You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. Centene is hiring a Remote Clinical Review Nurse – Prior Authorization to support our Duals team. The ideal candidate will have experience reviewing outpatient services, with a background in one or more of the following areas: - Imaging services - Durable Medical Equipment (DME) - Home Health Care - Elective inpatient services - Multi-State nursing license This role is responsible for conducting clinical reviews for prior authorization requests in accordance with medical necessity guidelines, regulatory requirements, and company policies. This is a remote position with standard business hours, Monday through Friday, 8:00 AM–5:00 PM. Candidates must reside and work within the Mountain or Pacific time zones. This role may also require flexibility for weekend, holiday, and on-call coverage. An alternative schedule of Sunday through Thursday, 9:00 AM–6:00 PM may be required based on business needs. Position Purpose: Analyzes all prior authorization requests to determine medical necessity of service and appropriate level of care in accordance with national standards, contractual requirements, and a member's benefit coverage. Provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care. - Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria - Works with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care - Coordinates as appropriate with healthcare providers and interdepartmental teams, to assess medical necessity of care of member - Escalates prior authorization requests to Medical Directors as appropriate to determine appropriateness of care - Assists with service authorization requests for a member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities - Collects, documents, and maintains all member’s clinical information in health management systems to ensure compliance with regulatory guidelines - Assists with providing education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care to members - Provides feedback on opportunities to improve the authorization review process for members - Performs other duties as assigned - Complies with all policies and standards Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience. Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. License/Certification: - LPN - Licensed Practical Nurse - State Licensure required Pay Range: $27.02 - $48.55 per hour 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

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary This is a remote work from home role anywhere in the US with virtual training. American Health Holding, Inc (AHH) is a medical management company that is a division within Aetna/CVS Health. Founded in 1993, AHH is URAC accredited in Case Management, Disease Management and Utilization Management. AHH delivers flexible medical management services that support cost-effective quality care for members. Key Responsibilities - This position consists of working intensely as a telephonic case manager with patients and their care team for fully and/or self-insured clients. - Application and/or interpretation of applicable criteria and clinical guidelines, standardized care management plans, polices, procedures and regulatory standards while assessing benefits and/or member’s needs to ensure appropriate administration of benefits. - Applies clinical judgment to the incorporation of strategies designed to reduce risk factors and barriers and address complex health and social indicators which impact care planning and resolution of member issues. - Assessments utilize information from various sources to address all conditions including co-morbid and multiple diagnoses that impact functionality. - Consults with supervisor and others in overcoming barriers in meeting goals and objectives, presents cases at case conferences for multidisciplinary focus to benefit overall claim management. - Using a holistic approach, consults with clinical colleagues, supervisors, Medical Directors and/or other programs to overcome barriers to meeting goals and objectives. - Utilizes case management processes in compliance with regulatory and company policies and procedures. - Utilizes motivational interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversations. - Identifies and escalates member’s needs appropriately following set guidelines and protocols. - Need to actively reach out to members to collaborate/guide their care. - Perform medical necessity reviews. Required Qualifications - 5+ years’ experience as a Registered Nurse with at least 1 year of experience in a hospital setting. - The AHH RN Case manager position requires the nurse to support members across multiple states. A RN who resides in a compact state is required to have an active multistate license through the Nurse Licensure Compact (NLC), allowing practice across participating states with one license. Nurses residing in non‑compact states must hold an individual, state‑specific RN license for each state they support. - 1+ years’ experience documenting electronically using a keyboard. - 1+ years’ current or previous experience in Oncology, Transplant, Specialty Pharmacy, Pediatrics, Medical/Surgical, Behavioral Health/Substance Abuse or Maternity/ Obstetrics experience. Preferred Qualifications - 1+ years’ Case Management experience or discharge planning, nurse navigator or nurse care coordinator experience as well as experience with transferring patients to lower levels of care. - 1+ years' experience in Utilization Review. - CCM and/or other URAC recognized accreditation preferred. - 1+ years’ experience with MCG, NCCN and/or Lexicomp. - Bilingual in Spanish preferred. Education - Diploma or Associates Degree in Nursing required. - BSN preferred. Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $54,095.00 - $155,538.00 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: - Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan. - No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. - Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits This job does not have an application deadline, as CVS Health accepts applications on an ongoing basis. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

