Role Description Come join Peak Health WVU Medicine to help design and build a health plan from the ground up as the Supervisor, Utilization Management. Reporting to the Manager of Utilization Management, the supervisor will be an integral member of the health plan’s medical management team. The UM supervisor is a collaborative member of the Medical Management team. The incumbent will be an excellent communicator who is ready to take on a new challenge in their career! Qualifications - Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse License Compact (eNCL). - Five (5) years of healthcare clinical experience. - Two (2) years of Health Plan Utilization Management experience. Requirements - Bachelor of Science in Nursing (BSN). - Medical Management for government programs and diverse populations. - Through understanding of utilization management process and regulatory requirements. - Medical Management for Medicare and/or Medicaid populations. - Excellent written and verbal communication skill. Core Duties and Responsibilities - Oversee the build and implement care management review processes (Prior Authorization, Predetermination, Concurrent Reviews, Retrospective Reviews) that are consistent with established industry and corporate standards. - Manage the build and implement all care management reviews according to accepted and established criteria, as well as other clinical guidelines and policies. - Ensure that interventions are collaborative and focus on maximizing the member’s health care outcomes. - Supervise the facilitation of the Peer-to-Peer Review process, and work with the Medical Directors to continuously improve member and Provider Network services for this process. - Oversee the education that is provided to internal and external stakeholders and partners to continuously improve processes and build network relationships. - Facilitates a collaborative environment that focuses on collaboration with other members of the medical management team to identify members whose healthcare outcomes may be enhanced by coaching and/or case management interventions. - Educate team members on the data that is collected within the position and facilitate improvement in outcomes within the team. - When needed, fill in for staff members to ensure that the operations of the medical management team are never compromised. - Commit to a career of life-long learning and continuous improvement of processes that span the realm of Utilization Review. Physical Requirements - Office work which includes sitting for extended periods of time. - Maintains confidential home office space. Working Environment - Standard office environment. Skills and Abilities - Working Knowledge of InterQual and/or Milliman Care Guidelines. - Demonstrated knowledge of federal and state laws, NCQA and industry regulations related to disease management, utilization management, case management and discharge planning. - Excellent written and oral communication. - Problem solving capabilities to drive improved efficiencies and customer satisfaction. - Attention to detail. - Proficiency with Microsoft Office. - Ability to work under stressful working conditions. - Ability to handle and maintain confidential information. - Ability to work cooperatively as a team member and leader in our Utilization Management Department. - Ability to work within multi-disciplinary groups. - Ability to work in a fast-paced and rapidly changing environment. - Extensive working knowledge of Microsoft Office applications (Excel and Word). Additional Job Description - Scheduled Weekly Hours: 40 - Shift: Exempt/Non-Exempt: United States of America (Exempt) - Company: PHH Peak Health Holdings - Cost Center: 500 PHH Administration

Anticipated End Date: 2026-04-17 Position Title: Medical Management Clinician Associate-Licensed Nurse Job Description: Medical Management Clinician Associate-Licensed Nurse Location: Tampa, FL or Miami, FL Virtual: This role enables associates to work virtually full-time, with the exception of required in-person training sessions (when indicated), providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. The Medical Management Clinician Associate is responsible for ensuring appropriate, consistent administration of plan benefits by reviewing clinical information and assessing medical necessity under relevant guidelines and/or medical policies. Focuses on less complex and potentially higher volume benefit plans and/or contracts, following standard procedures that do not require the training or skill of a registered nurse. How you will make an impact: - Confirms medical services are appropriate based on assigned benefit plan, medical policies, clinical guidelines, plan benefits, and/or scripted algorithms within scope of licensure. - Work may be facilitated, in part, by algorithmic or automated processes. - Handles less complex benefit plans and/or contracts. - Conducts and may approve precertification, concurrent, retrospective, out-of-network, and/or appropriateness of treatment setting reviews by assessing clinical information against appropriate medical policies, clinical guidelines, and the relevant benefit plan/contract. - May process a medical necessity denial determination made by a Medical Director. - Refers complex or non-routine reviews to more senior nurses and/or Medical Directors. - Does not issue medical necessity non-certifications. Minimum requirements: - Requires H.S. diploma or equivalent and a minimum of 2 years of clinical experience and/or utilization review experience. Current active, valid and unrestricted LPN/LVN or RN license and/or certification to practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States required. Multi-state licensure is required if this individual provides services in multiple states. Job Level: Non-Management Non-Exempt Workshift: Job Family: MED > Licensed Nurse Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health. Who We Are Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. How We Work At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business. We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few. Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws. Elevance Health is an Equal Employment Opportunity employer, and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act. Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration.

