RN-Utilization Management and Denials Liaison

SSM Health MO, US

It's more than a career, it's a calling.

MO-REMOTE

Worker Type:

Regular

Job Summary:

Serves as the Utilization Management system-wide point of coordination between regional clinical and operational team leaders, physician liaisons, and revenue cycle leaders.

Job Responsibilities and Requirements:

PRIMARY RESPONSIBILITIES

Serves as the direct resource for the regional physician liaisons regarding Utilization Management (UM) initiatives and regional specific UM issues.
Performs audits on UM denial write off accounts to ensure accurate categorizing of the root cause of denial and to identify potential opportunities for claims re-bill.
Collaborates with Managed Care Organization (MCO) team members to stay abreast of contractual updates to develop and maintain UM payer grids with contractual requirements.
Serves as a UM subject matter expert on state and federal regulatory requirements related to UM processes.
Represents the system UM team on committees and work groups as assigned by leadership.
Presents critical messages and complex information and reports to UM leadership.
Provides responses to questions and concerns raised by physician liaisons, clinical and operational team members, providers, and UM leaders.
Supports UM leadership and collaborating teams and providers with resources, data, and education to improve UM outcomes.
Applies the existing body of evidence-based practice and scientific knowledge in health care to medical-surgical nursing practice, ensuring that nursing care is delivered based on patient’s age-specific needs and clinical needs as described in the department's Scope of Service.
Performs other duties as assigned.

EDUCATION

Graduate of accredited school of nursing or education equivalency for licensing

EXPERIENCE

Two years' acute nursing experience, four years of Utilization Management experience

PHYSICAL REQUIREMENTS

Frequent lifting/carrying and pushing/pulling objects weighing 0-25 lbs.

Frequent sitting, standing, walking, reaching and repetitive foot/leg and hand/arm movements.

Frequent use of vision and depth perception for distances near (20 inches or less) and far (20 feet or more) and to identify and distinguish colors.

Frequent use of hearing and speech to share information through oral communication. Ability to hear alarms, malfunctioning machinery, etc.

Frequent keyboard use/data entry.

Occasional bending, stooping, kneeling, squatting, twisting and gripping.

Occasional lifting/carrying and pushing/pulling objects weighing 25-50 lbs.

Rare climbing.

REQUIRED PROFESSIONAL LICENSE AND/OR CERTIFICATIONS

State of Work Location: Illinois

Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR)

State of Work Location: Missouri

Registered Nurse (RN) Issued by Compact State
Or
Registered Nurse (RN) - Missouri Division of Professional Registration

State of Work Location: Oklahoma

Registered Nurse (RN) Issued by Compact State
Or
Registered Nurse (RN) - Oklahoma Board of Nursing (OBN)

State of Work Location: Wisconsin

Registered Nurse (RN) Issued by Compact State
Or
Registered Nurse (RN) - Wisconsin Department of Safety and Professional Services

Work Shift:

Day Shift (United States of America)

Job Type:

Employee

Department:

8746030033 Sys Utilization Management

Scheduled Weekly Hours:

Benefits:

SSM Health values our exceptional employees by offering a comprehensive benefits package to fit their needs.

Paid Parental Leave: we offer eligible team members one week of paid parental leave for newborns or newly adopted children (pro-rated based on FTE).
Flexible Payment Options: our voluntary benefit offered through DailyPay offers eligible hourly team members instant access to their earned, unpaid base pay (fees may apply) before payday.
Upfront Tuition Coverage: we provide upfront tuition coverage through FlexPath Funded for eligible team members.

Explore All Benefits

SSM Health is an equal opportunity employer. SSM Health does not discriminate on the basis of race, color, religion, national origin, age, disability, sex, sexual orientation, gender identity, pregnancy, veteran status, or any other characteristic protected by applicable law. Click here to learn more.