Summary Performs medical reviews using established criteria sets and/or performs utilization management of professional, inpatient or outpatient, facility benefits or services, and appeals. Documents decisions using indicated protocol sets or clinical guidelines. Provides support and review of medical claims and utilization practices. Description Position Purpose: Performs medical reviews using established criteria sets and/or performs utilization management of professional, inpatient or outpatient, facility benefits or services, and appeals. Documents decisions using indicated protocol sets or clinical guidelines. Provides support and review of medical claims and utilization practices. Logistics: PGBA - one of BlueCross BlueShield of South Carolina's subsidiary companies. Government Clearance: This position requires ability to obtain a security clearance, which requires applicants to be a U.S. Citizen. What You'll Do: - May provide any of the following in support of medical claims review and utilization review practices: Performs medical claim reviews and makes a reasonable charge payment determination. Monitors process's timeliness in accordance with contractor standards. Performs authorization process, ensuring coverage for appropriate medical services within benefit and medical necessity guidelines. - Utilizes allocated resources to back up review determination. Reviews interdepartmental requests and medical information in a timely/effective manner in order to complete utilization process. May conduct/perform high dollar forecasting research and formulate overall patient health summaries with future health prognosis and projected medical costs. Performs screenings/assessments and determines risk via telephone. - Reviews/determines eligibility, level of benefits, and medical necessity of services and/or reasonableness and necessity of services. Provides education to members and their families/caregivers. Reviews first level appeal and ensures utilization or claim review provides thorough documentation of each determination and basis for each. Conducts research necessary to make thorough/accurate basis for each determination made. - Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines. Responds accurately and timely with appropriate documentation to members and providers on all rendered determinations. - Participates in quality control activities in support of the corporate and team-based objectives. Participates in all Required Licenses and Certificates. To Qualify For This Position, You'll need the - Required Education: Bachelor's degree - Social Work, OR, Graduate of an Accredited School of Licensed Practical Nursing or Licensed Vocational Nursing. - Required Experience: 2 years clinical experience. - Required Skills and Abilities: Working knowledge of word processing software. Good judgment skills. Demonstrated customer service and organizational skills. Demonstrated proficiency in spelling, punctuation, and grammar skills. Analytical or critical thinking skills. Ability to handle confidential or sensitive information with discretion. Ability to remain in a stationary position and operate a computer. - Required Software and Tools: Microsoft Office - Required Licenses and Certificates: Active, unrestricted LPN/LVN licensure from the United States and in the state of hired, OR, active compact multistate unrestricted LPN license as defined by the Nurse Licensure Compact (NLC), OR, active, unrestricted LBSW (Licensed Bachelor of Social Work) licensure from the United States and in the state of hire. We Prefer that You have the Following: - Preferred Education: Associate Degree- Nursing OR Graduate of an Accredited School of Nursing. - Preferred Skills and Abilities: Working knowledge of spreadsheet and database software. Demonstrated oral and written communication skills. Ability to persuade, negotiate, or influence others. - Preferred Software and Others Tools: Knowledge of Microsoft Excel, Access, or other spreadsheet/database software. - Preferred Licenses and Certificates: Active, unrestricted RN licensure 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). Our Comprehensive Benefits Package Includes The following: We offer our employees great benefits and rewards. You will be eligible to participate in the benefits the first of the month following 28 days of employment. - Subsidized Health plans, dental and vision coverage - 401k retirement savings plan with company match - Life Insurance - Paid Time Off (PTO) - On-site cafeterias and fitness centers in major locations - Education Assistance - Service recognition - National discounts to movies, theaters, zoos, theme parks and more What We Can Do For You: We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company. What to Expect Next: After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with our recruiter to verify resume specifics and salary requirements. 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.

