Registered Nurse (RN) Utilization Review Jobs

RN Utilization Review Telehealth
L.A. Care Health Plan

Utilization Management Clinical Quality Nurse Reviewer RN II

L.A. Care Health Plan ID
$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 NursingEducation Preferred Bachelor's DegreeMaster's Degree in NursingExperience 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 LicenseLicenses/Certifications Preferred Required Training Physical Requirements LightAdditional 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)
RN Utilization Review Full-time
Munson Healthcare

Utilization Review Specialist (RN) - Hybrid in Traverse City, MI

Munson Healthcare Traverse City, MI
Company Description More Than Just Care, It’s Community Imagine doing meaningful work in a place where people vacation. That’s life at Munson Healthcare - northern Michigan’s largest healthcare system, with eight award-winning community hospitals serving over half a million residents across 29 counties. If you want a career in healthcare and a lifestyle most people only dream about – with freshwater lakes, scenic trails, charming downtowns, a vibrant arts scene, and endless outdoor adventures - you might just be Munson Material. To us, that means teammates who live by our values of excellence, teamness, positivity, creativity, and a commitment to creating exceptional experiences for our patients and each other. Join a team that delivers outstanding care in one of the most beautiful regions in the country. Invested in You Grow: Tuition reimbursement, in-person and online development, and access to our career hub to help you advance. Thrive: Full benefits, paid holidays, generous PTO, employee discounts, and free individual retirement counseling. Be Well: Free wellness platform for you and your family, plus personalized support for personal or family challenges. Be Heard: Share your ideas and help shape the way we work through improvement huddles, employee surveys, and town hall meetings Job Description A Day In The Life The Utilization Review Specialist (RN) is responsible for ensuring appropriate utilization of healthcare services across the continuum of care. This role evaluates patient admissions, continued stays, and transitions of care to ensure compliance with regulatory requirements, payer guidelines, and evidence-based standards of practice. Working collaboratively with physicians, case managers, nursing staff, payers, and interdisciplinary teams, the Utilization Review Specialist promotes high-quality, cost-effective patient care while supporting optimal reimbursement and organizational performance. The position requires strong clinical judgment, critical thinking, communication skills, and knowledge of utilization management principles. Schedule: Typically M-F 2PM -10:30PM with a weekend rotation every 4/5 weekend. Rotating holiday work as needed. Locations: MMC ED and Copper Ridge. Once established this position will be 50/50 hybrid & onsite. Training Schedule: Onsite M-F 8AM -4:30PM for the first 8 weeks (estimated). KEY AREAS OF REPSONSIBILITY Admission Reviews available documentation to assess all admissions for appropriate status and services according to patient condition and diagnosis. Applies standard guidelines to determine appropriateness for inpatient level of care or observation services based on documented condition plan of treatment and care. Supports physician decision-making by coaching on appropriateness of inpatient or observation status. Confers with admitting physician if documentation does not support hospital level of care to offer alternatives. Refers cases to the Physician Advisor when documentation is inadequate to support acute level of care and remains unresolved after discussing with referring/attending physician. Understands and applies federal law regarding the use of Hospital Initiated Notice of Non-Coverage (HINN) and Ambulatory Benefit Notice (ABN). Monitors insurer compliance with contractual obligations. Maintains proficiency in the use of electronic review applications including CERMe and EMR and enters information correctly, consistently and timely. Maintains proficiency in the use of hospital information systems to access information and record data. Continuing Stay Actively participate in daily huddles, patient care conferences, and hospitalist/nurses hand-off reports to maintain knowledge about the patient’s clinical status and progression of care. Consults with case manager and/or physician advisor as necessary to resolve progression-of-care barriers through appropriate administrative and medical channels. Identify potentially unnecessary services and care delivery settings and recommend alternatives when appropriate. Collaborates with community physicians and hospitalists to influence transition from one level of care to another. Notifies insurers and third party administrators of clinical review information. Maintains documentation on each patient to include specific criteria that support appropriate level of care and continued stay. Performs status changes as necessary Refers cases to the Physician Advisor when treatment plan documentation does not support acute level of care. Monitors timeliness of PA response. Identify and record episodes of preventable delays or avoidable days due to failure of progression-of-care processes. Promote physicians’ use of evidence based protocols and/or order sets to influence high quality and cost effective care. Transition Collaborate with clinical team to confirm benefit eligibility for post-acute services. Apply Interqual/Milliman discharge screens to assess patient’s readiness for a lower level of care. Updates all involved parties regarding potential, threatened or actual denials due to lack of medical necessity or barriers to the progression of care. Participates in reviewing 30-day Readmissions as directed by program manager. Reviews request for direct admissions and transfers for appropriate level of care. Coordinates with ED Case Manager to recommend alternate placement from the ED when patients do not qualify for Outpatient Observation or Inpatient status Program Support Serves as a resource person to physicians, case managers, physician offices, and billing office for coverage and compliance issues. Works closely with decision support personnel to review resource utilization data and trends to identify outliers who may benefit from real time coaching to improve outcomes. Encourage healthcare team members in collaborative problem solving regarding appropriate use of resources. Assists in developing and revising policies to support utilization management activities, including criteria and guidelines for appropriate use of services, clinical practice guidelines and treatment protocols. Recognizes and responds appropriately to risk factors. Keeps current on all regulatory changes that affect medical necessity or reimbursement of acute care services and shares that information with program colleagues and hospital associates at information meetings. May represent Utilization Management on various committees, professional organizations, physician or and community groups Establish and maintain effective professional working relationships with patients, families, interdisciplinary team members, payers and external case managers Qualifications Requirements Current licensure as a Registered Nurse (RN) in the State of Michigan. Minimum of three years clinical experience required. Strong clinical assessment, critical thinking, and decision-making skills. Effective verbal and written communication skills. Proficiency in Microsoft Office, Outlook, and related computer applications. Ability to independently organize workload, manage competing priorities, and meet deadlines. Demonstrated attention to detail and problem-solving abilities. Preferred Previous utilization review, utilization management, or case management experience within a hospital or insurance setting. Knowledge of managed care, Medicare, Medicaid, HMOs, and reimbursement methodologies. Experience with discharge planning and transitions of care. EHR Cerner exprience. Additional Information Schedule: Typically M-F 2PM -10:30PM with a weekend rotation every 4/5 weekend. Rotating holiday work as needed. Locations: MMC ED and Copper Ridge. Once established this position will be 50/50 hybrid & onsite. Training Schedule: Onsite M-F 8AM -4:30PM for the first 8 weeks (estimated). Munson Healthcare requires all employees be vaccinated or have lab confirmed immunity for Measles, Mumps, Rubella and Varicella. MHC also requires all employees to receive a flu vaccine during the flu season in the year that they are hired and annually thereafter, or receive an approved medical or religious exemption.
RN Utilization Review Outpatient Full-time
UHS

UTILIZATION - CASE MANAGER (RN/LIC) FT

UHS Eagle Pass, TX
Responsibilities The Behavioral Health Utilization Management Case Management-Coordinator supports the utilization management process for BH services provided. This position coordinates authorization activities, maintains accurate payer and clinical documentation, monitors authorization timelines, and facilitates communication among clinical teams, payers and revenue cycle departments. The UM coordinator helps ensure that services are reviewed timely, accurately documented, and provided at the appropriate level of care in accordance with payer requirements, regulatory standards and organizational policies. EEO Statement All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws. We believe that diversity and inclusion among our teammates is critical to our success. Notice At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skillset and experience with the best possible career path at UHS and our subsidiaries. We take pride in creating a highly efficient and best in class candidate experience. During the recruitment process, no recruiter or employee will request financial or personal information (Social Security Number, credit card or bank information, etc.) from you via email. The recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc. If you are suspicious of a job posting or job-related email mentioning UHS or its subsidiaries, let us know by contacting us at: https://uhs.alertline.com or 1-800-852-3449 . Qualifications Education: Bachelor’s Degree: Nursing, Counseling, Psychology or Social Work. Acute inpatient psychiatric setting as a treatment team member and/or utilization mgmt experience preferred. Licensure/Certification/Registration ( L ist the required and / or preferred licenses, certifications, or registrations, if any) Required Preferred Registered Nurse ☒ ☐ Social Work, Marriage and Family, Mental Health Counseling (i.e. LPC, LMHC, LCSW, LCPC, LPCC) ☐ ☒
RN Home Health Manager/Supervisor Utilization Review Home Health Full-time
Apollo Medical

Home Health Clinical Review Manager (RN)