Share this job

Related Jobs

Registered Nurse Utilization Management Specialist

UnityPoint Health West Des Moines, IA

Remote: Yes Area of Interest: Nursing FTE/Hours per pay period: .9 Department: Utilization Management Shift: Monday-Friday, 11:30am-8:00pm (one workday off per pay period) Job ID: 178312 Overview UnityPoint Health is seeking an RN Utilization Management Specialist to join our team! Under the direction of the Manager of Utilization Management, the RN Utilization Management Specialist serves a key role in coordinating the organization’s interdisciplinary effort to assess and promote appropriate utilization of health care resources, provision of high-quality health care, optimal clinical outcomes, and patient and provider satisfaction. The RN UM Specialist will work to track and minimize the inappropriate use of such resources, provides the Utilization Management function for patients admitted to UPH, and facilitates effective utilization of resources through ongoing interactions with physicians, third party payers and regulatory agencies. Location: Remote - applicants must reside within the UPH footprint of Iowa, Illinois, or Wisconsin Hours: Monday-Friday, 11:30am-8:00pm (one work day off per pay period) Why UnityPoint Health? At UnityPoint Health, you matter. We’re proud to be recognized as a Top Place to Work in Healthcare by Becker's Healthcare several years in a row for our commitment to our team members. Our competitive Total Rewards program offers benefits options focused on your needs and priorities, no matter what life stage you’re in. Here are just a few: Expect paid time off, parental leave, 401K matching and an employee recognition program. Dental, health and vision insurance, paid holidays, short and long-term disability and more. We even offer pet insurance for your four-legged family members. Early access to earned wages with Daily Pay, tuition reimbursement to help further your career and adoption assistance to help you grow your family. With a collective goal to champion a culture of belonging where everyone feels valued and respected, we honor the ways people are unique and embrace what brings us together. And, we believe equipping you with support and development opportunities is a vital part of delivering an exceptional employment experience. Join our team of experts and make a difference with UnityPoint Health. Responsibilities Performs utilization management reviews using established criteria to confirm medical necessity, appropriate level of care and efficient use of resources. Maximizes positive financial outcomes for patients and hospital by conducting timely initial and ongoing concurrent chart review for hospitalized patients to monitor appropriateness of treatment, resource utilization, quality of care. Applies utilization criteria using designated software to complete documentation related to utilization review activities in an accurate and timely manner for the purpose of providing information for other members of the healthcare team and to facilitate decision making. Requests secondary reviews with physician advisors as appropriate, if admission or continued stay criteria are not met, assuring appropriate and timely level of care status. Assesses patient status, including reviewing outpatient surgical and observation admissions for the appropriate level of care, and continuously monitors length of stay for appropriate and timely medical management. Applies accepted potentially avoidable day logic to reviews for accurate and timely data collection. Proactively monitors insurance approval status in partnership with the UM Administrative Coordinator. Provides education to staff and physicians regarding medical necessity, levels of care and appropriate utilization of resources as needed. Pursues denials at the affiliate level in a timely manner to secure payment of services. Serves as a resource to internal and external staff, providers, payers, and patients on issues related to utilization management. Maintains current knowledge of Utilization Review Methodology, software, criteria, and regulations governing various payment systems. Maintains current knowledge of the UPH Utilization Management Plan. Maintains current knowledge of CMS rules (e.g., Code 44, A – B Rebilling, HINN, etc.) and other regulatory agencies requirements to insure appropriate reimbursement. Coordinates and monitors appeals with internal and external physician advisors for Second Level Review as needed. Provides education to patients and families regarding the role of the Utilization Management Specialist and provides clarification when needed on level of care and their payer source regulatory requirements as needed. Qualifications Registered Nurse - licensed in Iowa. Will need to obtain RN in Illinois (proivded by UPH) Associates Degree or Diploma (RN) in Nursing required 2 years of nursing experience

UM Review Nurse

Astrana Health Monterey Park, CA

$34 - $42 / hour

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.

