Licensed to practice in the State of Arkansas. Graduate of an approved school of Nursing. Current RN licensure or permit as a registered nurse in the State of Arkansas, BSN preferred.
Experience
Minimum of three years clinical nursing experience. Case Management or Utilization Review Experience preferred. Works efficiently with others and demonstrates tact, discretion and diplomacy. Ability to operate technical equipment as acquired through orientation.
Physical
Normal hospital environment. Exposure to biological hazards. Frequent exposure to unpleasant odors. Close eye work. Hearing of normal and soft tones. Distinguish temperatures by touch and proximity. Carrying up to 40 lbs. Push/pulling up to 350 lbs. Frequent sitting, standing, walking, bending, stooping, climbing and reaching. Operates computer terminals
This is a safety sensitive position. Please see the St. Bernards Substance Abuse Policy for further information.
JOB SUMMARY
The Utilization Review Nurse follows the medical center Utilization Review plan and operates under the policies of the Support Services Dept. The position requires knowledge of field and utilization of discretion and judgment in role of utilization review and clinical documentation duties. The nurse must possess the ability to positively interact with other medical center departments, insurance companies, review agencies, and physician offices. The nurse must provide essential and appropriate medical information to those requiring it and do so in a timely manner and with concern for maintaining patient confidentiality. To achieve optimal clinical and financial outcomes, through utilization, service, quality indicators, and patient flow. Work closely with case management staff to ensure level of care change is communicated and flows smoothly. Works closely with the physicians, allied health nurses, and coding department to facilitate clinical documentation program. This position is required to utilize independent judgment.
UM Review Nurse Department: HS - UM Employment Type: Full Time Location: 1600 Corporate Center Dr., Monterey Park, CA 91754 Reporting To: Sandra Castellon Compensation: $34.00 - $42.00 / hour Description Astrana Health is looking for a CA-licensed Utilization Review Nurse to assist our Health Services Department. In this position, you will utilize your clinical judgement to approve or deny outpatient medical services for patients based on Medical Necessity Criteria, respective to various Health Plans. This position requires open availability between Monday through Sunday, 8 A - 8 P. You would be scheduled for 5 shifts per week. This is a remote position for CA-licensed nurses. Candidates must live in California. We are seeking nurses with at least one year of outpatient Utilization Management experience in a fast-paced setting. Our Values: Put Patients First Empower Entrepreneurial Provider and Care Teams Operate with Integrity & Excellence Be Innovative Work As One Team What You'll Do Complete prior authorization/retrospective review of elective inpatient admissions, outpatient procedures, post-homecare services, and durable medical equipment Refer cases to Medical Directors as needed/appropriate Maintain knowledge of state and federal regulations and accreditation standards Comply with internal policies and procedures Perform any other job duties as requested Qualifications Active and unrestricted LVN license in CA. 1+ years of outpatient UM experience Experience with Microsoft applications such as Word, Excel, and Outlook You’ll be Great for this Role If: Two (2) years of health plan, IPA or MSO experience Strong interpersonal skills Ability to collaborate with co-workers, senior leadership, and other management Experience educating and training staff Environmental Job Requirements and Working Conditions This is a remote position. Our office is located at 1600 Corporate Center Drive in Monterey Park, CA. Candidates who live within a 30 mile radius of the office may be expected to work hybrid. Typical business hours are Monday - Friday from 8:30 AM to 5 PM, however, this position requires open availability between 8 AM - 8 PM PST, M-Su. Your schedule will be compromised of 5 shifts per week. Nurses rotate weekend and holiday coverage. Overtime is required in this position. The national target pay range for this role is $34.00 - $42.00 per hour. Actual compensation will be based on job level, geographic location (current or future), experience, and other job-related factors. Astrana Health is proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based on race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. All employment is decided based on qualifications, merit, and business need. If you require assistance in applying for open positions due to a disability, please email us at humanresourcesdept@astranahealth.com to request an accommodation. Additional Information: The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.
