This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description Acentra Health is looking for a Clinical Supervisor - RN - Full-time to join our growing team. As the Clinical Supervisor, this individual plays a pivotal role in overseeing and managing the Utilization Management (UM) activities within the organization. - Ensure UM processes are executed efficiently, consistently, and in alignment with regulatory and contractual standards. - Uphold excellence in clinical programs, fostering continuous improvement and innovation in care management practices. - Cultivate and maintain strong relationships with customers and stakeholders, ensuring service delivery meets or exceeds expectations. - Oversee direct reports and participate in a rotating schedule that includes weekends and holidays. This position is remote U.S. Working hours between 8:00 a.m. and 6:00 p.m. EST, with rotational evenings, weekends, and holidays as required. - Lead and oversee all UM activities including prior authorization and retrospective reviews. - Conduct utilization reviews as needed to support workload demands and program requirements. - Monitor daily work queues and adjust staffing schedules to align with departmental demands. - Evaluate productivity and performance metrics of nurse reviewers. - Identify onboarding and ongoing learning needs for Clinical Reviewers. - Participate in leadership meetings, committees, and cross-functional workgroups. - Oversee quality assurance activities such as audits and Quality Improvement Plans (QIPs). - Identify areas for process and clinical improvements and develop action plans. - Serve as a liaison to customers and providers. - Stay current with clinical best practices and UM protocols. - Support departmental and organizational goals by performing additional duties as assigned. - Read, understand, and adhere to all corporate policies, including HIPAA policies. Qualifications - Active, unrestricted Registered Nurse (RN) license in the state of Indiana or a valid compact state license. - Associate degree or equivalent experience directly applicable to clinical practice. - A minimum of 5+ years of experience as a practicing RN. - A minimum of 5+ years of supervisory experience in a healthcare setting with at least 2+ years in Utilization Management. - A minimum of 2+ years of experience applying InterQual and/or MCG clinical criteria in utilization review processes. - Strong verbal and written communication skills. - Demonstrated customer-centric approach. - Excellent organizational and time management skills. - Proven ability to work independently and collaboratively. - Proficiency in Microsoft Office Suite and other relevant software applications. Requirements - Working hours between 8:00 a.m. and 6:00 p.m. EST, with rotational evenings, weekends, and holidays as required. Benefits - Comprehensive health plans. - Paid time off. - Retirement savings. - Corporate wellness. - Educational assistance. - Corporate discounts. - And more.

Company : Highmark Inc.Job Description : JOB SUMMARY This job works directly with providers in a variety of health care settings to appropriately identify members with chronic conditions and/or gaps in care that can be positively impacted related to quality and care costs. The incumbent's responsibilities could include working in a physician’s office, visiting physician practices on a routine basis, working within a hospital setting and/or assessing and coordinating member’s care within the member’s home. Helps members to coordinate care and navigate the healthcare system by recommending and/or implementing interventions related to the improvement of medical care and costs. ESSENTIAL RESPONSIBILITIES - Conduct member-facing clinical assessments that address the health and wellness needs of members using a broad set of clinical and motivational interviewing skills with the goal of impacting members’ self-management skills and positive behavior changes which will ultimately positively impact member satisfaction and care costs. - Serve as a subject matter expert to both internal and external sources (e.g. providers, regulatory agencies, UM and policy.) to provide education, consultation and training when indicated. - Serve as a resource to guide, mentor and counsel others in regard to understanding the drivers of health care costs to improve member outcomes related to Plan benefits and resources. - Collaborate, coordinate and communicate with the member’s treating provider(s) in more complex clinical situations requiring clinical and psychosocial intervention. - Develop/implement case or condition-specific plans of care and/or intervention plan, as needed, that can become a part of the member’s EMR or medical record to establish short and long-term goals. - Establish a plan for regular contact (face-to-face as often as possible) with each member and/or provider to monitor progress toward goals, provide additional education and evaluate the need for modification or change in the plan of care. - Proactively incorporate lifestyle improvement opportunities and preventive care into member interactions and coaching. - Collaborate with the appropriate individuals to offer solutions to refine and improve existing practices or participates in developing performance improvement processes that will enhance member outcomes and operational performance/excellence as well support all strategic initiatives including Health Care Reform and STARS initiatives. - Work with providers related to performance measures and activities to educate and influence the behavior of members and providers. - Ensure that all activities are documented and conducted in compliance with applicable business process requirements, regulatory requirements and accreditation standards that support all lines of business. - Other duties as assigned or requested. QUALIFICATIONS Required - Current State of PA RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC).and/or additional states as required or current Social Work license - 4 years of any combination of clinical, case management and/or disease/condition management, long-term care, home health, hospice, public health, assisted living, provider operations and/or health insurance experience - Clearances as required by specific practice or hospital, as applicable Substitutions - None Preferred - Certification in Case Management (CCM) - BSN or Bachelor’s degree in Social Work or in health, human, or education services - 5 years of any combination of clinical, case management and/or disease/condition management, long-term care, home health, hospice, public health, assisted living, provider operations, and/or health insurance experience Skills - Ability to work in a virtual environment (e.g., provider offices, facilities and/or member’s homes); accomplishing and coordinating work remotely - Proficiency in MS Excel and enhanced data and statistical analysis skills - Excellent interpersonal/ consensus building skills as well as the ability to work with a variety of internal and external colleagues from all levels of an organization - Broad knowledge of the health care delivery system including an understanding of health care costs drivers - Excellent verbal and written communication skills including individual and/or group education/training - Experience working with the healthcare needs of diverse populations and understanding the importance of cultural competency in addressing targeted populations. - Self-directed; self-starter; ability to work successfully with indirect supervision and moderate autonomy - Excellent organizational, time management and project management skills - Ability to work in a fast paced, high visibility, high performing team environment that requires flexibility - Ability to travel locally and work flexible hours in a practice or facility-based settings - Ability to communicate effectively in more than one language, preferred - Experience working directly with physicians in provider practice settings, members in a home environment or hospital discharge processes. Language (Other than English): None Travel Requirement: 0% - 25% PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS Position Type Office-based Teaches / trains others regularly Occasionally Travel regularly from the office to various work sites or from site-to-site Occasionally Works primarily out-of-the office selling products/services (sales employees) Never Physical work site required Yes Lifting: up to 10 pounds Constantly Lifting: 10 to 25 pounds Occasionally Lifting: 25 to 50 pounds Occasionally Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job. Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies. As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements. Pay Range Minimum: $50,200.00 Pay Range Maximum: $91,200.00 Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets. Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law. We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below. For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org California Consumer Privacy Act Employees, Contractors, and Applicants Notice

