Nurse Extern II Job at Advocate Health Care (Aurora)

Medical Appeals/Grievance Specialist II - Registered Nurse

Responsible for utilizing clinical acumen and managed care expertise related to ...

Location

United States , Phoenix

Salary:

Not provided

Blue Cross Blue Shield of Arizona

Expiration Date

Until further notice

Requirements

1 year experience in clinical and health insurance or other healthcare related field
3 years experience in clinical and health insurance or other healthcare related field AND 1 year Managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
5 years experience in clinical and health insurance or other healthcare related field AND 2 years Managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
8 years experience in clinical and health insurance or other healthcare related field AND 3 years above satisfactory job performance in the managed care environment with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
Associate’s Degree in a healthcare field of study or Nursing Diploma
Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) or a compact state as a Registered Nurse (RN), a Physical Therapist (PT) or a Licensed Master Social Worker LMSW.
Intermediate PC proficiency
Intermediate skill using office equipment, including copiers, fax machines, scanner and telephones
Maintain confidentiality and privacy
Advanced clinical knowledge

Job Responsibility

Perform in-depth analysis, clinical review and resolution of provider appeals/inquiries, corrected claims and subscriber reconsiderations, member appeals, corrected claims and provider grievances for all lines of business
Identify, research, process, resolve and respond to customer inquiries primarily through written / verbal communication.
Respond to a diverse and high volume of health insurance appeal related correspondence on a daily basis.
Analyze medical records and apply medical necessity criteria and benefit plan requirements to determine the appropriateness of appeal, grievance and reconsideration requests.
Maintain complete and accurate records per department policy.
Meet quality, quantity and timeliness standards to achieve individual and department performance goals as defined within the department guidelines and required by State, Federal and other accrediting organizations.
Demonstrate ability to apply plan policies and procedures effectively.
Consult and coordinate with various internal departments, external plans, providers, businesses, and government agencies to obtain information and ensure resolution of customer inquiries.
Attend staff and interdepartmental meetings.
Participate in continuing education and current developments in the fields of medicine and managed care.

Fulltime

Utilization Management Nurse Specialist RN II

The Utilization Management Nurse Specialist RN II facilitates, coordinates, and ...

Location

United States , Los Angeles

Salary:

88854.00 - 142166.00 USD / Year

L.A. Care Health Plan

Expiration Date

Until further notice

Requirements

Associate's Degree in Nursing
At least 5 years of varied RN clinical experience in an acute hospital setting
At least 2 years of Utilization Management/Case Management experience in a hospital or HMO setting
Registered Nurse (RN) - Active, current and unrestricted California License
Must be computer literate, with expertise in Outlook, Word, Excel, PowerPoint
Provision of excellent customer service required
Excellent time management and priority-setting skills
Maintains strict member confidentiality and complies with all HIPAA requirements
Strong verbal and written communication skills

Job Responsibility

Facilitates, coordinates, and approves medically necessary referrals that meet established criteria
Assures timely and accurate determination and notification of referrals and reconsiderations
Generates approval, modification and denial communications
Actively monitors for admissions in any inpatient setting
Performs telephonic and/or onsite admission and concurrent review
Collaborates with onsite staff, physicians, providers, member/family to develop and implement a successful discharge plan
Works with the UM Manager and Physician Advisor on case reviews
Monitors and oversees the collection and transfer of data (medical records) and referral requests by Providers
Acts as a department resource for medical service requests /referral management and processes
Receives incoming calls from providers, professionally handles complex calls

What we offer

Paid Time Off (PTO)
Tuition Reimbursement
Retirement Plans
Medical, Dental and Vision
Wellness Program
Volunteer Time Off (VTO)

Fulltime

Clinical Practice Nurse II

At Kaiser Permanente our nurses are leaders, clinicians, researchers, innovators...