Job Description Utilization Reviewer (RN) – Emergency Department Atlantic Health System – Newton, Hackettstown & Chilton Medical Center Full-Time | Days | Monday-Friday | 8:00 AM – 4:00 PM Atlantic Health System is seeking a Full-Time Utilization Reviewer RN to support Emergency Department operations at Overlook Medical Center. The Utilization Reviewer is responsible for conducting real-time medical necessity reviews and level-of-care determinations for patients presenting to the Emergency Department. This role serves as a key liaison between clinical teams and utilization management to ensure appropriate patient status assignment, regulatory compliance, and optimal patient throughput. Responsibilities Perform concurrent medical necessity reviews for Emergency Department patients utilizing MCG and/or InterQual criteria. Evaluate admission, observation, and level-of-care determinations in accordance with CMS, payer, and organizational guidelines. Collaborate with Emergency Department physicians, hospitalists, physician advisors, and care management teams to support timely patient placement decisions. Provide education and guidance regarding CMS Observation Rules, Two-Midnight Rule, and documentation requirements. Identify potential denial risks and compliance concerns and escalate as appropriate. Communicate patient status determinations and pertinent clinical information to inpatient Utilization Review staff for continuity of care. Participate in departmental quality initiatives, data collection, reporting, and performance improvement activities related to utilization management and patient throughput. Maintain current knowledge of regulatory and payer requirements impacting utilization review practices. Required QUALIFICATIONS Graduate of an accredited School of Nursing. Current New Jersey Registered Nurse (RN) License in good standing. Strong clinical assessment and critical thinking skills. Excellent communication and interdisciplinary collaboration abilities. Preferred Bachelor of Science in Nursing (BSN). Previous Case Management, Utilization Review, or Care Coordination experience. Experience utilizing MCG and/or InterQual criteria. Knowledge of CMS regulations, Observation Status requirements, and Utilization Management principles. Prior Emergency Department, Acute Care, Case Management, or Clinical Documentation experience. About Us At Atlantic Health, our promise to our communities is; Anyone who enters one of our facilities will receive the highest quality care delivered at the right time, at the right place, and at the right cost. This commitment is also echoed in the respect, development and opportunities we give to our more than 22,000 team members. Headquarters in Morristown, New Jersey, we are one of the leading non-profit health care systems in the nation. Our facilities and sites of care include: Atlantic Health Morristown Medical Center, Morristown, NJ Atlantic Health Overlook Medical Center, Summit, NJ Atlantic Health Newton Medical Center, Newton, NJ Atlantic Health Chilton Medical Center, Pompton Plains, NJ Atlantic Health Hackettstown Medical Center, Hackettstown, NJ Atlantic Health Goryeb Children's Hospital, Morristown, NJ Atlantic Health CentraState Healthcare System, Freehold, NJ Atlantic Medical Group Atlantic Visiting Nurse Atlantic Mobile Health Atlantic Rehabilitation We have more than 900 community-based healthcare providers affiliated through Atlantic Medical Group. We Have Received Awards And Recognition For The Services We Have Provided To Our Patients, Team Members And Communities. Below Are Just a Few Of Our Accolades Chosen for 17 years by Fortune as one of the magazine’s “100 Best Companies to Work For." Atlantic Health Morristown and Atlantic Health Overlook Named by Newsweek as two of the “World’s Best Hospitals” in 2026. Atlantic Health Morristown and Atlantic Health Overlook ranked within the top three hospitals in New Jersey by U.S. News & World Report’s 2025-2026 Best Hospital rankings. Atlantic Health scored four “A” grades by The Leapfrog Group in its Fall 2025 Hospital Safety Grades, performance measures reflecting errors, accidents, injuries and injections, as well as systems hospitals have in place to prevent harm. Atlantic Health Morristown and Atlantic Health Overlook are New Jersey's only hospitals to be named among America's 50 Best hospitals by Healthgrades in 2026. Named by Becker's Healthcare as one of the "165 Top Places to Work in Healthcare – 2026. Atlantic Health Morristown, Atlantic Health Overlook, Atlantic Health Chilton and Atlantic Health Newton all Forbes Top Hospitals for 2026. Named by Newsweek as one of America’s Greatest Workplaces for Inclusion & Diversity 2025. Atlantic Health rated LEVEL 9 - 2025 CHIME Digital Health Most Wired. Summary Atlantic Health offers a competitive and comprehensive Total Rewards package that supports the health, financial security, and well-being of all team members. Offerings vary based on role level (Team Member, Director, Executive). Below is a general summary, with role-specific enhancements highlighted: Team Member Benefits Medical, Dental, Vision, Prescription