Title: Medical Field Case Manager Location: Sterling Heights United States Job Description: Company Overview At Enlyte, we combine innovative technology, clinical expertise, and human compassion to help people recover after workplace injuries or auto accidents. We support their journey back to health and wellness through our industry-leading solutions and services. Whether you're supporting a Fortune 500 client or a local business, developing cutting-edge technology, or providing clinical services you'll work alongside dedicated professionals who share your commitment to excellence and make a meaningful impact. Join us in fueling our mission to protect dreams and restore lives, while building your career in an environment that values collaboration, innovation, and personal growth. Be part of a team that makes a real difference. Job Description This is a full-time, hybrid position. You must be located in the Sterling Heights, MI area due to regular local travel (80% of the time) for in-person patient appointments. Case Manager Perks: Mileage Reimbursement Travel Reimbursement Professional Time Bonus Plan Perks: Full and comprehensive benefits program, 24 days of paid vacation/holidays in your first year plus sick days, home office equipment including laptop and desktop monitor, mileage and travel reimbursement, Employee Assistance and Referral Program, and hands-on workers' compensation case management training. Join our compassionate team and help make a positive difference in an injured person's life. As a Field Case Manager, you will work closely with treating physicians/providers, employers, customers, legal representatives, and the injured/disabled person to create and implement a treatment plan that returns the injured/disabled person back to work appropriately, ensure appropriate and cost-effective healthcare services, achievement of maximum medical recovery and return to an optimal level of work and functioning. In this role, you will: - Demonstrate knowledge, skills, and competency in the application of case management standards of practice. - Use advanced knowledge of types of injury, medications, comorbidities, treatment options, treatment alternatives, and knowledge of job duties to advise on a treatment plan. - Interview disabled persons to assess overall recovery, including whether injuries or conditions are occupational or non-occupational. - Collaborate with treating physicians/providers and utilize available resources to help create and implement treatment plans tailored to an individual patient. - Work with employers and physicians to modify job duties where practical to facilitate early return to work. - Evaluate and modify case goals based on injured/disabled person's improvement and treatment effectiveness. - Independently manage workload, including prioritizing cases and deciding how best to manage cases effectively. - Complete other duties, such as attend injured worker's appointments when appropriate, prepare status updates for submittal to customers, and other duties as assigned. Qualifications - Education: Associates Degree or Bachelor's Degree in Nursing or related field. - Experience: 2+ years clinical practice preferred. Workers' compensation-related experience preferred. - Skills: Ability to advocate recommendations effectively with physicians/providers, employers, and customers. Ability to work independently. Knowledge of basic computer skills including Excel, Word, and Outlook Email. Proficient grammar, sentence structure, and written communication skills. - Certifications, Licenses, Registrations: - Active Registered Nurse (RN) license required. Must be in good standing. - URAC-recognized certification in case management (CCM, CDMS, CRC, CRRN or COHN, COHN-S, RN-BC, ACM, CMAC, CMC). - Travel: Must have reliable transportation and be able to travel to and attend in-person appointments with injured workers in assigned geography. - Internet: Must have reliable internet. Benefits We're committed to supporting your ultimate well-being through our total compensation package offerings that support your health, wealth and self. These offerings include Medical, Dental, Vision, Health Savings Accounts / Flexible Spending Accounts, Life and AD&D Insurance, 401(k), Tuition Reimbursement, and an array of resources that encourage a lifetime of healthier living. Benefits eligibility may differ depending on full-time or part-time status. Compensation depends on the applicable US geographic market. The expected base pay for this position ranges from $80,000 - $88,000 annually. In addition to the base salary, you will be eligible to participate in our productivity-based bonus program. Your total compensation, including base pay and potential bonus, will be based on a number of factors including skills, experience, education, and performance metrics. The Company is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability. #LI-MC1 Registered Nurse (RN), Nursing, Home Care Registered Nurse, Emergency Room Registered Nurse, Clinical Nurse, Nurse Case Manager, Field Case Manager, Medical Nurse Case Manager, Workers' Compensation Nurse Case Manager, Critical Care Registered Nurse, Advanced Practice Registered Nurse (APRN), Nurse Practitioner, Case Management, Case Manager, Home Healthcare, Clinical Case Management, Hospital Case Management, Occupational Health, Patient Care, Utilization Management, Acute Care, Orthopedics, Rehabilitation, Rehab, CCM, Certified Case Manager, CDMS, Certified Disability Management Specialist, CRC, Certified Rehab Certificate, CRRN, Certified Rehab Registered Nurse, COHN, Certified Occupational Health Nurse, CMC, Cardiac Medicine Certification, CMAC, Case Management Administrator Certification, ACM, Accredited Case Manager, MSW, Masters in Social Work, URAC, Vocational Case Manager