Location

United States , San Diego

Salary:

171000.00 - 198000.00 USD / Year

Kaiser Permanente

Expiration Date

Until further notice

Requirements

Minimum two (2) years of leadership experience in nursing and or healthcare related field with or without direct reports
Bachelors degree in nursing or related field AND minimum four (4) years of experience in direct patient care or a directly related field
Registered Nurse License (California) required at hire

Job Responsibility

Provides consultation and leadership in designated areas of expertise independently
Collaborates with interdisciplinary teams and stakeholders to address issues and achieve project objectives
Coordinates advanced knowledge and best practices with peers and staff, serving as a role model to support a culture continuous learning
Guides regulatory compliance by using advanced knowledge of state, federal, and agency requirements to support and conduct complex audits, investigations, and chart reviews to identify compliance issues and implement plans
Implements and develops policies, procedures, protocols, and educational programs to maintain compliance and address deficiencies
Provides consultation, designs, and delivers training sessions, seminars, and workshops for staff and practitioners
Mentors and coaches staff on policies, procedures, protocols, educational programs, and best practices
Identifies and explores innovation opportunities in care delivery models and workflows
Engages independently with internal and external stakeholders to facilitate collaboration and achieve project objectives
Implements policies, procedures, and standards while providing recommendations for improvement

What we offer

Medical, Vision & Dental
Retirement Plans
Educational Opportunities & Tuition Reimbursement
Supportive Teams & Resources
Career Growth & Development

Fulltime

Care Management Specialist II, D-SNP Team

The Care Management Specialist II utilizes clinical skills and training to perfo...

Location

United States , Los Angeles

Salary:

88854.00 - 142166.00 USD / Year

L.A. Care Health Plan

Expiration Date

Until further notice

Requirements

Associate's Degree in Nursing for Registered Nurses OR Master's Degree in Social Work for Licensed Clinical Social Workers
Minimum of 3 years of recent care management experience with responsibilities of managing complex acute or chronic conditions in collaboration with members and interdisciplinary care professionals in a hospital, medical group or managed care setting, such as a health insurance environment and/or experience as care manager in home health or hospice environments
Experience providing care management with complex/catastrophic conditions
Current knowledge of clinical standards of care and disease processes
Critical thinking skill
Excellent customer service skills
Ability to clinically analyze the most complex cases involving highly acute physical health, behavioral health, complex/catastrophic and/or psychosocial issues to determine and implement the most effective member-centered interventions
Ability to triage immediate member health and safety risks
Ability to sensitively manage member or family responses associated with high acuity cases and support effective coping
Strong verbal and written communications skills to consult effectively with interdisciplinary teams, coordinate care with members and their families, and other internal and external stakeholders

Job Responsibility

Utilizes clinical skills and training to perform essential functions of care management for identified and assigned member population according to Health Insurance Portability and Accountability Act (HIPAA) guidelines
Manages a specified caseload across the entire continuum of programmatic levels including those within National Committee for Quality Assurance (NCQA) scope or otherwise Complex/Catastrophic cases
Management of the caseload assigned by Manager includes: coordinating health care benefits, providing education and facilitating member access to care in a timely and cost-effective manner
Collaborates and communicates with member, family, and interdisciplinary health team to promote wellness and member empowerment, while ensuring access to appropriate services across the healthcare continuum and maximizing member benefit
Serves as clinical advocate for members, active interdisciplinary team member, liaison with other departments and external health care team
Provides direction and assistance to Care Coordinators and to Community Health Workers (CHW) of members needs including the need for special educational mailings, reminder calls, satisfaction surveys, incentives or any additional service needs according to specific program guidelines
Uses claims processing and care management software to look up member information, document contacts, and track member progress
Applies clinical knowledge and experience to evaluate information regarding prospective care management members referred by health risk assessment (HRA), risk stratification, predictive modeling, provider’s utilization review vendors, members, Call Center, claims staff, Health Homes Program (HHP) eligibility or other data sources to determine whether care management intervention is necessary to meet the member's needs
Conducts Care Management services for the most complex and vulnerable members including: engaging in member centric communication which includes the interdisciplinary team, providers and family or authorized representatives
reviewing member claims histories and identifies intervention opportunities through the professional standards of practice

What we offer

Paid Time Off (PTO)
Tuition Reimbursement
Retirement Plans
Medical, Dental and Vision
Wellness Program
Volunteer Time Off (VTO)

Fulltime

Surgical Scheduler II

Under general supervision and following established policies and procedures, coo...