Apollo Medical Swansea, IL
Clinical Review Manager Compensation: Salary, processed bi-weekly (26 pay periods). Shift Type: Full-time, on-site, Monday - Friday, with participation in on-call rotations. Benefits: 100% Company Paid Premiums for Dental, Vision, & Short-Term Disability Coverage 3 Medical Plan Options with Low Premiums Whole Person Approach Monthly Mobile Device Reimbursement 401(k) with 3.5% Match Long-Term Disability Coverage Voluntary Life Insurance Provided Device PTO Mileage Reimbursement Paid Holidays Paid Bereavement Leave Employee Assistance Program Positive & Supportive Culture Professional Growth Opportunities Summary The Clinical Review Manager (CRM) is responsible for the clinical review, approval, and oversight of Plans of Care, OASIS documentation, physician orders, add-on evaluation requests, transfers, recertifications, and discharges. The Clinical Review Manager (CRM) ensures clinical accuracy, regulatory compliance, appropriate utilization of services, and adherence to Medicare Conditions of Participation and agency standards. The Clinical Review Manager (CRM) serves as a clinical resource to field clinicians and leadership by promoting documentation excellence, optimizing patient outcomes, and supporting the delivery of appropriate home health services. Primary Responsibilities: Clinical Documentation Review Review and approve Plans of Care (POCs), Add-On Evaluation requests, transfers, recertifications, and discharges. Review and approve physician orders for clinical appropriateness, completeness, and regulatory compliance. Ensure OASIS assessments accurately reflect patient condition, functional status, and homebound eligibility. Verify documentation supports skilled need, visit utilization, and reimbursement requirements. The Clinical Review Manager (CRM) ensure care plans are individualized, clinically appropriate, and aligned with physician orders. Quality and Compliance Monitor documentation quality and regulatory compliance with Medicare Conditions of Participation, state regulations, and agency policies. Identify trends related to OASIS accuracy, documentation deficiencies, and utilization concerns. Collaborate with leadership to implement corrective actions and education plans. Participate in QAPI activities, audits, and chart reviews. Support survey readiness initiatives and compliance programs. Clinical Resource and Education Serve as a subject matter expert regarding OASIS, documentation standards, regulations, and care planning. Provide coaching and feedback to clinicians regarding documentation quality and accuracy. Support onboarding and ongoing education related to clinical documentation. Collaborate with Clinical Field Managers to address clinician performance opportunities. Care Coordination Collaborate with physicians, field clinicians, Clinical Field Managers, and agency leadership to ensure appropriate patient care delivery. Assist with resolution of clinical documentation issues impacting patient care or reimbursement. Escalate significant compliance, quality, or patient safety concerns to leadership. Other duties as reasonably assigned. Qualifications: Current unrestricted RN license in the state of practice. Minimum three (3) years of home health experience preferred. Strong knowledge of OASIS, Medicare Conditions of Participation, and home health reimbursement. Experience with clinical documentation review, coding, quality improvement, or leadership preferred. Excellent analytical, organizational, and communication skills. Proficiency with electronic medical records and home health software. EEO Statement: LiveWell provides equal employment opportunities (EEO) to all team members and applicants for employment without regard to race, color, religion, sex, national origin, age, disability, or genetics. In addition to federal law requirements, LiveWell complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training. LiveWell expressly prohibits any form of workplace harassment based on race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, genetic information, disability, or veteran status. Improper interference with the ability of LiveWell team members to perform their job duties may result in discipline, up to and including discharge.
RN Utilization Review Outpatient Full-time
PIH Health

RN Peer Review Analyst, Qualtiy Review, Full Time, Days

PIH Health Los Angeles, CA
$107,598.40 - $183,768 / year
Responsible for the retrospective review of medical records and compiling data to validate quality of care, appropriateness of care , and accuracy of documentation. RN Peer Review Analyst will audit charts for appropriateness of admission, continued stay, compliance to hospital metrics and to monitor care provided by our caregivers. RN Peer Review Analyst will interact with physicians, nurses and other professionals regarding chart documentation and actively participate in team meetings to help improve charting for physicians and clinical staff. Case found not meeting approved guidelines will be selected for peer review and follow up. PIH Health is a nonprofit, regional healthcare network that serves approximately 3 million residents in the Los Angeles County, Orange County and San Gabriel Valley region. The fully integrated network is comprised of PIH Health Downey Hospital, PIH Health Good Samaritan Hospital, PIH Health Whittier Hospital, 37 outpatient medical office buildings, a multispecialty medical (physician) group, home healthcare services and hospice care, as well as heart, cancer, digestive health, orthopedics, women’s health, urgent care and emergency services. The organization is nationally recognized for excellence in patient care and patient experience, and the College of Healthcare Information Management Executives (CHIME) has identified PIH Health as one of the nation’s top hospital systems for best practices, cutting-edge advancements, quality of care and healthcare technology. For more information, visit PIHHealth.org or follow us on Facebook , Twitter , or Instagram . Required Skills SPECIFIC SKILLS NEEDED Organizational, analytical, writing and interpersonal skills. Dependable and self directed. Critical thinking, problem solving and deductive reasoning skills. Basic computer skills – Familiarity with Windows based software programs. Knowledge of Medicare Part A and B. Understanding of regulatory environment. Understanding and supporting documentation strategies. Understand and communicate Medicare requirements and how they impact DRG assignment. Required Experience Required: LA City Fire Card within 6 months of employment Current California RN license Preferred: RN Degree in Nursing, a Bachelor’s Degree or Master’s Degree preferred. Five years of clinical chart review, conducting chart aults and working in Quality Managment, Case Managment, ED or ICU Address 1225 Wilshire Boulevard Salary 107598.40-183768.00 Shift Days Zip Code 90017
RN Utilization Review Full-time
Prime Healthcare

RN Case Manager - Utilization Review

Prime Healthcare Lynwood, CA
$47.20 - $63.45 / hour
Overview St. Francis Medical Center is one of the leading comprehensive healthcare institutions in Los Angeles. St. Francis provides vital healthcare services for the 700,000 adults and 300,000 children in our community who count on the hospital for high quality and compassionate medical care. St. Francis is recognized for its full range of diagnostic and treatment services in specialties including Cardiovascular, Surgical, Orthopedics, Obstetrics, Pediatrics, Behavioral Health, and Emergency and Trauma Care. In addition, the hospital offers a broad array of education and outreach programs that advance community health. St. Francis Medical Center is a Comprehensive Stroke Center, STEMI Receiving Center, ED Approved for Pediatrics, Geriatric ED, Level III Neonatal ICU, and Level II Trauma Center. Please visit www.stfrancismedicalcenter.com for more information. Join an award-winning team of dedicated professionals committed to compassion, quality, and service! Responsibilities Responsible for the quality and resource management of all patients that are admitted to the facility from the point of their admission and across the continuum of the health care management. Works on behalf of the advocate, promoting cost containment and demonstrates leadership to integrate the health care providers to achieve a perceived seamless delivery of care. The methodology is designed to facilitate and ensure the achievement of quality, clinical and cost-effective outcomes and to perform a holistic and comprehensive admission and concurrent review of the medical record for the medical necessity, intensity of service and severity of illness. Qualifications EDUCATION, EXPERIENCE, TRAINING Required Qualifications: Minimum 5 years' work experience post-graduation of an accredited school of nursing and a current state Registered Nurse license At least one year experience in case management, discharge planning or nursing management Experience and knowledge in basic to intermediate computer skills. Preferred Qualifications: Five years of acute care nursing experience. preferred CCM or obtained within 1year Knowledge of Milliman Criteria and InterQual Criteria preferred. Current BCLS certificate, preferred Pay Transparency St. Francis Medical Center offers competitive compensation and a comprehensive benefits package that provides employees the flexibility to tailor benefits according to their individual needs. Our Total Rewards package includes, but is not limited to, paid time off, a 401K retirement plan, medical, dental, and vision coverage, tuition reimbursement, and many more voluntary benefit options. Benefits may vary based on collective bargaining agreement requirements and/or the employment status, i.e. full-time or part-time. The current compensation range for this role is $47.20 to $63.45. The exact starting compensation to be offered will be determined at the time of selecting an applicant for hire, in which a wide range of factors will be considered, including but not limited to, skillset, years of applicable experience, education, credentials and licensure. Employment Status Full Time Shift Evenings Equal Employment Opportunity Company is an equal employment opportunity employer. Company prohibits discrimination against any applicant or employee based on race, color, sex, sexual orientation, gender identity, religion, national origin, age (subject to applicable law), disability, military status, genetic information or any other basis protected by applicable federal, state, or local laws. The Company also prohibits harassment of applicants or employees based on any of these protected categories. Know Your Rights: https://www.eeoc.gov/sites/default/files/2022-10/EEOC_KnowYourRights_screen_reader_10_20.pdf Privacy Notice Privacy Notice for California Applicants: https://www.primehealthcare.com/wp-content/uploads/2024/04/Notice-at-Collection-and-Privacy-Policy-for-California-Job-Applicants.pdf
RN Utilization Review Part-time
Johns Hopkins Medicine

Utilization Mgmt Registered Nurse

Johns Hopkins Medicine Columbia, MD
$43.61 - $67.59 / hour
Make It Happen At Hopkins Evaluates the medical necessity and appropriateness of healthcare services to ensure cost-effective and quality patient care. Conducts clinical reviews, coordinates with healthcare providers, and communicates with payors to secure required authorizations. Advocates for patients and optimizes care coordination. Reviews complex inpatient, outpatient, and post-acute cases to ensure compliance with medical policy, regulatory requirements, and payor guidelines. Communicates effectively with payors and healthcare providers to resolve utilization issues, support authorization decisions, and reduce avoidable denials. Essential Functions: • Reviews patient medical records to determine the appropriateness of admissions and continued stays. • Coordinates patient cases and ensures appropriate utilization of resources. • Communicates with internal and external stakeholders for service authorizations and appeals. • Monitors patient progress and intervenes in cases, as required. • Participates in interdisciplinary team meetings for care coordination. • Documents utilization management activities and outcomes accurately. Position Details: Location: Howard County Medical Center Hours: Day Shift ( 24 hours per week) Qualifications: • Bachelor of Science in Nursing (BSN) in nursing (Required) • RN - Registered Nurse License (Required) • CPR - Basic CPR (Required) • 5+ years of experience in clinical nursing (Required) Salary Range: Minimum 43.61/hour - Maximum 67.59/hour. Compensation will be commensurate with equity and experience for roles of similar scope and responsibility. In cases where the range is displayed as a $0 amount, salary discussions will occur during candidate screening calls, before any subsequent compensation discussion is held between the candidate and any hiring authority. The Hospital reserves the right to modify employee schedules as needed. We are committed to creating a welcoming and inclusive environment, where we embrace and celebrate our differences, where all employees feel valued, contribute to our mission of serving the community, and engage in equitable healthcare delivery and workforce practices. Johns Hopkins Health System and its affiliates are drug-free workplace employers.
RN Utilization Review Full-time
Prime Healthcare