Title: Nurse Navigator I Location: Remote NJ United States Category RNs Shift 1 Type Full Time Department Name Amb Ops Experience Center 1 Federal Street Job Description: About Us At Cooper University Health Care, our commitment to providing extraordinary health care begins with our team. Our extraordinary professionals are continuously discovering clinical innovations and enhanced access to the most up-to-date facilities, equipment, technologies and research protocols. We have a commitment to our employees to provide competitive rates and compensation programs. Cooper offers full and part-time employees a comprehensive benefits program, including health, dental, vision, life, disability, and retirement. We also provide attractive working conditions and opportunities for career growth through professional development. Discover why Cooper University Health Care is the employer of choice in South Jersey. Short Description Must be local Remote after 6 months of training Supports, educates, and assists patients and their families, serving as a link to their doctors and supportive services. This position's role is key in the implementation of multi-disciplinary care. Supports, educates and assists patients and their families, serves as a patient advocate. 25%Demonstrates effective teamwork as a member of the interdisciplinary care team, fostering and exemplifying a culture of respect. May participate in the direct care of patients during the Provider visit. 25%Responsible for the coordination of care, assists in securing prescriptions and supplies for proper care. Participates in telephone triage 25% Consistently follows evidence-based practice and nursing standards/procedures to provide nursing care that eliminates preventable events of patient harm and promotes excellent patient outcomes. 25%Scheduling patient appointments for refill requests. Experience Required Candidates with Pediatric experience Education Requirements BSN Required License/Certification Requirements NJ RN License BLS American Heart Association Salary Min ($) USD $36.00 Salary Max ($) USD $59.00

Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015. Position Summary The Utilization Appeals Review Nurse will be responsible for clinical review of member and provider appeals and/or claims disputes. Collaborating with our team of Medical Directors and internal stakeholders, you will use your clinical expertise to apply Martin’s Point medical policies, CMS and TRICARE regulations to deliver accurate, timely, and compliant appeal or claims disputes decisions. Job Description PRIMARY DUTIES AND RESPONSIBILITIES Employees are expected to work consistently to demonstrate the mission, vision, and core values of the organization. - Responsible for the review and resolution of clinical appeals and disputes - Reviews documentation and interprets data obtained from clinical records to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and provider issues. - Ensures care delivery aligns with specific line-of-business benefits while maintaining full compliance with contractual and regulatory standards, e.g. Department of Defense, Centers for Medicaid and Medicare, NCQA, Employer contracts and state insurance regulations, as applicable. - Stays current with industry regulations and accreditation standards to ensure continuous operational compliance - Consistently delivers high-quality outcomes that meet or exceed established departmental benchmarks and performance standards. Participates in quality initiatives, committees, work groups, projects, and process improvements that reinforce best practice medical management programming and offerings. - Independently coordinates the clinical resolution with internal/external clinician support as required. - This position will be accountable for appeals, claims disputes, and QOC review - This is a full-time remote position with standard hours of Monday–Friday, 8:00 AM to 5:00 PM (local time). - Demonstrates flexibility and agility in working in a fast-paced, team-oriented environment, able to multi-task from one case type to another. - Assumes extra duties as assigned based on business needs. - Weekend and holiday on-call coverage may be required. POSITION QUALIFICATIONS Education - Associate Degree in Nursing (ADN) - Bachelor’s degree in nursing preferred Licensure/certification - Active, unrestricted Compact Registered Nurse (RN) license. Experience - 3+ years of RN clinical experience, preferably in a hospital setting, along with experience in utilization management in a health plan UM department and in managing appeals or disputes - Coding/CPC preferred Knowledge - Thorough understanding of CMS Medicare Advantage regulations (Parts C & D) and NCQA guidelines - Thorough knowledge of MCG, Interqual of other clinical guidelines - HIPAA & privacy requirements - Concurrent, prior authorization and appeals review - Critical thinking and case analysis - Clinical writing and summarization - Electronic UM systems - Tricare regulation experience preferred - MCQA standards experience preferred - Claims disputes review experience preferred Skills - Ability to extract relevant clinical facts from progress notes, labs, imaging, and treatment plans. - Correct use of MCG, and Martiin’s Point medical policies to determine medical necessity. - Ability to identify inconsistencies, missing information, or red flags in documentation - Understanding appeal levels, timeframes, coverage rules, and documentation requirements. - Ability to produce rationales that meet CMS, TRICARE, and NCQA standards - Ability to write clear, defensible rationales that explain the clinical and regulatory basis for the determination. - Ability to write concise, objective, and compliant appeal rationales Abilities - Ability to analyze data metrics, outcomes, and trends. - Ability to prioritize time and tasks efficiently and effectively. - Ability to manage multiple demands. - Ability to function independently. This position is not eligible for immigration sponsorship. We are an equal opportunity/affirmative action employer. Martin's Point complies with federal and state disability laws and makes reasonable accommodations for applicants and employees with disabilities. If a reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact jobinquiries@martinspoint.org Do you have a question about careers at Martin’s Point Health Care? Contact us at: jobinquiries@martinspoint.org