This is a remote opportunity within the Colorado/New Mexico Home Therapy operational area! The individual selected must reside in the Colorado/New Mexico Home Therapy territory. Travel required! PURPOSE AND SCOPE: The Clinical Quality Manager is responsible for developing, implementing, and monitoring quality assurance and performance improvement (QAPI) programs to ensure the highest standards of patient care and regulatory compliance. This role oversees clinical outcomes, coordinates quality initiatives, ensures adherence to regulations, and collaborates with the interdisciplinary team to drive continuous improvement in patient safety and clinical quality performance. The scope of the clinical quality oversight of the position covers assigned treatment modalities (e.g. in-center, home modalities, or home hemodialysis and home peritoneal dialysis) PRINCIPAL DUTIES AND RESPONSIBILITIES: - Lead or participate in the clinic’s Quality Assessment and Performance Improvement (QAPI) program in alignment with CMS, state, and organizational standards. - Develop and implement action plans to address deficiencies and improve care delivery. - Conduct regular audits and quality reviews to ensure compliance with clinical policies & procedures. - Facilitate staff education and training related to quality improvement, patient safety, and best practices. - Collaborate with physicians, nurses, dietitians, social workers, and leadership to support evidence-based clinical initiatives. - Prepare and present quality reports to clinic leadership and governing bodies. - Ensure accurate documentation, data collection, and reporting for internal and external stakeholders. - Promote a culture of accountability, safety, and continuous improvement within the clinic. - Manages the execution and achievement of Quality key performance indicators (assigned by Quality leadership team) and other clinical initiatives, interventions and standardized education materials with clinic teams within the assigned area(s). - Performs other related duties as assigned. PHYSICAL DEMANDS AND WORKING CONDITIONS: - The physical demands and work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. - Day-to-day work includes desk and personal computer work and interaction with facility staff and physicians. - The work environment is characteristic of a health care facility with air temperature control and moderate noise levels. May be exposed to infectious and contagious diseases/materials. - Field: The position requires travel between assigned facilities and various locations within the community, approx. 60%-80%. ○ Travel to Regional, Division and Corporate meetings may be required. - Remote: The position could require travel up to 10-15% SUPERVISION: - None EDUCATION AND REQUIRED CREDENTIALS: - Registered Nurse required - BSN or bachelor’s degree in healthcare-related field preferred (or equivalent experience). - Certification in Nephrology Nursing or quality preferred EXPERIENCE AND SKILLS: - 3+ years of dialysis experience required. - 2+ years' experience in a leadership role. - Strong organizational, critical thinking and customer service skills. - Demonstrated leadership competencies and adaptability to changes in priorities - Ability to work collaboratively with other members of the team, gain support and input while participating in quality improvement activities. - Strong verbal and written communications skills. - Ability to analyze and propose alternate solutions, assist in resolving sensitive to complex issues Fresenius Medical Care is an equal opportunity employer and does not discriminate on the basis of race, color, religion, sexual orientation, gender identity, parental status, national origin, age, disability, military service, or other non-merit-based factors

You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility. **This role requires approximately 50% travel to support members in Johnson County. Applicants have the flexibility to work remotely from their home the remaining time. We provide all required equipment and reimburse for mileage at the current IRS rate. The schedule is Monday - Friday, 8am - 5pm. Previous IDD experience is preferred. ** Position Purpose: Assists in developing, assessing, and coordinating holistic care management activities to enable quality, cost-effective healthcare outcomes. May develop or assist with developing personalized service care plans/service plans for long-term care members and educates members and their families/caregivers on services and benefits available to meet member needs. - Evaluates the needs of the member, the resources available, and recommends and/or facilitates the plan for the best outcome - Assists with developing ongoing long-term care plans/service plans and works to identify providers, specialist, and/or community resources needed for long-term care - Coordinates as appropriate between the member and/or family/caregivers and the care provider team to ensure identified services are accessible to members - Provides resource support to members and their families/caregivers for various needs (e.g. employment, housing, participant direction, independent living, justice, foster care) based on service assessment and plans - Monitors care plans/service plans, member status and outcomes, as appropriate, and provides recommendations to care plan/service plan based on identified member needs - Interacts with long-term care healthcare providers and partners as appropriate to ensure member needs are met - Collects, documents, and maintains long-term care member information and care management activities to ensure compliance with current state, federal, and third-party payer regulators - May perform home and/or other site visits to assess member’s needs and collaborate with healthcare providers and partners - Provides and/or facilitates education to long-term care members and their families/caregivers on procedures, healthcare provider instructions, service options, referrals, and healthcare benefits - Provides feedback to leadership on opportunities to improve and enhance quality of care and service delivery for long-term care members in a cost-effective manner - Performs other duties as assigned. - Complies with all policies and standards. Education/Experience: Requires a Bachelor's degree and 2 – 4 years of related experience. Or equivalent experience acquired through accomplishments of applicable knowledge, duties, scope and skill reflective of the level of this position. 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