RN Case Manager - Utilization Review

Prime Healthcare Lynwood, CA
$47.20 - $63.45 / hour
Overview St. Francis Medical Center is one of the leading comprehensive healthcare institutions in Los Angeles. St. Francis provides vital healthcare services for the 700,000 adults and 300,000 children in our community who count on the hospital for high quality and compassionate medical care. St. Francis is recognized for its full range of diagnostic and treatment services in specialties including Cardiovascular, Surgical, Orthopedics, Obstetrics, Pediatrics, Behavioral Health, and Emergency and Trauma Care. In addition, the hospital offers a broad array of education and outreach programs that advance community health. St. Francis Medical Center is a Comprehensive Stroke Center, STEMI Receiving Center, ED Approved for Pediatrics, Geriatric ED, Level III Neonatal ICU, and Level II Trauma Center. Please visit www.stfrancismedicalcenter.com for more information. Join an award-winning team of dedicated professionals committed to compassion, quality, and service! Responsibilities Responsible for the quality and resource management of all patients that are admitted to the facility from the point of their admission and across the continuum of the health care management. Works on behalf of the advocate, promoting cost containment and demonstrates leadership to integrate the health care providers to achieve a perceived seamless delivery of care. The methodology is designed to facilitate and ensure the achievement of quality, clinical and cost-effective outcomes and to perform a holistic and comprehensive admission and concurrent review of the medical record for the medical necessity, intensity of service and severity of illness. Qualifications EDUCATION, EXPERIENCE, TRAINING Required Qualifications: Minimum 5 years' work experience post-graduation of an accredited school of nursing and a current state Registered Nurse license At least one year experience in case management, discharge planning or nursing management Experience and knowledge in basic to intermediate computer skills. Preferred Qualifications: Five years of acute care nursing experience. preferred CCM or obtained within 1year Knowledge of Milliman Criteria and InterQual Criteria preferred. Current BCLS certificate, preferred Pay Transparency St. Francis Medical Center offers competitive compensation and a comprehensive benefits package that provides employees the flexibility to tailor benefits according to their individual needs. Our Total Rewards package includes, but is not limited to, paid time off, a 401K retirement plan, medical, dental, and vision coverage, tuition reimbursement, and many more voluntary benefit options. Benefits may vary based on collective bargaining agreement requirements and/or the employment status, i.e. full-time or part-time. The current compensation range for this role is $47.20 to $63.45. The exact starting compensation to be offered will be determined at the time of selecting an applicant for hire, in which a wide range of factors will be considered, including but not limited to, skillset, years of applicable experience, education, credentials and licensure. Employment Status Full Time Shift Days Equal Employment Opportunity Company is an equal employment opportunity employer. Company prohibits discrimination against any applicant or employee based on race, color, sex, sexual orientation, gender identity, religion, national origin, age (subject to applicable law), disability, military status, genetic information or any other basis protected by applicable federal, state, or local laws. The Company also prohibits harassment of applicants or employees based on any of these protected categories. Know Your Rights: https://www.eeoc.gov/sites/default/files/2022-10/EEOC_KnowYourRights_screen_reader_10_20.pdf Privacy Notice Privacy Notice for California Applicants: https://www.primehealthcare.com/wp-content/uploads/2024/04/Notice-at-Collection-and-Privacy-Policy-for-California-Job-Applicants.pdf
RN Utilization Review Full-time
Prime Healthcare

RN Case Manager - Utilization Review

Prime Healthcare Lynwood, CA
$47.20 - $63.45 / hour
Overview St. Francis Medical Center is one of the leading comprehensive healthcare institutions in Los Angeles. St. Francis provides vital healthcare services for the 700,000 adults and 300,000 children in our community who count on the hospital for high quality and compassionate medical care. St. Francis is recognized for its full range of diagnostic and treatment services in specialties including Cardiovascular, Surgical, Orthopedics, Obstetrics, Pediatrics, Behavioral Health, and Emergency and Trauma Care. In addition, the hospital offers a broad array of education and outreach programs that advance community health. St. Francis Medical Center is a Comprehensive Stroke Center, STEMI Receiving Center, ED Approved for Pediatrics, Geriatric ED, Level III Neonatal ICU, and Level II Trauma Center. Please visit www.stfrancismedicalcenter.com for more information. Join an award-winning team of dedicated professionals committed to compassion, quality, and service! Responsibilities Responsible for the quality and resource management of all patients that are admitted to the facility from the point of their admission and across the continuum of the health care management. Works on behalf of the advocate, promoting cost containment and demonstrates leadership to integrate the health care providers to achieve a perceived seamless delivery of care. The methodology is designed to facilitate and ensure the achievement of quality, clinical and cost-effective outcomes and to perform a holistic and comprehensive admission and concurrent review of the medical record for the medical necessity, intensity of service and severity of illness. Qualifications EDUCATION, EXPERIENCE, TRAINING Required Qualifications: Minimum 5 years' work experience post-graduation of an accredited school of nursing and a current state Registered Nurse license At least one year experience in case management, discharge planning or nursing management Experience and knowledge in basic to intermediate computer skills. Preferred Qualifications: Five years of acute care nursing experience. preferred CCM or obtained within 1year Knowledge of Milliman Criteria and InterQual Criteria preferred. Current BCLS certificate, preferred Pay Transparency St. Francis Medical Center offers competitive compensation and a comprehensive benefits package that provides employees the flexibility to tailor benefits according to their individual needs. Our Total Rewards package includes, but is not limited to, paid time off, a 401K retirement plan, medical, dental, and vision coverage, tuition reimbursement, and many more voluntary benefit options. Benefits may vary based on collective bargaining agreement requirements and/or the employment status, i.e. full-time or part-time. The current compensation range for this role is $47.20 to $63.45. The exact starting compensation to be offered will be determined at the time of selecting an applicant for hire, in which a wide range of factors will be considered, including but not limited to, skillset, years of applicable experience, education, credentials and licensure. Employment Status Full Time Shift Days Equal Employment Opportunity Company is an equal employment opportunity employer. Company prohibits discrimination against any applicant or employee based on race, color, sex, sexual orientation, gender identity, religion, national origin, age (subject to applicable law), disability, military status, genetic information or any other basis protected by applicable federal, state, or local laws. The Company also prohibits harassment of applicants or employees based on any of these protected categories. Know Your Rights: https://www.eeoc.gov/sites/default/files/2022-10/EEOC_KnowYourRights_screen_reader_10_20.pdf Privacy Notice Privacy Notice for California Applicants: https://www.primehealthcare.com/wp-content/uploads/2024/04/Notice-at-Collection-and-Privacy-Policy-for-California-Job-Applicants.pdf
RN Utilization Review Full-time
Luminis Health

Utilization Management Nurse - Surgical Services POE

Luminis Health Annapolis, MD
$34 - $55 / hour
Position Objective: Conducts concurrent and retrospective chart review for clinical, financial, and resource utilization information. Provides intervention and coordination to decrease avoidable delays and denial of payment. Essential Job Duties: 1. Chart Review : Reviews the medical record by applying utilization review criteria, to assess clinical, financial, and resource utilization; enters clinical review in EPIC; maintains close communication with external reviews, care coordinators, and providers; reconciles and records days authorized in EPIC 2. Denial Management : Monitors and identifies patterns or trends in utilization management; monitors potential and actual denials and collaborates with care coordinator for any follow up necessary; documents actions taken to avoid denial; assists Care Coordinator in communicating with the patient denied hospital days with work toward resolution and discharge. 3. Care Coordination: Collaborates with the Care Coordinator to achieve optimal and efficient patient outcomes while decreasing length of stay, avoidable delays and denied days; utilizes Physician Advisor and administrative personnel for unresolved issues; identifies opportunities for expedited appeals and collaborates with the care coordinator and Physician Advisor to resolve payer issues. 4. Process improvement initiatives Participates in nursing unit and department clinical outcome projects as well as process improvement initiatives of care management. Educational/Experience Requirements: Bachelor’s of Science in Nursing or Associate’s degree in Nursing with equivalent experience. BSN must be achieved within 5 years of start date in the role. Three years of clinical nursing in an acute care hospital setting. Required License/Certifications: Current RN license from Maryland Board of Nursing. Working Conditions, Equipment, Physical Demands: There is a reasonable expectation that employees in this position will be exposed to blood-borne pathogens. Physical Demands - The physical demands and work environment that have been described are representative of those an employee encounters while performing the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions in accordance with the Americans with Disabilities Act. The above job description is an overview of the functions and requirements for this position. This document is not intended to be an exhaustive list encompassing every duty and requirement of this position; your supervisor may assign other duties as deemed necessary. Pay Range $34 — $55 USD Luminis Health Benefits Overview: • Medical, Dental, and Vision Insurance • Retirement Plan (with employer match for employees who work more than 1000 hours in a calendar year) • Paid Time Off • Tuition Assistance Benefits • Employee Referral Bonus Program • Paid Holidays, Disability, and Life/AD&D for full-time employees • Wellness Programs • Employee Assistance Programs and more *Benefit offerings based on employment status Opt-in for text notifications! Luminis Health's two-way SMS texting platform lets you receive notifications and messages from our Talent Acquisition team directly on your phone. To enable this feature, select "yes" when asked to "opt-in to receive text messages" and to "Receive updates from a recruiter about this job via SMS" when completing your application. Once you are opted in, you can easily opt-out at any time. Standard text messaging rates may apply based on the candidate's mobile carrier plan. Luminis Health is not responsible for any charges incurred by the recipient. Candidates are encouraged to review their mobile carrier's plan for applicable text messaging rates and usage charges.
RN Utilization Review Outpatient Full-time
Denver Health

RN Registered Nurse, Utilization - Denver Health Medical Plan (Must Live In Colorado. Weekly On Site Requirement.)