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. Schedule: Mon–Fri, 8am–5pm PT Daily volume: 17–20 concurrent reviews/day Training: 4/5 weeks Ramp-up: 12 weeks, 0 → 20 cases, with preceptor support. - RN + UM experience; managed care/health plan/hospital UM background. - Review hospital requests for payment approval and determine authorization for a defined number of inpatient days - California RN license required Position Purpose: Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member. - Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care - Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member - Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered - Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines - Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings - Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members - Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines - Reviews member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities - Collaborates with care management on referral of members as appropriate - 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. 2+ years of acute care experience required. Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. License/Certification: For Health Net of California: RN license required 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

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description We are looking for a passionate, versatile nurse to join Trovo as a foundational member of our clinical operations team. This is a broad-scope “utility player” role for a clinician who is equally comfortable performing hands-on care management work, collaborating with product and engineering teams to refine automated technology workflows, and coaching staff on quality and clinical standards. You will work across Trovo’s full portfolio of care team agents, supporting everything from chronic condition management and care gap outreach to complex prior authorizations and clinical documentation improvement. In this role, you will serve as an expert-in-the-loop: the clinical voice that ensures we deliver safe, high-quality care at scale. - Deliver high-impact clinical work: Perform care management outreach, chronic condition follow-ups, care gap closure, and other clinical activities powered by Trovo’s AI platform. - Support complex clinical operations workflows: Review prior authorizations, appeals, and other clinical-administrative tasks that require human clinical judgment. - Partner with product and engineering: Serve as a clinical subject matter expert, participating in workflow design sessions, testing new agent capabilities, identifying edge cases, and providing feedback. - Provide quality oversight: Conduct quality audits of clinical operations activities, identify trends in errors or gaps, and develop remediation plans. Maintain and evolve quality scorecards and clinical rubrics. - Develop clinical content and coach staff: Build the clinical protocols, scripts, and decision-support content that power Trovo’s AI agents, and onboard and train clinical team members on Trovo's platform, workflows, and quality standards. Qualifications - Active clinical licensure: Current RN, NP, or equivalent clinical license in good standing. Multi-state or Compact licensure is a plus. - Strong clinical experience: 5+ years spanning direct patient care and virtual or telephonic care delivery, with meaningful exposure to care management, utilization management, prior authorization, or population health workflows. - Healthtech experience: Prior experience in a healthtech company, venture-backed startup, health plan, or technology-enabled clinical services organization. - Quality mindset and entrepreneurial approach: You are detail-oriented, comfortable delivering constructive feedback, and energized by early-stage environments where you’re creating processes from the ground up. Location This role may be remote or hybrid. NYC-based candidates are a plus. Compensation Target compensation for this role is $100 – $150k+, plus a generous benefits package. Compensation within this range will depend on experience, licensure level, and scope of responsibilities. Equal Opportunity Employer Trovo Health is an equal opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all employees. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.