Entry Level Utilization Review Nurse Jobs in Reno, NV

** This is a Hybrid role where applicants should reside within the state of Nevada to be strongly considered for this position. **

About Activate Care:

At Activate Care, we’re on a mission to improve health equity and drive improved health outcomes across the country. Our Community Care Record platform enables healthcare and community organizations to coordinate care for populations challenged with health-related social needs. Path Assist is our tech-enabled community health worker program for HRSN utilizing an evidence-based, structured intervention. Our goal is simple: increase health confidence, improve self-efficacy, and reduce inappropriate healthcare spending.

Role Overview:

The Clinical Case Manager is the senior clinical resource embedded within a team of Community Health Workers (CHWs) serving Medicaid members. While this role has no direct reports, the Clinical Case Manager is a leader on the team, providing clinical oversight, case consultation, and hands-on assistance to CHWs as they engage members and address health-related social needs. You bring licensed clinical judgment to the team's most complex and highest-risk situations, conduct assessments within your scope of practice, support care planning within an interdisciplinary care team, and serve as the escalation point when members present with behavioral health, crisis, or safety concerns. The goal is to elevate the clinical quality and safety of the team's work while building the CHWs' confidence and skills.

We are open to a range of licensed backgrounds for this role, including RN, LPN, LCSW, and LMHC, as well as experienced case managers from hospital, discharge planning, and managed care settings. Specific clinical activities are performed within each person's scope of practice.

Responsibilities:

• Serve as the embedded clinical resource for a team of CHWs
• Provide real-time case consultation, clinical guidance, and side-by-side assistance to CHWs on complex member situations.
• Own the daily clinical audit of the Transitions of Care (TOC) queue, utilizing health plan guidelines to appropriately triage complex Level 2 cases and route clean Level 1 referrals to the CHW team.
• Identify members whose needs exceed the CHW scope and step in directly or coordinate the appropriate clinical hand-off.
• Lead and represent the organization in monthly joint Level 1 and Level 2 case conferences with health plan clinical leadership.
• Coach and mentor CHWs to strengthen engagement skills, recognition of behavioral health and risk indicators, and appropriate escalation.
• Oversee the end-to-end Medicaid claims cycle for the clinical team, including pre-submission documentation reviews, code utilization tracking, and denial management.
• Identify and execute direct-billing opportunities for licensed behavioral health interventions and assessments allowable under Nevada Medicaid.
• Help develop and reinforce team workflows, clinical protocols, and best practices in partnership with leadership.
• Conduct biopsychosocial and behavioral health assessments to identify member needs, strengths, and risks.
• Provide brief, evidence-based clinical intervention (such as motivational interviewing and solution-focused techniques) and warm hand-offs to ongoing behavioral health treatment.
• Contribute clinical expertise to individualized care plans as part of the interdisciplinary care team (ICT).
• Apply trauma-informed and culturally responsive practice across a diverse, predominantly Medicaid population.
• Serve as the team's escalation point for members presenting with behavioral health, safety, or crisis concerns.
• Conduct risk assessment and coordinate appropriate crisis response, follow-up, and linkage to emergency or stabilization services.
• Support CHWs through difficult situations in the field and debrief afterward.
• Partner with CHWs to connect members to behavioral health services, community resources, and supports addressing social determinants of health, including housing, food, transportation, employment, and benefits.
• Build and maintain relationships with community-based organizations and behavioral health providers across the assigned territory.
• Coordinate with PCPs, care managers, and health-plan partners to close gaps in care.
• Maintain timely, accurate clinical documentation in the care management platform.
• Ensure work meets Medicaid, state, NCQA, and organizational clinical and privacy (HIPAA) standards.
• Contribute to quality initiatives and outcome tracking for the team.
• Other duties as assigned

Qualifications & Skills:

• Active, unrestricted Nevada license in one of the following: Registered Nurse (RN), Licensed Practical Nurse (LPN), Licensed Clinical Social Worker (LCSW), or Licensed Mental Health Counselor (LMHC).
• Degree appropriate to your licensure (for example, ASN or BSN for nursing, MSW for LCSW, master's in counseling for LMHC).
• Prior case management, hospital, discharge planning, or care coordination experience.
• Case Management Certification (for example, CCM) is preferred.
• 3+ years of post-licensure clinical or case management experience, including assessment and, where applicable to your scope, crisis intervention.
• Experience working with Nevada Medicaid, underserved, or community-based populations.
• Demonstrated experience with Medicaid documentation, billing workflows, or CPT/HCPCS coding within an integrated care or care management setting is a plus.
• Strong knowledge of social determinants of health and community resource navigation.
• Ability to work effectively alongside CHWs and interdisciplinary teams as a non-supervisory clinical resource.
• Comfort with community/field-based work and telehealth; valid driver's license and reliable transportation if field travel is required.
• Managed care, care management, or integrated behavioral health experience preferred
• Familiarity with local community resources and the regional behavioral health landscape.

Diversity & Inclusion:

At Activate Care, we are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates without regard to race, color, religion, sex, pregnancy (including childbirth, lactation, and related medical conditions), national origin, age, physical and mental disability, marital status, sexual orientation, gender identity, gender expression, military, and veteran status, and any other characteristic protected by applicable law. Activate Care believes that diversity and inclusion among our teammates is critical to our success as a company, and we seek to recruit, develop and retain the most talented people from a diverse candidate pool.

The organization is committed to providing reasonable accommodations to qualified individuals with disabilities throughout the hiring process. If you require an accommodation to participate in the interview process, please let our team know at the time of scheduling.

The Company will not sponsor applicants for work visas at this time.