At Prime Therapeutics (Prime), we are a different kind of PBM, with a purpose beyond profits and a unique ability to connect care for those we serve. Looking for a purpose-driven career? Come build the future of pharmacy with us. Job Posting Title Initial Review Pharmacy TechnicianJob Description Plays a key role in medical and pharmacy management initiatives critical to the company achieving revenue goals and operational objectives. Responsible for executing utilization management programs on behalf of health plan/payor customers, while utilizing additional clinical knowledge pertaining to a set list of managed medications across all health plans, with additional training for each medication and therapeutic class. Primary activities center on reviewing both prospective and retrospective requests for therapeutic appropriateness using sound clinical criteria. Responsible for making and receiving calls to and from physicians, patients, and pharmacies to gather additional clinical information to determine medication reimbursement. Recommendations will be based on an in-depth understanding of specific specialty medications and industry guidelines, on both pre- and post-service requests. Coordinates with operations, clinical, medical, reporting and other internal departments as needed. Responsibilities - Reviews pertinent patient information and checks appropriateness using clinical criteria. Makes approval recommendations on all services that meet clinical review criteria. Refers all cases not meeting clinical criteria to pharmacist clinical reviewer. - Practices and maintains the principles of utilization management by adhering to the company policies and procedures. Upholds clinical integrity of pharmaceutical solutions by participating in on-going training programs to ensure quality performance in compliance with applicable standards and regulations. Expert within the organization. - Conducts Program Integrity Audits including outreach and review of medical records to audit authenticity of provider response during Prior Authorization and reporting results to client. - Assists with the documentation and implementation of both written and verbal communications to physicians/prescribers and assists in the maintenance of the edits and data elements that support the edits. - Available for consultation in pharmacy related questions to resolve claims submission related to medication edits. - Contacts physicians/prescribers to obtain pertinent clinical history/information. Provides optimum customer service through professional/accurate communication while maintaining NCQA and health plan`s required timeframes. - Regularly reviews and monitors information on pended claims identified as outliers by internal and/or external analysis of pharmacy claims data. - Supports Intake call volume and order entry if necessary. - Determines eligibility for medication reimbursement based upon established clinical criteria and clinical knowledge and enters approvals or denials in the system. - Electronically documents both written and verbal communications with physicians, their staff, cardholders, and pharmacies. - Escalates medical exception requests to nurse, pharmacist or physician on the utilization review clinical team when further review is necessary. - Other duties as assigned. Minimum Qualifications - HS diploma or GED is required - 4 years of Pharmacy Experience - CPT/ExCPT/LPT/PTCB/RPT, Pharmacy Technician, State Requirements - Pharmacy - Must be eligible to work in the United States without the need for work visa or residency sponsorship Additional Qualifications - Must have an active pharmacy technician licensure or registration in accordance with state requirements. - If state does not require an exam for licensure/registration, must possess both active pharmacy technician licensure or - registration in accordance with state requirements AND an active national certification (e.g., PTCB or ExCPT). - In states that do not require licensure or registration, must have an active national certification (e.g., PTCB or ExCPT). - Minimum of 2 years of pharmacy experience without a Bachelors degree OR 2 years of pharmacy experience with a - Bachelors degree in Science, Health, Medical or related field. - Specialty or retail pharmacy experience, previous reimbursement experience, and/or working in a health plan/health care setting. - Experience as Pharmacy Technician, Utilization Management or Customer Service in a high-volume, multi-functional call center environment. - Must be comfortable with using computers and the internet; basic skills with Microsoft office products and ability to quickly learn proprietary systems, typing. - Strong team orientation with respect for all members. - Excellent verbal and written communications skills. - People skills are essential that allow for the successful consultation with physicians, prescribers and pharmacists and for successful collaboration with company employees and external vendors who do not directly report to this position. - Analytic skills which can translate into practical and pragmatic recommendations. - In-depth knowledge of specialty injectable prescription drugs, disease states, health plan formulary management techniques and medical terminology. Preferred Qualifications - Oncology pharmacy or other clinical pharmacy experience. - 4 years of pharmacy experience Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their job, and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures Every employee must be able to perform the essential functions of the job and, if requested, reasonable accommodations will be made to enable employees with disabilities to perform the essential functions, absent undue hardship. In addition, Prime retains the right to change or assign other duties to this job. Potential pay for this position ranges from $23.08 - $37.02 based on experience and skills. To review our Benefits, Incentives and Additional Compensation, visit our Benefits Page and click on the "Benefits at a glance" button for more detail (https://www.primetherapeutics.com/benefits). Prime Therapeutics LLC is proud to be an equal opportunity and affirmative action employer. We encourage diverse candidates to apply, and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sex (including pregnancy), national origin, disability, age, veteran status, or any other legally protected class under federal, state, or local law.   We welcome people of different backgrounds, experiences, abilities, and perspectives including qualified applicants with arrest and conviction records and any qualified applicants requiring reasonable accommodations in accordance with the law. Prime Therapeutics LLC is a Tobacco-Free Workplace employer. Positions will be posted for a minimum of five consecutive workdays.