Coverage (22.5 hours per week or above for full-time and part-time team members) Life & AD&D Insurance. Short-Term and Long-Term Disability (with options to supplement) 403(b) Retirement Plan: Employer match, additional non-elective contribution PTO & Paid Sick Leave Tuition Assistance, Advancement & Academic Advising Parental, Adoption, Surrogacy Leave Backup and On-Site Childcare Well-Being Rewards Employee Assistance Program (EAP) Fertility Benefits, Healthy Pregnancy Program Flexible Spending & Commuter Accounts Pet, Home & Auto, Identity Theft and Legal Insurance ____________________________________________ Note: In Compliance with the NJ Pay Transparency Act (effective Sunday, June 1, 2025), all job postings will include the hourly wage or salary (or a range), as well as this summary of benefits. Final compensation and benefit eligibility may vary by role and employment status and will be confirmed at the time of offer. EEO STATEMENT Atlantic Health, Inc. is an equal employment opportunity employer and federal contractor or subcontractor and therefore abides by applicable laws to protect applicants and employees from discrimination in hiring, promotion, discharge, pay, fringe benefits, job training, classification, referral, and other aspects of employment, on the basis of race, color, religion, sex (including pregnancy, gender identity and sexual orientation), national origin, citizenship status, disability, age, genetics, or veteran
Job Description Utilization Reviewer (RN) – Emergency Department Atlantic Health System – Overlook Medical Center Full-Time | Days | Monday-Friday | 8:00 AM – 4:00 PM Atlantic Health System is seeking a Full-Time Utilization Reviewer RN to support Emergency Department operations at Overlook Medical Center. The Utilization Reviewer is responsible for conducting real-time medical necessity reviews and level-of-care determinations for patients presenting to the Emergency Department. This role serves as a key liaison between clinical teams and utilization management to ensure appropriate patient status assignment, regulatory compliance, and optimal patient throughput. Responsibilities Perform concurrent medical necessity reviews for Emergency Department patients utilizing MCG and/or InterQual criteria. Evaluate admission, observation, and level-of-care determinations in accordance with CMS, payer, and organizational guidelines. Collaborate with Emergency Department physicians, hospitalists, physician advisors, and care management teams to support timely patient placement decisions. Provide education and guidance regarding CMS Observation Rules, Two-Midnight Rule, and documentation requirements. Identify potential denial risks and compliance concerns and escalate as appropriate. Communicate patient status determinations and pertinent clinical information to inpatient Utilization Review staff for continuity of care. Participate in departmental quality initiatives, data collection, reporting, and performance improvement activities related to utilization management and patient throughput. Maintain current knowledge of regulatory and payer requirements impacting utilization review practices. Required QUALIFICATIONS Graduate of an accredited School of Nursing. Current New Jersey Registered Nurse (RN) License in good standing. Strong clinical assessment and critical thinking skills. Excellent communication and interdisciplinary collaboration abilities. Preferred Bachelor of Science in Nursing (BSN). Previous Case Management, Utilization Review, or Care Coordination experience. Experience utilizing MCG and/or InterQual criteria. Knowledge of CMS regulations, Observation Status requirements, and Utilization Management principles. Prior Emergency Department, Acute Care, Case Management, or Clinical Documentation experience. About Us At Atlantic Health, our promise to our communities is; Anyone who enters one of our facilities will receive the highest quality care delivered at the right time, at the right place, and at the right cost. This commitment is also echoed in the respect, development and opportunities we give to our more than 22,000 team members. Headquarters in Morristown, New Jersey, we are one of the leading non-profit health care systems in the nation. Our facilities and sites of care include: Atlantic Health Morristown Medical Center, Morristown, NJ Atlantic Health Overlook Medical Center, Summit, NJ Atlantic Health Newton Medical Center, Newton, NJ Atlantic Health Chilton Medical Center, Pompton Plains, NJ Atlantic Health Hackettstown Medical Center, Hackettstown, NJ Atlantic Health Goryeb Children's Hospital, Morristown, NJ Atlantic Health CentraState Healthcare System, Freehold, NJ Atlantic Medical Group Atlantic Visiting Nurse Atlantic Mobile Health Atlantic Rehabilitation We have more than 900 community-based healthcare providers affiliated through Atlantic Medical Group. We Have Received Awards And Recognition For The Services We Have Provided To Our Patients, Team Members And Communities. Below Are Just a Few Of Our Accolades Chosen for 17 years by Fortune as one of the magazine’s “100 Best Companies to Work