Denver Health Lincoln Park, CO
We are recruiting for a mission-driven RN Registered Nurse, Utilization - Denver Health Medical Plan (Must Live In Colorado. Weekly On Site Requirement.) to join our team! We're with you for life’s journey. At Denver Health, purpose isn’t just something we believe in—it’s something we live every day, for life’s journey. Our Values Respect | Belonging | Accountability | Transparency Department Managed Care Administration * Must live in Colorado * This is a hybrid role with a requirement of being in the office 2 days per week. Job Summary Under general supervision the RN, Utilization Coordinator performs initial inpatient or outpatient utilization review activities to determine the efficiency, effectiveness and quality of medical and behavioral health services. In collaboration with the UM Supervisor, serves as liaison between ordering and service providers and the Health Plan. Makes medical determination decisions within defined protocols based on review of the service requests, clinical and non-clinical data, Member eligibility, and benefit levels in accordance with contract and policy guidelines. Convey approval or denial of requested services, identifies and reports on specific cases, and provides information regarding utilization management requirements and operational procedures to members, providers and facilities. Essential Functions : Performs clinical review of inpatient or outpatient service request using clinical judgment, nationally accepted clinical guidelines, knowledge of departmental procedures and policies within timeliness guidelines for preservice, urgent or concurrent review. (30%) Consults on cases with Supervisor, Manager, Director or Medical Director. Requests additional info from requesting providers, as needed. (20%) Creates correspondence to Members and Providers related to clinical determination; adjusts language to appropriate literacy level to support lay person understanding of medical terminology. (15%) Routes potential denials of service/care are referred to Medical Directors for review in a comprehensive, timely and professional manner. (10%) Support and collaborate with the UM and CM Managers and Supervisors in the implementation and management of UM/CM activities. (10%) Mentors and performs peer reviews. (10%) Participates in ongoing education and training related to health plan benefits and limitations, regulatory requirements, clinical guidelines, inter-rater reliability testing, community standards of patient care, and professional nursing standards of practice. (5%) Education : Associate's Degree Completion of a nursing education program that satisfies the licensing requirements of the Colorado State Board of Nursing for Registered Nurses required Work Experience : 1-3 years clinical experience in a hospital, acute care, home health/hospice, direct care or case management required - Or - 1-3 years experience in care coordination, case management or member navigation required Medicaid and Medicare Managed Care experience preferred Home care/field-based case management, or working with the needs of vulnerable populations who have chronic medical, behavioral health or social needs preferred Certification in Case Management preferred Licenses : RN-Registered Nurse - DORA - Department of Regulatory Agencies required Knowledge, Skills and Abilities : Knowledge and understanding of case management/coordination of care principles, programs, and processes in either a hospital or outpatient healthcare environment. Effectively collaborate with and respond to varied personalities in differing emotional conditions, and maintain professional composure at all times. Strong customer service orientation and aptitude. Problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action. Ability to communicate verbally and in writing complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others. * Must live in Colorado * This is a hybrid role with a requirement of being in the office 2 days per week. Shift Days (United States of America) Work Type Regular Salary $71,400.00 - $107,100.00 / yr Benefits At Denver Health, we take care of the people who take care of our community. Our benefits are built to support your life, your family, and your future — with generous paid time off, fully paid parental leave, exceptional retirement contributions, comprehensive health coverage, and nationally recognized well-being programs. We invest in your growth through tuition assistance, career advancement pathways, and professional development — while also offering meaningful financial advantages through loan forgiveness eligibility and employer contributions. When you join Denver Health, you’re joining a mission-driven organization that invests in you. Here is a small list of our benefit programs: Paid time off starting at 28 days per year, inclusive of vacation, personal/sick, and 7 Holidays 100% paid parental leave up to 6 weeks Immediate eligibility for retirement plans with employer contribution up to 9.5% Generous medical, dental, vision plans in addition to employer paid disability and life insurance. Comprehensive well-being programs including on-site employee fitness center located on Denver Health main campus and nationally recognized RESTORE Center Free RTD EcoPass (public transportation) Childcare discount programs & exclusive perks on large brands, travel, and more Tuition reimbursement & assistance Education, coaching, and professional development opportunities through the Workforce Development Center (WFDC) that support internal career growth and advancement pathways Professional clinical advancement program & shared governance Public Service Loan Forgiveness (PSLF) eligible employer+ free student loan coaching and assistance navigating the PSLF program National Health Service Corps (NHCS) and Colorado Health Service Corps (CHSC) eligible employer About Denver Health Denver Health is an integrated, high-quality academic healthcare system considered a model for the nation that includes a Level I Trauma Center, a 555-bed acute care medical center, Denver’s 911 emergency medical response system, 10 family health centers, 19 school-based health centers, Rocky Mountain Poison & Drug Safety, the Public Health Institute at Denver Health, Denver Health Medical Plan and Denver Health Foundation. As Colorado’s primary, and essential, safety-net healthcare system, Denver Health is a mission-driven organization that has provided millions in uncompensated care for the uninsured each year. Located near downtown Denver, Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer. Denver Health is an equal opportunity employer (EOE). We value the unique ideas, talents and contributions reflective of the needs of our community. All job applicants for safety-sensitive positions must pass a pre-employment drug test, once a conditional offer of employment has been made. Applicants will be considered until the position is filled.
RN Utilization Review Full-time
MedStar Health

RN Utilization Review Nurse

MedStar Health Northwest Washington, DC
$89,065 - $162,801 / year
About this Job: General Summary of Position Conducts admission concurrent and retrospective case reviews to ensure appropriate admit status and level of care by utilizing the nationally approved guidelines. Collaborates with medical staff and ancillary hospital disciplines to ensure high-quality patient care in the most efficient way. This position is remote but must be willing to travel to Washington DC area for regular meetings. Ideal candidate living in the DC, MD or VA area is required. Primary Duties and Responsibilities Conducts admission concurrent and retrospective case reviews to meet hospital objectives of high-quality patient care in the most efficient way Strives to meet the department goals adheres to organizational policies procedures and quality standards. Complies with rules and regulations set forth by the governmental and accrediting agencies. Collaborates with medical staff physician advisor social workers and other ancillary hospital disciplines to meet patients' health care needs in the most cost-effective way. Performs patients' medical record reviews document pertinent information and communicate with third party payors in a timely fashion to ensure proper hospital reimbursement and eliminate unnecessary denials. Implements strategies to avoid potential denials by communicating with all the key stakeholders including attending physician. If necessary non-coverage ABN MOON letters and other appropriate documents as per organizational governmental and accrediting organizations policies and regulations. Actively participates in IDRs Length of Stay and other meetings as per hospital policies. Identifies potential risks pertaining to patients' care and communicates with appropriate hospital discipline including risk management quality safety and infection control. Serves as a resource to the health care team by educating the health care team through in-services staff meetings and formal educational settings in areas of utilization management. Demonstrate current knowledge of State and Federal regulatory requirements as it pertains to the utilization review process. Identifies dynamics of neglect/abuse and reports to the appropriate in-house departments and governmental agencies. Minimal Qualifications Education Associate's degree in Nursing required Bachelor's degree in Nursing preferred Experience 3 or more years' Experience in an acute care setting. required Minimum of 2 years' experience in case management insurance utilization review required Licenses and Certifications RN - Registered Nurse - State Licensure and/or Compact State Licensure in the District of Columbia or the State of Maryland depending on work location required CCM - Certified Case Manager preferred Knowledge Skills and Abilities Excellent problem-solving skills and ability to exercise independent judgment. Business acumen and leadership skills. Strong verbal and written communication skills with ability to effectively interact with all levels of management internal departments and external agencies. Working knowledge of various computer software applications. This position has a hiring range of : USD $89,065.00 - USD $162,801.00 /Yr.
RN Utilization Review Telehealth Full-time
LCMC Health

RN Care Manager - Utilization Review

LCMC Health New Orleans, LA
Your job is more than a job You overthink every care option and scenario because, as a Care Manager, you’re the hub of your patient's case management and care plan. You assure quality through the continuum of care, collaborate with members of the care team, and implement the plan of care and transition strategies. Achieving the best possible patient outcomes, appropriate length of stay, efficient utilization of resources, coordination of patient, family, and staff communication and education is the center of your nursing universe. You give new meaning to a 9 to 5 schedule because caring doesn’t stop just because you’ve punched a clock and neither does your innovative brain. If it were your loved one, you’d expect nothing less, so you give so much more. Gatekeeper, facilitator and decision-maker, and hand-holder, you apply nursing knowledge, logic, and a little “extra” heart into everything you do. We love that about you. Your experiences, knowledge, skills, empathy, compassion, and your “little something extra” all add up to you. And we’re excited to get to know you and find out what you’ll bring to this case management nursing role. Your Everyday Develop individualized care plans, including prioritized goals, that consider the patient’s and caregivers’ goals, preferences and desired level of involvement in the care management plan. Make outbound calls to assess patient’s current health status. Identify gaps or barriers in treatment plans. Coordinate care for members and makes referrals to outside sources. Ensure members discharging from hospital or emergency department receive the necessary services and resources, including medication reconciliation. Triage symptom-based calls per approved protocols for a wide range of patients. Enroll patients and manage alerts for various home monitoring programs. Provide approved general health information and guidance to public caller from approved sources by assessing needs of the caller. Document all workflows in EPIC system for purposes of tracking and quality assessment. Provide patient education to assist with self-management of wellness and disease. Educate enrolled members on chronic and acute disease processes. Interact with LCMC Health care partners, leadership and/or physicians to discuss clinical questions, concerns, strategies, and care plans to achieve quality and cost management objectives. Demonstrate energy, excitement, and a passion for quality work. The Must-Haves Minimum: Current nursing license to practice in Louisiana and as defined by the Louisiana State Board of Nursing. 2 years of professional nursing or care management experience. WORK SHIFT: Days (United States of America) LCMC Health is a community. Our people make health happen. While our NOLA roots run deep, our branches are the vessels that carry our mission of bringing the best possible care to every person and parish in Louisiana and beyond and put a little more heart and soul into healthcare along the way. Celebrating authenticity, originality, equity, inclusion and a little “come on in” attitude is the foundation of LCMC Health’s culture of everyday extraordinary Your extras Deliver healthcare with heart. Give people a reason to smile. Put a little love in your work. Be honest and real, but with compassion. Bring some lagniappe into everything you do. Forget one-size-fits-all, think one-of-a-kind care. See opportunities, not problems – it’s all about perspective. Cheerlead ideas, differences, and each other. Love what makes you, you - because we do You are welcome here. LCMC Health is an equal opportunity employer. All qualified applicants receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability status, protected veteran status, or any other characteristic protected by law. The above job summary is intended to describe the general nature and level of the work being performed by people assigned to this work. This is not an exhaustive list of all duties and responsibilities. LCMC Health reserves the right to amend and change responsibilities to meet organizational needs as necessary. Simple things make the difference. 1. To get started, take your time to fully and accurately complete the application for employment. Incomplete applications get bogged down and are often eliminated due to missing information. 2. To ensure quality care and service, we may use information on your application to verify your previous employment and background. 3. To keep our career applications up-to-date, applications are inactive after 6 months and, therefore, require a new application for employment to be completed. 4. To expedite the hiring process, proof of citizenship or immigration status will be required to verify your lawful right to work in the United States.
RN Manager/Supervisor Utilization Review Home Health Full-time
Personal Touch Home Aides of New York