Location

United States , Boston

Salary:

21.47 - 33.55 USD / Hour

Boston Children's Hospital

Expiration Date

Until further notice

Requirements

High School Diploma/GED
Minimum 2 years of healthcare admin experience
1 year of direct surgical scheduling experience required for external candidates
Analytical skills to gather and interpret data in situations in which the information or problems are relatively routine
The ability to communicate effectively both orally and in writing and provide empathy in difficult interpersonal situations

Job Responsibility

Schedules inpatient and ambulatory surgical procedures for operating rooms according to predetermined block schedules and established policies and procedures
Prepares complete daily surgical schedules, including special equipment requirements and incorporating radiology and other non-surgical use of operating room facilities
Communicates with surgeons, secretarial staff, and admissions personnel to obtain needed information, coordinate and confirm schedules and identify special requirements for procedures
Notifies all referring physicians of upcoming procedures and surgeries
Identifies additional OR time for surgeon separate and apart from block time as needed
Records and compiles scheduling information on hospital and departmental computer systems
Reviews and verifies accuracy of basic patient information
Prints and distributes schedules to designated areas of the program
Identifies and communicates critical information, such as surgeon and physician availability, and special supply and equipment requests, to nursing and other appropriate staff, as necessary
Works with nursing, surgical, and anesthesiology staff to monitor and evaluate scheduling procedures and develop strategies to promote efficient utilization of surgical suites

What we offer

flexible schedules
affordable health, vision and dental insurance
child care and student loan subsidies
generous levels of time off
403(b) Retirement Savings plan
Pension
Tuition and certain License and Certification Reimbursement
cell phone plan discounts
discounted rates on T-passes

Fulltime

Flight Nurse

The primary focus of a Flight Nurse is to provide advanced life support to reduc...

Location

United States

Salary:

Not provided

Pafford EMS

Expiration Date

Until further notice

Requirements

Current licensure to practice in the State of Arkansas and Oklahoma
Minimum of two years current staff nursing experience (within the last 5 years)
Minimum two years critical care/emergency department experience in an intensive care or emergency department setting at a Level I or II trauma center or regional referral/tertiary care center
Ability to demonstrate critical thinking skills and autonomous practice
Demonstrated leadership abilities
Demonstrated problem solving skills and independent decision making
Demonstrated outstanding interpersonal skills
Current Nursing licensure with state licensure achieved in 6 mos
Current ACLS/PALS/NRP certification
Ability to safely and successfully perform the essential job functions

Job Responsibility

Autonomously evaluate critically ill or injured patients of all age groups, provide therapeutic intervention, emergency interventions, and preparation for transport
Provide patient care within the policies, protocols and guidelines
Assess for and detect changes in the status of patients
Maintain complete and accurate records, participate in unit quality assurance programs, perform data collection and participate in research activities
Communicate effectively in working with outside institutions/agencies
Plan, organize and position equipment and supplies for use in emergency conditions
Maintain contact with patients, families and referring facility personnel
Participate in clinical instruction for internal and external groups
Collect, compile and assess clinical and demographic data
Maintain clinical competence across all aspects of the scope of practice

Clinical Research Associate II

As a Clinical Research Associate (CRA) at Parexel, you act as an integral part t...