Supervisor, Utilization Management (RN)

Centene North Sacramento, CA

$75,300 - $135,400 / year

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. Position Purpose: Supervises Prior Authorization, Concurrent Review, and/or Retrospective Review Clinical Review team to ensure appropriate care to members. Supervises day-to-day activities of utilization management team. Monitors and tracks UM resources to ensure adherence to performance, compliance, quality, and efficiency standards Collaborates with utilization management team to resolve complex care member issues Maintains knowledge of regulations, accreditation standards, and industry best practices related to utilization management Works with utilization management team and senior management to identify opportunities for process and quality improvements within utilization management Educates and provides resources for utilization management team on key initiatives and to facilitate on-going communication between utilization management team, members, and providers Monitors prior authorization, concurrent review, and/or retrospective clinical review nurses and ensures compliance with applicable guidelines, policies, and procedures Works with the senior management to develop and implement UM policies, procedures, and guidelines that ensure appropriate and effective utilization of healthcare services Evaluates utilization management team performance and provides feedback regarding performance, goals, and career milestones Provides coaching and guidance to utilization management team to ensure adherence to quality and performance standards Assists with onboarding, hiring, and training utilization management team members Leads and champions change within scope of responsibility Performs other duties as assigned Complies with all policies and standards Education/Experience: Requires Graduate of an Accredited School Nursing or Bachelor's degree and 4+ years of related experience. Knowledge of utilization management principles preferred. License/Certification: RN - Registered Nurse - State Licensure and/or Compact State Licensure required CA RN LICENSE REQUIRED Pay Range: $75,300.00 - $135,400.00 per year 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

Utilization Management Claims Review Nurse RN II

L.A. Care Health Plan Los Angeles, CA

$88,854 - $142,166 / year

Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job Summary The Utilization Management (UM) Claims Review Nurse RN II is responsible for conducting clinical review of medical claims to ensure services were medically necessary, appropriately documented, accurately billed, and compliant with established clinical policies and regulatory standards. This position supports payment integrity initiatives through retrospective and pre-payment review processes, helps reduce unnecessary denials, and monitors for potential fraud, waste, and abuse (FWA). The UM Claims Review Nurse RN II collaborates closely with internal teams to ensure accurate adjudication and compliance. This position collaborates closely with internal stakeholders and external entities to support compliance with state, federal, and accreditation requirements. Duties Perform claims pre-payment review by supporting the Claims team in evaluating flagged claims prior to adjudication to ensure services are medically necessary, documentation supports billed services, coding is accurate and aligned with authorization when applicable, and unnecessary denials are reduced through accurate clinical validation. Conduct comprehensive retrospective reviews, applying established clinical criteria, policies, and regulatory guidelines to determine medical necessity and appropriateness of services rendered. Complete Provider Dispute Review (PDR) clinical evaluations for disputed claims requiring medical necessity scrutiny and clinical determination. Apply internal and external clinical policies, including those developed by the Clinical Policy team, to ensure compliance with guidelines intended to limit fraud, waste, and abuse (FWA). Ensure adherence to federal and state regulations, and accreditation standards. Monitor trends related to contested claims and identify potential FWA concerns; escalate findings in accordance with organizational compliance protocols. Collaborate with internal teams to support payment integrity initiatives. Provide clear, well-documented clinical rationales supporting approval, denial, or adjustment decisions. Maintain productivity and quality standards consistent with departmental expectations. Participate in audits, regulatory readiness activities, and quality improvement initiatives as assigned. Document review outcomes clearly and accurately within designated systems, ensuring audit readiness and traceability. Remain current with evolving clinical guidelines, coding standards, reimbursement methodologies, and regulatory requirements. Perform other duties as assigned. Duties Continued Education Required Associate's Degree in Nursing Education Preferred Bachelor's Degree in Nursing Experience Required: At least 5 years of experience in Clinical Nursing. At least 3 years of experience with Medi-Cal and Medicare in a managed care environment. Experience in performing and creating clinical documentation. Experience in regulatory compliance for a health plan. Preferred: Experience with Provider Dispute Review (PDR) processes. Experience applying clinical guidelines (e.g., InterQual, MCG, or internally developed criteria) in processes. Prior experience in payment integrity, compliance, or fraud, waste, and abuse (FWA) monitoring. Skills Required: Knowledge of medical necessity criteria, reimbursement principles, and managed care operation. Working knowledge of clinical policies. Working knowledge of CPT/HCPC Codes, and ICD-10. Proficient in claims processing systems and electronic medical record platforms. Strong problem-solving skills and the ability to identify discrepancies, assess risk, and recommend actionable solutions. Strong verbal and written communication skills. Ability to work independently with a high degree of initiative, organization, and self-direction. Ability to work effectively with diverse teams in cross-functional work groups. Ability to multitask, re-prioritize tasking, and streamline day-to-day operations. Familiarity with regulatory and accreditation standards (e.g., CMS, Medi-Cal, NCQA). Understanding of the managed care industry and market conditions. High organizational and time-management skills. Preferred: Strong analytical and investigative skills with the ability to synthesize clinical and claims information into clear, defensible determinations are highly valued. Advanced knowledge of medical necessity criteria tools such as InterQual or MCG. Extensive knowledge in claims reviews includes retrospective reviews, pre-payment claims review, and medical necessity determinations. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California License Licenses/Certifications Preferred Required Training Physical Requirements Light Additional Information Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. L.A. Care offers a wide range of benefits including Paid Time Off (PTO) Tuition Reimbursement Retirement Plans Medical, Dental and Vision Wellness Program Volunteer Time Off (VTO)