RN Quality Review Manager- Registered Nurse

Personal Touch Home Aides of New York New York, NY
$90,000 - $105,000 / year
RN Quality Review Manager- Registered Nurse Brooklyn, NY This a full time , in-person position based out of Brooklyn, NY . RN new grads are welcome . Pay: $90, 000- $105, 000/ annually About Us : With over 50 years of dedicated service to our communities, Personal Touch has been a trusted provider of home care. Our priority lies in ensuring exemplary patient care while fostering a supportive and empowering workplace culture for all team members. We are currently seeking compassionate and skilled nurses to join our team and continue our legacy of providing personalized and attentive care to patients in the comfort of their own home. Why Choose Us: At Personal-Touch Home Care, we are committed to creating a rewarding and fulfilling experience for our team members. Our established history and reputation provide a stable and trusted foundation for your career. Join us in positively impacting the lives of our patients and their families. As a member of our team, you will enjoy a wide range of benefits that enhance your overall well-being and support your career growth. They include: Employee Recognition Programs: We acknowledge and celebrate your contributions. Comprehensive Health Benefits: We offer an inclusive package with Medical, Dental, Vision, Accident, and Long-Term Disability Coverage to ensure access to quality medical care while promoting overall wellness. Generous Paid Time Off: We provide generous paid time off to ensure you can recharge and return to work refreshed, leading to greater productivity and job satisfaction. We support a healthy work-life balance. Retirement Benefits: We offer a 401k plan to secure your financial future and help you save for retirement. Life Insurance: We offer company paid life insurance providing peace of mind and financial protection for you and your loved ones. Opportunities for Professional Growth and Development: Empowering you to thrive and grow. Employee Assistance Program: Supporting the well-being of you and your family. Perks Program: Exclusive deals and offers on products, services, and experiences you need and love Job Details Overview: As a RN Clinical Manager/ Quality Review Manager , you will play a pivotal role in coordinating and managing patient care to ensure the highest standards are met. This position involves supervising clinical personnel and ensuring the delivery of quality home care services. Responsibilities: Receives case referrals. Reviews available patient information related to case, including disciplines required, to determine home care needs. Reviews each case by evaluating the services provided by clinicians, performs record review, instructs and guides clinicians to promote more effective performance and delivery of quality home care services and is always available during operating hours to assist clinicians as appropriate. Establishes patient’s clinical diagnosis according to referral documentation and coding guidelines, ensuring appropriate ICD-10 Coding and sequencing as it relates to the patient’s medical condition including any comorbidities. Assists clinicians in establishing the POC including but not limited to medications review, ordered procedures/treatments, short and long-term therapeutic goals. Oversight of all patient care services and personnel. Prospective review of OASIS assessments to include Start of Care, Resumption of Care, Recertification, Transfers, and Discharge to ensure appropriateness, completeness, and compliance with state and federal regulations. Consults with the appropriate clinician to clarify any issues and/or corrections to documentation; documents same in the medical record. Track any trends issues while reviewing OASIS documentation and alerts the DOE for additional training as needed. Directs case conference meetings with Organization personnel to facilitate coordination of care. Conducts quarterly record reviews and communicates findings and recommendations to appropriate Organization personnel. Assists in the orientation of new Organization personnel as requested. Assists Director of Education in the planning, implementation and evaluations of in-service and continuing education programs. Performs direct patient care duties as appropriate. Complies with accepted professional standards and principles. Promotes customer service to all Organization personnel. Stays informed about changes in the field of home health care. Performs other duties and activities as delegated by the Administrator/Branch Director/Branch Manager. Performs all other duties as assigned. Qualifications: Registered Nurse (RN) with current licensure to practice professional nursing in the State. Graduate of an accredited nursing school; BSN degree preferred. Two (2) years of prior home health care experience. At least one (1) year of management or supervisory experience in a health care setting, preferably home care. Demonstrates excellent observation, verbal and written communication skills. Verbal and written communication skills in English. Job type: Full-time Pay: $90, 000- $105, 000/ annually We are excited to welcome passionate and dedicated individuals to join our team at Personal Touch Home Care . We’re more than just a company, we’re a close-knit family dedicated to supporting each other’s success and well-being. Apply now and join us in making a positive impact on the communities we serve.
RN Utilization Review Outpatient Full-time
UHS

RN Central Utilization Review Nurse

UHS Temecula, CA
Responsibilities Join the Southwest Healthcare Team! About Us: Creating Health and Harmony, Southwest Healthcare is a comprehensive network of care with convenient hospital and ambulatory care/outpatient locations here to serve the Southern California community. With over 6,000 passionate providers and healthcare employees, our shared goal is to provide convenient access to a wide range of healthcare services in a way that benefits you, your family, and the entire community. Southwest Healthcare is comprised of five acute care hospitals and several non-hospital access points, including: Corona Regional Medical Center, Palmdale Regional Medical Center, Southwest Healthcare Rancho Springs Hospital, Southwest Healthcare Inland Valley Hospital and Temecula Valley Hospital, Temecula Valley Day Surgery, A+ Urgent Care Centers, and Riverside Medical Clinics. For more information, please visit our website at www.swhealthcaresystem.com . Job Summary: The Southwest Healthcare Regional office in Temecula, CA is seeking a Full-Time RN Central Utilization Review Nurse who will be responsible for carrying out utilization management functions by planning, coordinating, and managing patient needs during hospitalization and throughout the continuum of care. Duties include but not limited to: Conducts admission and continued stay reviews per guidelines to ensure medical necessity of level of care and hospitalization for multiple entities. Reviews medical record for presence of accurate placement orders reconciles variances with patient providers. Works collaboratively with attending providers, specialty providers, and physician advisors to ensure application of evidence-based guidelines for determining appropriate status. Collaborates with Patient Access team to ensure correct payer source for hospitalization and communication. Ensures compliance of utilization review practices as required by payers, external regulatory agencies, and organization. Hybrid schedule may be considered after 90 days of employment. Must be available to work weekends and holidays. Benefit Highlights: Challenging and rewarding work environment. Competitive Compensation & Generous Paid Time Off. Excellent Medical, Dental, Vision and Prescription Drug Plans. 401(K) with company match and discounted stock plan. SoFi Student Loan Refinancing Program. Tuition, CEU, Certification, Licenses Reimbursement program. Career development opportunities within UHS and its 300+ Subsidiaries! More information is available on our Benefits Guest Website: UHS Guest Benefits Qualifications Experience/Training/Experience: Associates degree in Nursing or Graduate of a Vocational Nursing school required. Two (2) years of clinical experience in an acute care hospital setting with (1) year in an inpatient or outpatient case management setting required. Certifications/Licenses: Current license as a RN in the State of California required. Other Skills and Abilities: Demonstrates knowledge and ensures compliance with the Nurse Practice Act, The Joint Commission and Title 22 standards and guidelines. Demonstrates compliance with hospital policies and procedures at all times. Demonstrates strong leadership, organization, communication and interpersonal skills. Demonstrates ability to relate to clinical personnel and medical staff, as well as ability to interact well with the public. Must have knowledge of PC and applications. Capable of resolving escalated issues arising from operations and requiring coordination with other Knowledgeable in Interqual guidelines. About Universal Health Services Headquartered in King of Prussia, PA, Universal Health Services, Inc. (NYSE: UHS) is one of the nation’s largest and most respected providers of hospital and healthcare services. Since our founding in 1979, UHS has grown steadily into a premier Fortune 500® corporation perennially recognized by multiple esteemed national rating entities. Through its subsidiaries, UHS operates inpatient acute care facilities, inpatient behavioral health facilities, outpatient and other facilities, nationwide virtual behavioral health services, an insurance offering, a physician network and various related services with physical locations in the U.S., Puerto Rico, Ireland and United Kingdom. www.uhs.com . From Fortune , ©2025 , 2026 Fortune Media IP Limited. All rights reserved. Used under license. EEO Statement: All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws. We believe that diversity and inclusion among our teammates is critical to our success. Avoid and Report Recruitment Scams: We are aware of a scam whereby imposters are posing as Recruiters from UHS, and our subsidiary hospitals and facilities. Beware of anyone requesting financial or personal information. At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skill set and experience with the best possible career path at UHS and our subsidiaries. During the recruitment process, no recruiter or employee will request financial or personal information (e.g., Social Security Number, credit card or bank information, etc.) from you via email. Our recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc. If you suspect a fraudulent job posting or job-related email mentioning UHS or its subsidiaries, we encourage you to report such concerns to appropriate law enforcement. We encourage you to refer to legitimate UHS and UHS subsidiary career websites to verify job opportunities and not rely on unsolicited calls from recruiters.
RN Utilization Review Full-time
The MetroHealth System

RN Clinical Appeals Reviewer- Utilization Management

The MetroHealth System Cleveland, OH
Location: METROHEALTH MEDICAL CENTER Biweekly Hours: 80.00 Shift: 7a-330p The MetroHealth System is redefining health care by going beyond medical treatment to improve the foundations of community health and well-being: affordable housing, a cleaner environment, economic opportunity and access to fresh food, convenient transportation, legal help and other services. The system strives to become as good at preventing disease as it is at treating it. Founded in 1837, Cuyahoga County’s safety-net health system operates four hospitals, four emergency departments and more than 20 health centers. Summary Advocates for the patient and ensures that appropriate and necessary healthcare services are covered by insurance. Reviews clinical criteria to support patient care inquiries regarding the appropriateness of requested treatments, procedures, and therapies for patients of The MetroHealth System (MHS). Analyzes medical records, reviews insurance policies, and consults with healthcare providers to gather the necessary information required for the appeal process when appropriate. Participates in on-going efforts to identify and educate providers regarding evidence-based and cost-effective alternatives for care delivery. Upholds the mission, vision, values and customer service standards of the MHS. Qualifications Bachelor’s degree in nursing. Current Registered Nurse License State of Ohio. Minimum of 5 years clinical experience. Knowledge and experience with medical necessity criteria for inpatient admission and observation placement. Knowledge and experience of denials based on the absence of documented medical necessity or failure to meet severity of illness and intensity of service criteria. Knowledge of internal criteria set and Milliman Health Management Guidelines. Current working knowledge of, utilization management, case-management, performance improvement, and managed care reimbursement. Excellent interpersonal communication, critical thinking and negotiation skills. Strong analytical, data management, and PC skills. Ability to work independently and as a member of an interdisciplinary team. Ability to interact effectively with a wide range of cultural, ethnic, racial, and socioeconomic backgrounds Preferred: 3 years of experience with a Utilization Management focus. Working knowledge of current utilization management, revenue cycle, performance improvement, and / or managed care reimbursement practices. Physical Demands: May need to move around intermittently during the day, including sitting, standing, stooping, bending, and ambulating. May need to remain still for extended periods, including sitting and standing. Ability to communicate in face-to-face, phone, email, and other communications. Ability to read job-related documents. Ability to use computer.
RN Utilization Review Full-time
Atlanticare