Overview: We seek a Patient Education Liaison (PEL) to support AMVUTTRA® (vutrisiran). The U.S. Food and Drug Administration (FDA) recently approved the supplemental New Drug Application (sNDA) for AMVUTTRA® (vutrisiran). The approval expands the indication for AMVUTTRA, which now becomes the first and only therapeutic approved by the FDA for the treatment of ATTR-CM and the polyneuropathy of hereditary transthyretin-mediated amyloidosis (hATTR-PN) in adults. The PEL is a critical component of the product brand commercial strategy and works in close coordination with Field Sales, Field Reimbursement, Patient Services, Advocacy, and Marketing teams to support Alnylam’s patient-focused vision of harnessing a revolution in biology for human health. The Patient Education Liaison is responsible for educating patients, caregivers, families, nurses, medical assistants, office staff, professional nursing organizations, and pertinent community groups on disease state and Alnylam’s RNAi treatments for all Alnylam brands. Using approved materials, the Patient Education Liaison will educate on the disease state, Alnylam treatments, and Alnylam’s services, through phone-based, in-person, and virtual meetings. Central to this role is the ability to work with regional, field-based and internal colleagues to identify barriers to patient access and work to resolve them. The successful candidate must be passionate about science and deeply motivated by the quest of delivering education to patients and their families with the long-term success of the company in mind. The ideal candidate will be a self-motivated, self-starter with an innovative, entrepreneurial spirit. Key Responsibilities: - Actively collaborates with Field Sales, Patient Services, Medical Affairs, Marketing, Advocacy and other critical internal teams to increase disease-state awareness and early diagnosis - Leads regional effort to provide disease-state education, treatment education and support to patients their families/caregivers, nurses, medical assistants, office staff, nursing organizations, and community groups - Maintains disease-state and product expertise through continuing medical education and attendance at relevant symposia, conferences and other educational opportunities - Provides comprehensive updates on activity to PEL Lead and regional colleagues, ensuring that the regional team appropriately works as one entity to support patients in early diagnosis and access to treatment - Accountable for executing on targeted workplan - Completes required work in CRM system to facilitate tracking of critical launch metrics - Ensures compliance with all corporate and industry policies with training provided by Alnylam Commercial, Legal, Regulatory and Compliance Officers Qualifications: - Bachelor of Science in Nursing, Registered Nurse (required) - 2+ yrs. Pharmaceutical/biotech experience in a similar role - Experience supporting and providing education to patients, family members, nurses, medical assistants, office staff, nursing organizations, and community groups - Strong presentation skills - Cardiology experience preferred - Exceptional interpersonal skills, professional communications, problem-solving, compassion and the ability to navigate difficult conversations - Ability to translate scientific/medical information into patient-friendly language - Ability to work well and lead within cross-functional groups and in a matrix organization - Desire to innovate and work in a fast-paced, energetic environment - Self-starter who is highly passionate about Alnylam’s core values: Commitment to People, Fiercely Innovative, Open Culture, Passion for Excellence, and Purposeful Urgency. - This position requires frequent travel within the region and at times nationally. Includes overnight travel and weekends. - Must be able to travel up to 75% - Valid Driver’s License #LI-ST1 #LI-Remote U.S. Pay Range $136,000.00 - $184,000.00 The pay range reflects the full-time base salary range we expect to pay for this role at the time of posting. Base pay will be determined based on a number of factors including, but not limited to, relevant experience, skills, and education. This role is eligible for an annual short-term incentive award (e.g., bonus or sales incentive) and an annual long-term incentive award (e.g., equity). Alnylam’s robust Total Rewards package is designed to support your overall health and well-being. We offer comprehensive benefits including medical, dental, and vision coverage, life and disability insurance, a lifestyle reimbursement program, flexible spending and health savings accounts and a 401(k)with a generous company match. Eligible employees enjoy paid time off, wellness days, holidays, and two company-wide recharge breaks. We also offer generous family resources and leave. Our commitment to your well-being reflects our belief that caring for our people fuels the impact we create together. Learn more about these and additional benefits offered by Alnylam by visiting the Benefits section of the Careers website: https://www.alnylam.com/careers About Alnylam We are the leader in RNAi therapeutics – a revolutionary approach with the potential to transform the lives of people with rare and common diseases. Built on Nobel Prize-winning science, Alnylam has delivered the breakthroughs that made RNAi therapeutics possible and are just at the beginning of what’s possible. Our deep pipeline, late-stage programs, and bold vision reflect our core values: fierce innovation, passion for excellence, purposeful urgency, open culture and commitment to people. We're proud to be a globally recognized top employer, where an authentic, inclusive culture and breakthrough thinking fuel one another. At Alnylam, we commit to an inclusive recruitment process and equal employment opportunity. Qualified applicants will receive consideration for employment without regard to their sex, gender or gender identity, sexual orientation, race, color, ethnicity, national origin, ancestry, citizenship, religion, creed, physical or mental disability, pregnancy status or related conditions, genetic information, veteran or military status, marital or familial status, political affiliation, age, or any other factor protected by federal, state, or local law. Alnylam is an E-Verify Employer.