For." Atlantic Health Morristown and Atlantic Health Overlook Named by Newsweek as two of the “World’s Best Hospitals” in 2026. Atlantic Health Morristown and Atlantic Health Overlook ranked within the top three hospitals in New Jersey by U.S. News & World Report’s 2025-2026 Best Hospital rankings. Atlantic Health scored four “A” grades by The Leapfrog Group in its Fall 2025 Hospital Safety Grades, performance measures reflecting errors, accidents, injuries and injections, as well as systems hospitals have in place to prevent harm. Atlantic Health Morristown and Atlantic Health Overlook are New Jersey's only hospitals to be named among America's 50 Best hospitals by Healthgrades in 2026. Named by Becker's Healthcare as one of the "165 Top Places to Work in Healthcare – 2026. Atlantic Health Morristown, Atlantic Health Overlook, Atlantic Health Chilton and Atlantic Health Newton all Forbes Top Hospitals for 2026. Named by Newsweek as one of America’s Greatest Workplaces for Inclusion & Diversity 2025. Atlantic Health rated LEVEL 9 - 2025 CHIME Digital Health Most Wired. Summary Atlantic Health offers a competitive and comprehensive Total Rewards package that supports the health, financial security, and well-being of all team members. Offerings vary based on role level (Team Member, Director, Executive). Below is a general summary, with role-specific enhancements highlighted: Team Member Benefits Medical, Dental, Vision, Prescription Coverage (22.5 hours per week or above for full-time and part-time team members) Life & AD&D Insurance. Short-Term and Long-Term Disability (with options to supplement) 403(b) Retirement Plan: Employer match, additional non-elective contribution PTO & Paid Sick Leave Tuition Assistance, Advancement & Academic Advising Parental, Adoption, Surrogacy Leave Backup and On-Site Childcare Well-Being Rewards Employee Assistance Program (EAP) Fertility Benefits, Healthy Pregnancy Program Flexible Spending & Commuter Accounts Pet, Home & Auto, Identity Theft and Legal Insurance ____________________________________________ Note: In Compliance with the NJ Pay Transparency Act (effective Sunday, June 1, 2025), all job postings will include the hourly wage or salary (or a range), as well as this summary of benefits. Final compensation and benefit eligibility may vary by role and employment status and will be confirmed at the time of offer. EEO STATEMENT Atlantic Health, Inc. is an equal employment opportunity employer and federal contractor or subcontractor and therefore abides by applicable laws to protect applicants and employees from discrimination in hiring, promotion, discharge, pay, fringe benefits, job training, classification, referral, and other aspects of employment, on the basis of race, color, religion, sex (including pregnancy, gender identity and sexual orientation), national origin, citizenship status, disability, age, genetics, or veteran
JOB DESCRIPTION Job Summary Provides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines. • Analyzes clinical service requests from members or providers against evidence based clinical guidelines. • Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. • Conducts reviews to determine prior authorization/financial responsibility for Molina and its members. • Processes requests within required timelines. • Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner. • Requests additional information from members or providers as needed. • Makes appropriate referrals to other clinical programs. • Collaborates with multidisciplinary teams to promote the Molina care model. • Adheres to utilization management (UM) policies and procedures. Required Qualifications • At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience. • Registered Nurse (RN). License must be active and unrestricted in state of practice. • Ability to prioritize and manage multiple deadlines. • Excellent organizational, problem-solving and critical-thinking skills. • Strong written and verbal communication skills. • Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications • Certified Professional in Healthcare Management (CPHM). • Recent hospital experience in an intensive care unit (ICU) or emergency room. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $23.76 - $51.49 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
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. ***Applicants must have and maintain active New York State (NYS) RN licensure to be considered. The standard fully remote work schedule is Monday through Friday, 8:30 a.m. to 5:00 p.m. with the potential for weekend and/or holiday coverage based on business needs.*** 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 graduation from an accredited school of nursing or a Bachelor’s degree in Nursing (BSN), along with 2–4 years of related nursing experience. A minimum of 2 years of acute care experience is 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: LPN - Licensed Practical Nurse - State Licensure required NYS RN Licensure Strongly Preferred 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
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