Registered Nurse - Utilization Management - Full Time

Atlanticare Egg Harbor Township, NJ
Position Summary JOB DESCRIPTION The RN Utilization Management is responsible for the overall Utilization Management process for assigned patient population. This includes reviewing clinical information to determine the appropriate level of care assignment, along with the completion and submission of reviews to insurance payers with appropriate follow-up. The RN u tilizes Evidenced Based ""MCG"" criteria/guidelines and other approved Atlanticare applications to assess and document the medical necessity and appropriate patient status/level of care determination. This position a nalyzes clinical information received to facilitate authorization from insurance providers, maximize reimbursement by preventing denials, and ensures clinical data is sufficient to obtain an authorization. The RN works closely with Physician Advisors (PAs) to confirm that status and level-of-care mismatches, along with provider documentation concerns, are thoroughly reviewed and addressed, including follow-up on final decisions and peer-to-peer discussion outcomes as required. This position ensures that the obligation for clinical review is met according to the payer contracts and validates the accuracy of insurance information in the system. The RN is knowledgeable of the payer contracting arrangements, admission notification and clinical review requirements, as well as the regulatory and compliance requirements for government payers regarding clinical reviews and medical necessity. This role ensures that appropriate and accurate information is placed into the patient accounting system to result in clean, compliant, and timely claim processing. This role also provides notification of denial issues and potential avoidance of a denial, along with changes in insurance information to all appropriate areas (e.g. clinical team, Patient Accounting). The RN supports system-wide improvement initiatives within the hospitals and the medical staff structure to ensure effective and timely performance improvement. This role Participates in UR Committee work as requested. Qualifications EDUCATION: Graduate of an accredited school of nursing required. Bachelor's in nursing Required. Utilization/Coding certification preferred or in process. License/Certification Current licensure as a Registered Nurse in the State of New Jersey or current multi state license required. Effective Jan 2026: Current MCG (Milliman Clinical Guideline) certification required within 2 years of hire or transfer. Current incumbents must obtain MCG by 1/1/2027. American Heart Association BLS certification required within 6 months of hire or transfer. Current incumbents must obtain BLS by 6/30/2026. EXPERIENCE: Prior Utilization/insurance case management experience Preferred. Experience on MCG/InterQual, HEDIS, CDI or Quality review preferred. Recent acute care Medical-Surgical nursing experience preferred. Proficient in using common computer software applications preferred (Word, Excel formatting). Proficiency in Clinical Applications preferred at time of hire; incumbents within position will be trained appropriately and then skill will be required for this position within 30-60 days from date of hire. PERFORMANCE EXPECTATIONS Demonstrates the technical competencies as established on the Assessment and Evaluation Tool. WORK ENVIRONMENT This position requires desk/computer work a majority of the time. There is some standing, walking and occasional lifting up to 20 pounds. The essential functions for this position are listed on the Assessment and Evaluation Tool. REPORTING RELATIONSHIP This position reports to department leadership. The above statement reflects the general details considered necessary to describe the principal functions of the job as identified and shall not be considered as a detailed description of all work requirements that may be inherent in the position. About Us Total Rewards at AtlantiCare Benefits At AtlantiCare, we believe in supporting the whole person. Our market-competitive Total Rewards package is designed to promote the physical, emotional, social, and financial well-being of our team members. We offer a comprehensive suite of benefits and resources, including: Generous Paid Time Off (PTO) Medical, Prescription Drug, Dental & Vision Insurance Retirement Plans with employer contributions Short-Term & Long-Term Disability Coverage Life & Accidental Death & Dismemberment Insurance Tuition Reimbursement to support your educational goals Flexible Spending Accounts (FSAs) for healthcare and dependent care Wellness Programs to help you thrive Voluntary Benefits , including Pet Insurance and more Benefits offerings may vary based on position and are subject to eligibility requirements. Join a team that values your well-being and invests in your future. Pay Transparency In order to support the Fair Compensation Strategy by the US Govt., HR Dept., clients are required to adhere to "Pay Transparency Law" in impacted states, which mandate employers to list salary ranges in job advertisements and promotions. AtlantiCare is an Equal Opportunity Employer
RN Utilization Review Telehealth
UnitedHealthcare

Preservice Review RN - Remote in HI

UnitedHealthcare Honolulu, HI
$29 - $52 / hour
Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us in making healthcare work better for everyone through people-led, responsible AI while Caring. Connecting. Growing together. General Job Profile: Generally work is self-directed and not prescribed Works with less structured, more complex issues Serves as a resource to others If you are located in Hawaii, you will have the flexibility to work remotely* as you take on some tough challenges. Primary Responsibilities: Assesses and interprets customer needs and requirements Identifies solutions to non-standard requests and problems Solves moderately complex problems and/or conducts moderately complex analyses Works with minimal guidance; seeks guidance on only the most complex tasks Translates concepts into practice Provides explanations and information to others on difficult issues Coaches, provides feedback, and guides others Acts as a resource for others with less experience Functional Competencies: CPS_Conduct Non-Clinical Research to Support Determinations Determine that the case is assigned to the appropriate team for review (e.g., Medicare, Medicaid, Commercial) -Validate that cases/requests for services require additional research Identify and utilize appropriate resources to conduct non-clinical research (e.g., benefit documents, evidence of coverage, state/federal mandates, online resources) Prioritize cases based on appropriate criteria (e.g., date of service, urgent, expedited) Ensure compliance with applicable federal/state requirements and mandates (e.g., turnaround times, medical necessity) CPS_Review Existing Clinical Documentation Review/interpret clinical/medical records submitted from provider (e.g., office records, test results, prior operative reports) -Identify missing information from clinical/medical documentation, and request additional medical or clinical documentation as needed (e.g., LOI process, phone/fax) Review and validate diagnostic/procedure/service codes to ensure their relevance and accuracy, as applicable (e.g., PNL list, EPAL list, state grid, LCDs, NCDs) Identify and validate usage of non-standard codes, as necessary (e.g., generic codes) Apply understanding of medical terminology and disease processes to interpret medical/clinical records Make determinations per relevant protocols, as appropriate (e.g., approval, denial process, conduct further clinical or non-clinical research) Review care coordinator assessments and clinical notes, as appropriate CPS_Conduct Clinical Research to Support Determinations Identify relevant information needed to make medical or clinical determinations Identify and utilize medically-accepted resources and systems to conduct clinical research (e.g., clinical notes, MCG, medical policies, Coverage Determination Guidelines [CDG], National Comprehensive Cancer Network [NCCN], state/federal mandates) -Review/interpret other sources of clinical/medical information to support clinical or medical determinations (e.g., previous diagnoses, authorizations/denials, case management documentation) Obtain information from patients, providers and/or care coordinators as needed to verify services rendered and/or recommend additional options (e.g., Organization Determination Appeals and Grievance [ODAG], steerage calls) Apply knowledge of applicable state/federal mandates, benefit language, medical/ reimbursement policies and consideration of relevant clinical information to support determinations Collaborate with applicable internal stakeholders as needed to drive the clinical coverage review process (e.g., Medical Directors and their staff, Optum, UHC, Account Management) CPS_Make Final Determinations Based on Clinical and Departmental Guidelines Demonstrate understanding of business implications of clinical decisions to drive high quality of care Understand and adhere to applicable legal/regulatory requirements (e.g., federal/state requirements, DOI, HIPAA, CHAP, CMS, NCQA/URAC accreditation) Ask critical questions to ensure member- and customer-centric approach to work Identify and consider appropriate options to mitigate issues related to quality, safety or risk, and escalate to ensure optimal outcomes, as needed Utilize evidence-based guidelines (e.g., medical necessity guidelines, practice standards, industry standards, best practices, and contractual requirements) to make clinical decisions, improve clinical outcomes and achieve business results Identify and implement innovative approaches to the practice of nursing, in order to achieve or enhance quality outcomes Use appropriate business metrics to optimize decisions and clinical outcomes Prioritize work based on business algorithms and established work processes (e.g., assessments, case/claim loads, previous hospitalizations, acuity, morbidity rates, quality of care follow up) CPS_Achieve and Maintain Established Productivity and Quality Goals Meet/exceed established productivity goals Adhere to relevant quality audit standards in performing reviews, making determinations and documenting recommendations -Manage/prioritize workload and adjust priorities to meet quality and productivity goals CPS_Drive Effective Clinical Decisions Within a Business Environment Ask critical questions to ensure member/customer centric approach to work Identify and consider appropriate options to mitigate issues related to quality, safety or affordability when they are identified, and escalate to ensure optimal outcomes, as needed Utilize evidence-based guidelines (e.g., medical necessity guidelines, practice standards, industry standards, best practices, and contractual requirements) to make clinical decisions, improve clinical outcomes and achieve business results Identify and implement innovative approaches to the nursing role, in order to achieve or enhance quality outcomes and/or financial performance Understand and operate effectively/efficiently within legal/regulatory requirements (e.g., HIPAA, healthcare reform, URAC/NCQA/ERISA/state accreditation) You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications: Valid RN license in Hawaii Residence in Hawaii 3+ years of RN experience in an acute setting Advanced computer proficiency (Microsoft Word, Outlook, and Internet) Saturday availability Preferred Qualification: 3+ years of experience as an RN in utilization management *All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $29 - $52 per hour based on full-time employment. We comply with all minimum wage laws as applicable. At UnitedHealth Group, our mission is to help people live healthier lives and help make the health system work better for everyone. Together, we are shaping the future of healthcare by harnessing technology and innovation to make care simpler to navigate, more affordable and more connected for the people we serve. We are committed to creating an inclusive workplace where everyone feels welcomed, valued, heard and respected, empowering people to bring their authentic selves to work and strengthening our collective impact through diverse talents, backgrounds, experiences and perspectives. UnitedHealth Group and its affiliated brands are an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations. UnitedHealth Group and its affiliated brands are a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
RN Utilization Review Full-time
Cottage Health

