersey License Required) Dane Street is seeking experienced Dermatologists licensed in New Jersey to join our growing team of expert clinical reviewers. In this role, you will apply your dermatology expertise to conduct comprehensive reviews of clinical cases and provide objective, evidence-based opinions related to dermatologic conditions, treatments, and procedures. This is a remote telework opportunity that allows you to customize your schedule while working as a 1099 independent contractor. Your primary responsibilities will include reviewing medical records, preparing clear and concise clinical summaries, and responding to specific questions from our clients regarding dermatologic diagnoses, treatment plans, procedures, and medical necessity. Join a team that values your clinical judgment and commitment to improving the quality, accuracy, and consistency of healthcare assessments. Your expertise plays a vital role in supporting high-quality, defensible clinical determinations. Requirements - Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) - Board Certified or Board Eligible in Dermatology - Current, unrestricted New Jersey medical license - Minimum of 5+ years of clinical dermatology experience - Strong understanding of medical, surgical, and cosmetic dermatologic conditions and treatments - Ability to attend required orientation and training sessions - Maintain appropriate credentialing, state licensure, and any certifications required to perform the role Benefits - Independent consultant role offering schedule flexibility and predictable work hours - Ability to choose case types and workload based on your availability - No doctor–patient relationship established; no treatment is provided — all reviews are advisory only - Streamlined case flow through a user-friendly online work portal - Dane Street manages administrative processes, medical record organization, and communications - Fully prepared cases with organized medical records and applicable clinical guidelines - Initial training and ongoing support, including a dedicated point of contact

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description Dane Street is seeking experienced Dermatologists licensed in New Jersey to join our growing team of expert clinical reviewers. In this role, you will apply your dermatology expertise to conduct comprehensive reviews of clinical cases and provide objective, evidence-based opinions related to dermatologic conditions, treatments, and procedures. This is a remote telework opportunity that allows you to customize your schedule while working as a 1099 independent contractor. Your primary responsibilities will include: - Reviewing medical records - Preparing clear and concise clinical summaries - Responding to specific questions from our clients regarding dermatologic diagnoses, treatment plans, procedures, and medical necessity Join a team that values your clinical judgment and commitment to improving the quality, accuracy, and consistency of healthcare assessments. Your expertise plays a vital role in supporting high-quality, defensible clinical determinations. Qualifications - Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) - Board Certified or Board Eligible in Dermatology - Current, unrestricted New Jersey medical license - Minimum of 5+ years of clinical dermatology experience - Strong understanding of medical, surgical, and cosmetic dermatologic conditions and treatments - Ability to attend required orientation and training sessions - Maintain appropriate credentialing, state licensure, and any certifications required to perform the role Benefits - Independent consultant role offering schedule flexibility and predictable work hours - Ability to choose case types and workload based on your availability - No doctor–patient relationship established; no treatment is provided — all reviews are advisory only - Streamlined case flow through a user-friendly online work portal - Dane Street manages administrative processes, medical record organization, and communications - Fully prepared cases with organized medical records and applicable clinical guidelines - Initial training and ongoing support, including a dedicated point of contact