Utilization Management Clinical Quality Nurse Reviewer RN II

L.A. Care Health Plan Los Angeles, CA

$88,854 - $142,166 / year

Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job Summary The Utilization Management Clinical Quality Nurse Reviewer RN II, under the purview of the Utilization Management (UM) Department Leadership Team, is responsible for conducting and tracking targeted and random internal department documentation audits. This role ensures that UM practices and supporting documentation are compliant with all regulatory requirements. The Incumbent also serves as a Subject Matter Expert during external audits as well as leads pre- and post-audit preparation/follow-up. This position actively participates in the development and review of policies and procedures to certify compliance with regulatory guidelines and mandates. This position focuses on UM cases for all lines of business to identify areas of opportunity for increasing positive audit outcomes and improved service to L.A. Care’s membership. This position is responsible for identifying and monitoring staff (non-clinical, nurse, and physician) performance against key performance indicator trends that warrant recognition or remediation. This position performs data mining and analysis and creates reports on audit findings, as well as makes recommendations, to submit to the department's Quality Assurance Team and UM Management. Duties Facilitates the development, review, and revision of organizational and departmental process flows to ensure compliance with relevant regulatory, organizational, and departmental guidelines. Keenly focuses on practices and documentation of clinical staff, serving as a resource on state and federal industry mandates applicable to UM functions. Generates results of findings, enhances, and analyzes various reports related, but not limited to, quality and accuracy of case documentation. Works with department leadership to assess for all opportunities related to quality improvements. Compiles and presents quality report cards that measure adherence to quality and regulatory compliance. Keeps UM Leadership apprised of departmental and industry trends, deficiencies, and any potential risks, and collaborates with the team to develop and execute mitigation efforts. Serves as a consultant to the organization's Compliance team on an ad hoc basis. Performs other duties as assigned. Duties Continued Education Required Associate's Degree in Nursing Education Preferred Bachelor's Degree Master's Degree in Nursing Experience Required: At least 5 years of experience in Clinical Nursing. Minimum of 2 years of auditing clinical documentation. Active participation in at least two state regulatory audits and one federal regulatory audits. Previous experience with Medi-Cal and Medicare in a managed care environment and experience with mitigation planning and implementation. Preferred: Experience performing clinical documentation for a health plan. Active participation in at least three state regulatory audits, at least one National Committee for Quality Assurance (NCQA) audit and/or Centers for Medicare and Medicaid Services (CMS) audit. Background in teaching and/or clinical education. Skills Required: Superior verbal and written communication skills. Advanced computer proficiency in both Microsoft Word and Excel. Strong analytical and team building skills. Ability to work independently and be self-directed. Ability to work effectively with diverse team members. Strong problem-solving skills. Ability to multitask and streamline day-to-day operations. Ability to translate regulatory requirements into auditable tools. Preferred: Proven ability to lead successful performance improvement projects. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California License Licenses/Certifications Preferred Required Training Physical Requirements Light Additional Information Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. L.A. Care offers a wide range of benefits including Paid Time Off (PTO) Tuition Reimbursement Retirement Plans Medical, Dental and Vision Wellness Program Volunteer Time Off (VTO)