Utilization Management Case Manager

Cottage Health Santa Barbara, CA
$60 - $92 / hour
Job Description Santa Barbara Cottage Hospital seeks a Utilization Management Case Manager for their SBCH Care Management department responsible for the utilization management, quality assurance, and discharge planning activities for assigned services/areas/patients within Cottage Health. Case management activities will result in quality outcomes, optimal care/cost management of services and/or procedures, a high level of customer satisfaction and contribution to an overall value-oriented experience of stakeholders and persons served. Qualifications QUALIFICATIONS: All job qualifications listed indicate the minimum level necessary to perform this job proficiently. Education: Minimum: Associate's Degree in Nursing (ADN). Preferred: Bachelor's Degree in Nursing (BSN). Certifications, Licenses, Registrations: Minimum: Current California Nursing license in good standing. Preferred: Certification in Case Management. Years of Related Work Experience: Minimum: 2 years direct patient care experience in an acute care setting. Other patient care experience may be considered. Preferred: Previous experience as a case manager in an acute care setting. About Us Cottage Health is a leading acute care hospital system, located on the central coast of California, widely known for our superior patient care, innovation, medical research and education. Our health system operates primarily in Santa Barbara, CA, since 1888, and consists of three acute care hospitals, a Rehabilitation Hospital, multiple clinics and a multi-site Urgent Care system. Our mission is to serve the central coast communities with excellence, integrity, and compassion. Every day we touch thousands of lives in many different ways, resolute in our mission to put patients first. We take pride in helping our patients get back to living their lives - in the places they love. Pay for non-physician positions is determined based on related years of experience and internal equity. Eligible employees may also receive additional forms of compensation, including shift differentials, on-call pay, incentive pay, and bonus opportunities, where applicable. Manager and above positions may participate in Cottage Health’s annual management incentive program. Physician compensation is determined based upon specialty and may include bonus potential. For more information on our comprehensive Total Rewards offerings, please visit https://cottagehealth.org/careers/total-rewards . If you're already a Cottage Health employee, please apply on this link only.
RN Utilization Review Full-time
Health & Hospital Corporation

Utilization Review Nurse RN

Health & Hospital Corporation Indianapolis, IN
Division:Eskenazi Health Sub-Division: Hospital Req ID: 26738 Schedule: Full Time Shift: Days Eskenazi Health serves as the public hospital division of the Health & Hospital Corporation of Marion County. Physicians provide a comprehensive range of primary and specialty care services at the 327-bed hospital and outpatient facilities both on and off of the Eskenazi Health downtown campus as well as at 10 Eskenazi Health Center sites located throughout Indianapolis. FLSA Status Exempt #EXPRNJob Role Summary The Utilization Review Nurse works behind the scenes to maximize the quality and cost efficiency of health care services. Through regular reviews and audits, ensures that patients receive the care they need without burdening the health care system with unnecessary procedures, ineffective treatments or overlong hospital stays. This position is responsible for ensuring the provision of quality patient care, effective utilization of available health services, review of medical necessity of admissions, and necessity for continued stay in hospital; analyzes patient records to ensure compliance with government and insurance company reimbursement policies and accrediting standards.Essential Functions and Responsibilities Work behind the scenes to maximize the quality and cost efficiency of health care services. Through regular reviews and audits, ensure that patients receive the care they need without burdening the health care system with unnecessary procedures, ineffective treatments or overlong hospital staysCommunicates secondary review decisions determining appropriate patient status provided by secondary reviewer processEnsuring the provision of quality patient care, effective utilization of available health services, review of medical necessity of admissions, and necessity for continued stay in hospital; analyzes patient records to ensure compliance with government and insurance company reimbursement policies and accrediting standardsResponsible for managing each patient's plan of care, monitoring for appropriate resource utilization, and collaborating with the inpatient team as well as outpatient providers to coordinate the patient's transition plan of care Serves as a patient advocate, ensuring that efficient health care is provided. The role is to provide primary nurse support through all aspects of utilization management across the continuum of care and is not limited to the initial review processAssesses degree of medical necessity for any patient seen in the Emergency Department and perform Utilization Review using the Eskenazi Health approved clinical decision support criteriaReviews patients' admissions for appropriateness and type. Refers case to Medical Director and/or Department leadership for review when case fails to meet admission standardsCoordinates the most accurate and appropriate patient status for care Identifies strategies to reduce the length of stay and resource consumption within the appropriate length of stayAssesses patient's health status through collection of information from EMR, interview any other relevant sources to collect specific information in an attempt to provide the necessary determination for patient's status for appropriate medical regimenTrack readmissions and Emergency Department visits for patients assignedCompletes an admission review even when the patient under assessment has been relocated to an admitted or observation bedCollaborates with Emergency Physicians and Attending Physicians to ensure that patients meet criteria for Admission, Placement on Observation Status or neitherOversees the initial admission review, utilizing criteria, within 24-48 hours of the patient's admission to the hospital to ensure appropriateness of the assigned level of care and timely implementation of the treatment plan Applies appropriate clinical criteria to complete initial reviews within 24-48 hours of patient presentationCommunicate with the Inpatient Case Manager to ensure appropriate status and level of care for patient, and that transition plan is implemented with determined goals in mindCommunicates with Payor Specialist for UR/UM to ensure proper status change and accurate billing practicesEvaluatesthe active funding for each patient and communicates with Inpatient Case Manager/Social Worker to facilitate initiation of appropriate funding applicationsDemonstrates knowledge of levels of care of Inpatient and Outpatient statusEnsures that transitions to post-acute services such as Acute Rehabilitation Centers is appropriate and streamlined, and home care services, as well as durable medical equipment is appropriately utilizedEnsure the need for any services not provided at Eskenazi Health is evaluated and appropriate authorization is given and documentedJob Requirements Current Indiana nursing license requiredMinimum of 4 years clinical nursing experience requiredKnowledge, Skills & Abilities Must demonstrate knowledge of the Utilization Management managed care processesCompetency in the following areas required: interpersonal, written/verbal communication, and negotiation skills diplomacy, flexibility, and professionalism cohesive networking with the Interdisciplinary Team Accredited by The Joint Commission and named one of the nation’s 150 best places to work by Becker’s Hospital Review for four consecutive years and Forbes list of best places to work for women, and Forbes list of America’s best midsize employers’ Eskenazi Health’s programs have received national recognition while also offering new health care opportunities to the local community. As the sponsoring hospital for Indianapolis Emergency Medical Services, the city’s primary EMS provider, Eskenazi Health is also home to the first adult Level I trauma center in Indiana, the first verified adult burn center in Indiana, the first community mental health center in Indiana and the Eskenazi Health Center Primary Care – Center of Excellence in Women’s Health, just to name a few.
RN Utilization Review Full-time
Cottage Health

Utilization Management Case Manager

Cottage Health Santa Barbara, CA
$60 - $92 / hour
Job Description Santa Barbara Cottage Hospital seeks a Utilization Management Case Manager for their SBCH Care Management department responsible for the utilization management, quality assurance, and discharge planning activities for assigned services/areas/patients within Cottage Health. Case management activities will result in quality outcomes, optimal care/cost management of services and/or procedures, a high level of customer satisfaction and contribution to an overall value-oriented experience of stakeholders and persons served. Qualifications QUALIFICATIONS: All job qualifications listed indicate the minimum level necessary to perform this job proficiently. Education: Minimum: Associate's Degree in Nursing (ADN). Preferred: Bachelor's Degree in Nursing (BSN). Certifications, Licenses, Registrations: Minimum: Current California Nursing license in good standing. Preferred: Certification in Case Management. Years of Related Work Experience: Minimum: 2 years direct patient care experience in an acute care setting. Other patient care experience may be considered. Preferred: Previous experience as a case manager in an acute care setting. About Us Cottage Health is a leading acute care hospital system, located on the central coast of California, widely known for our superior patient care, innovation, medical research and education. Our health system operates primarily in Santa Barbara, CA, since 1888, and consists of three acute care hospitals, a Rehabilitation Hospital, multiple clinics and a multi-site Urgent Care system. Our mission is to serve the central coast communities with excellence, integrity, and compassion. Every day we touch thousands of lives in many different ways, resolute in our mission to put patients first. We take pride in helping our patients get back to living their lives - in the places they love. Pay for non-physician positions is determined based on related years of experience and internal equity. Eligible employees may also receive additional forms of compensation, including shift differentials, on-call pay, incentive pay, and bonus opportunities, where applicable. Manager and above positions may participate in Cottage Health’s annual management incentive program. Physician compensation is determined based upon specialty and may include bonus potential. For more information on our comprehensive Total Rewards offerings, please visit https://cottagehealth.org/careers/total-rewards . If you're already a Cottage Health employee, please apply on this link only.
RN Utilization Review Full-time
Health & Hospital Corporation