Location

India , Bengaluru

Salary:

Not provided

Parexel

Expiration Date

Until further notice

Requirements

Substantial start up experience or equivalent experience in clinical research, with understanding of clinical trials methodology and terminology
Educated to degree level (biological science, pharmacy, or other health-related discipline preferred) or equivalent nursing qualification or other equivalent experience
Demonstrate strong problem-solving skills
Able to take initiative and work independently, and to proactively seek guidance when necessary
Excellent presentation skills
Client focused approach to work
Ability to interact professionally within a client organization
Flexible attitude with respect to work assignments and new learning
Ability to prioritize multiple tasks and achieve project timelines
utilizing strong analytical skills to make decision autonomously due to the unpredictable nature of the issues that arise

Job Responsibility

Act as Parexel’s direct point of contact with assigned sites, accountable for quality and delivery during the start-up phase
Build relationships with investigators and site staff
Support on request country specific feasibility and/or site pre-qualification and qualification activities
Manage country and site level TMF issues ensuring documents’ First Time Quality (FTQ) as well as providing direct resolution to reported site problems
Develop strategy to configure, distribute, collect, and review and approve, high quality country specific and/or site specific documents or essential regulatory documents
Customize, review, and negotiate as needed, country/site specific Informed Consent Forms (ICF), translations, and customize and negotiate any amendments
Prepare and submit IRB/IEC and MoH/RA (if applicable) application(s), resolving conflicts, determining appropriate follow up until receipt of final approval
Submit all pertinent documentation to the trial master file as per project plans/sponsor/company policy
Forecast, develop, manage, and revise plans and strategies for IRB/IEC and MoH / RA submission/approval and Site activation
Update and maintain appropriate Clinical Trial Management System (CTMS) in a timely manner

What we offer

Patient-focused in everything we do
Supportive and inclusive environment
Career growth and development
Flexible work arrangements
Diverse therapeutic areas and project exposure
Advanced Technology

New

Certified Occupational Therapy Assistant

Certified Occupational Therapy Assistant position in Home Care Occupational Ther...

Location

United States , Waukesha/Jefferson Counties

Salary:

26.55 - 39.85 USD / Hour

Advocate Health Care

Expiration Date

Until further notice

Requirements

Graduate of an AOTA approved Occupational Therapy Assistant Program
Successful completion of two month supervised Level II fieldwork experience
Successful completion of certification process
Current AOTA Certification
Current IL/WI licensure or obtain IL licensure within 90-days of hire
Current CPR Certification
Basic Life Support (BLS) for Healthcare Providers certification issued by the American Heart Association (AHA) needs to be obtained within 6 months unless department leader has determined it is not required
A valid driver’s license issued by the Division of Motor Vehicles
Completion of fieldwork/program requirements
Ability to lift up to 35 pounds without assistance

Job Responsibility

Implementation of Occupational Therapy treatment programs for patients with multiple and specialized diagnoses safely and effectively, as planned, in conjunction with OTR
Performs therapy treatment programs on inpatients and/or outpatients
Instructs patients and patients' families in home programs and provide education as needed
Trains patients in ADL skills and use of ADL equipment
Monitors patient response to treatment modifying as necessary
Follows established procedure and safety precautions in the application and use of modalities
Acts as an assistant to the OTR when the OTR is performing tests, evaluation, and treatment procedures
Conferences with physicians and other allied health professionals to make recommendations for occupational therapy treatment programs
Schedules patients according to need/priority
Maximizes support personnel by delegating as appropriate

What we offer

Paid Time Off programs
Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
Flexible Spending Accounts for eligible health care and dependent care expenses
Family benefits such as adoption assistance and paid parental leave
Defined contribution retirement plans with employer match and other financial wellness programs
Educational Assistance Program

Fulltime

Nurse Extern II

Advocate Health Care

Location:
United States , Aurora

Category:
Nursing

Contract Type:
Not provided

Salary:

Job Description:

Job Responsibility:

Requirements:

Additional Information:

Job Posted:
February 01, 2026

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Medical Appeals/Grievance Specialist II - Registered Nurse