RN - Utilization Review Nurse

Health & Hospital Corporation Indianapolis, IN
Division:Eskenazi Health Sub-Division: Hospital Req ID: 26738 Schedule: Full Time Shift: Days Eskenazi Health serves as the public hospital division of the Health & Hospital Corporation of Marion County. Physicians provide a comprehensive range of primary and specialty care services at the 327-bed hospital and outpatient facilities both on and off of the Eskenazi Health downtown campus as well as at 10 Eskenazi Health Center sites located throughout Indianapolis. FLSA Status Exempt #EXPRNJob Role Summary The Utilization Review Nurse works behind the scenes to maximize the quality and cost efficiency of health care services. Through regular reviews and audits, ensures that patients receive the care they need without burdening the health care system with unnecessary procedures, ineffective treatments or overlong hospital stays. This position is responsible for ensuring the provision of quality patient care, effective utilization of available health services, review of medical necessity of admissions, and necessity for continued stay in hospital; analyzes patient records to ensure compliance with government and insurance company reimbursement policies and accrediting standards.Essential Functions and Responsibilities Work behind the scenes to maximize the quality and cost efficiency of health care services. Through regular reviews and audits, ensure that patients receive the care they need without burdening the health care system with unnecessary procedures, ineffective treatments or overlong hospital staysCommunicates secondary review decisions determining appropriate patient status provided by secondary reviewer processEnsuring the provision of quality patient care, effective utilization of available health services, review of medical necessity of admissions, and necessity for continued stay in hospital; analyzes patient records to ensure compliance with government and insurance company reimbursement policies and accrediting standardsResponsible for managing each patient's plan of care, monitoring for appropriate resource utilization, and collaborating with the inpatient team as well as outpatient providers to coordinate the patient's transition plan of care Serves as a patient advocate, ensuring that efficient health care is provided. The role is to provide primary nurse support through all aspects of utilization management across the continuum of care and is not limited to the initial review processAssesses degree of medical necessity for any patient seen in the Emergency Department and perform Utilization Review using the Eskenazi Health approved clinical decision support criteriaReviews patients' admissions for appropriateness and type. Refers case to Medical Director and/or Department leadership for review when case fails to meet admission standardsCoordinates the most accurate and appropriate patient status for care Identifies strategies to reduce the length of stay and resource consumption within the appropriate length of stayAssesses patient's health status through collection of information from EMR, interview any other relevant sources to collect specific information in an attempt to provide the necessary determination for patient's status for appropriate medical regimenTrack readmissions and Emergency Department visits for patients assignedCompletes an admission review even when the patient under assessment has been relocated to an admitted or observation bedCollaborates with Emergency Physicians and Attending Physicians to ensure that patients meet criteria for Admission, Placement on Observation Status or neitherOversees the initial admission review, utilizing criteria, within 24-48 hours of the patient's admission to the hospital to ensure appropriateness of the assigned level of care and timely implementation of the treatment plan Applies appropriate clinical criteria to complete initial reviews within 24-48 hours of patient presentationCommunicate with the Inpatient Case Manager to ensure appropriate status and level of care for patient, and that transition plan is implemented with determined goals in mindCommunicates with Payor Specialist for UR/UM to ensure proper status change and accurate billing practicesEvaluatesthe active funding for each patient and communicates with Inpatient Case Manager/Social Worker to facilitate initiation of appropriate funding applicationsDemonstrates knowledge of levels of care of Inpatient and Outpatient statusEnsures that transitions to post-acute services such as Acute Rehabilitation Centers is appropriate and streamlined, and home care services, as well as durable medical equipment is appropriately utilizedEnsure the need for any services not provided at Eskenazi Health is evaluated and appropriate authorization is given and documentedJob Requirements Current Indiana nursing license requiredMinimum of 4 years clinical nursing experience requiredKnowledge, Skills & Abilities Must demonstrate knowledge of the Utilization Management managed care processesCompetency in the following areas required: interpersonal, written/verbal communication, and negotiation skills diplomacy, flexibility, and professionalism cohesive networking with the Interdisciplinary Team Accredited by The Joint Commission and named one of the nation’s 150 best places to work by Becker’s Hospital Review for four consecutive years and Forbes list of best places to work for women, and Forbes list of America’s best midsize employers’ Eskenazi Health’s programs have received national recognition while also offering new health care opportunities to the local community. As the sponsoring hospital for Indianapolis Emergency Medical Services, the city’s primary EMS provider, Eskenazi Health is also home to the first adult Level I trauma center in Indiana, the first verified adult burn center in Indiana, the first community mental health center in Indiana and the Eskenazi Health Center Primary Care – Center of Excellence in Women’s Health, just to name a few.
RN Utilization Review
Community First Medical Center

Case Manager - Utilization Review RN

Community First Medical Center Chicago, IL
$43.47 - $53 / hour
Description Under the general direction of the Director of Behavioral Health, the Case Manager – Utilization Review RN provides clinically based case management and utilization review services to support the delivery of high-quality, cost-effective patient care. The RN is responsible for concurrent utilization review, medical necessity determination, denial prevention, discharge planning, care coordination, and resource management across the continuum of care. The Case Manager – Utilization Review RN collaborates with physicians, interdisciplinary team members, physician advisors, social workers, revenue cycle staff, and third-party payers to ensure appropriate utilization of hospital resources, regulatory compliance, optimal reimbursement, and safe patient transitions. Community First Medical Center offers benefits to all its full-time and part-time employees : United Healthcare Medical PPO/HMO/HSA Plans, premiums as low as $50.00/full time, $85.00/Part Time Met Life Dental and Vision Paid Time Off (PTO) with annual accruals up to 168 hrs./year Six paid holidays Company Paid Life insurance and Short-term Disability 401(k) after 90 days Continuing Education reimbursement and 2 days paid off separate from PTO Free Parking Garage Internal Growth Opportunities Requirements To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. QUALIFICATIONS Education Associate Degree in Nursing required. Bachelor of Science in Nursing (BSN) preferred. Experience Minimum three (3) years of acute care nursing experience required. Minimum two (2) years of Case Management and/or Utilization Review experience preferred. Experience with discharge planning, utilization review, denial management, and payer authorization preferred. Licensure Current Illinois Registered Nurse license required. ACM, CCM, or CMAC certification preferred. KNOWLEDGE, SKILLS & ABILITIES Knowledge of Medicare, Medicaid, and commercial insurance regulations. Working knowledge of InterQual and/or MCG criteria. Behavioral Health background knowledge Access to Behavioral Health Networks Understanding of utilization management and care coordination principles. Knowledge of discharge planning and post-acute care resources. Strong analytical and critical thinking skills. Excellent verbal and written communication skills. Ability to prioritize multiple complex patient cases. Ability to build collaborative relationships with physicians and interdisciplinary teams. Computer proficiency and electronic medical record experience. PERFORMANCE EXPECTATIONS Success in this role is measured by: Appropriate admission status determination Denial prevention and appeal success Timely discharge planning Reduction in avoidable days Average Length of Stay management Readmission reduction Documentation compliance Regulatory compliance Patient throughput Patient and physician satisfaction
RN Utilization Review Full-time
Havenwyck Hospital

Utilization Management Case Manager

Havenwyck Hospital Lake Angelus, MI
Responsibilities HAVENWYCK HOSPITAL (a UHS facility) Havenwyck Hospital is a Joint Commission-accredited and licensed psychiatric hospital, overlooking Lake Galloway in Auburn Hills, Michigan. We specialize in providing comprehensive, compassionate behavioral health services to children, adolescents and adults. It is the ultimate goal of our dedicated staff to build strength, confidence and knowledge within each patient, in hopes that they may continue learning and understanding their needs and practicing self-care for the rest of their lives. If you would like to learn more about this position before applying, please contact Havenwyck Hospital at 248-373-9200. POSITION SUMMARY: The Utilization Management Case Manager has a responsibility for organizing and conducting the manager care process. These duties shall be directed toward supporting the hospital's mission in the pursuit of excellence in care/service and will include (but not limited to ): conducting timely admission and continues stay record reviews with external payers, utilizing approved criteria to make determinations of medical necessity and level of care planning, verifying active treatment by completing internal audit reviews within approved time frames, assisting the treatment team when indicated in the discharge planning process, and acting as liaison with MD/Clinical Treatment Team and external agencies. Report authorizations, denials, and documentation concerns, as well as collaborate effectively across departments to minimize denials/facilitate optimal use of hospital resources. DUTIES AND RESPONSIBILITIES: Through clinical skills (experience and knowledge), reports to external insurance and review entities an accurate presentation of the medical management of a patient's illness, length of stay and care alternatives available within the confines on the client's benefits and financial resources. Communicates with the Treatment Team (physicians, nursing staff, social workers, etc.) as necessary to advocate for the patient's clinical treatment within the confines on the client's benefits and financial resources. Using clinical skills (experience and knowledge) assists the team in ensuring the completeness and accuracy of the medical records. Performs other related duties as assigned. BENEFIT HIGHLIGHTS: Challenging and rewarding work environment Competitive Compensation & Generous Paid Time Off Excellent Medical, Dental, Vision and Prescription Drug Plan 401(K) with company match and discounted stock plan Career development opportunities within UHS and its 300+ Subsidiaries Free Basic Life Insurance Tuition Reimbursement SoFi Student Loan Refinancing Program Student Loan Repayment Program - for some degrees and criteria What do our current employees value at Havenwyck Hospital and UHS? An environment that puts patient care first. One of the most rewarding aspects of this job is providing excellent care, comfort, and security to the patients and families you treat, at their most vulnerable times. Supportive and responsive leadership. You are never alone, as you are part of a large network of peer co-workers that routinely exchange ideas and review current topics within the industry. Having the opportunity to grow, learn, and advance in your career. There are very robust continuing education options and opportunities for skills diversification and career advancement with UHS. About Universal Health Services One of the nation’s largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (UHS) has built an impressive record of achievement and performance. Growing steadily since its inception into an esteemed Fortune 500® corporation, annual revenues during 2025 were $17.4 billion. In 2026, UHS was again recognized as one of Fortune World’s Most Admired Companies™ and in 2025, was listed in Forbes ranking of America’s Largest Public Companies. Headquartered in King of Prussia, PA, UHS has approximately 101,500 employees and continues to grow through its subsidiaries. Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory care access points, an insurance offering, a physician network and various related services located in 40 U.S. states, Washington, D.C., Puerto Rico and the United Kingdom. For additional information visit www.uhs.com . Qualifications QUALITICATIONS: Bachelor Degree in social work, psychology, counseling or nursing required. Master's degree in social work, psychology, or counseling preferred. Limited or fully licensed (LBSW, RN, LLMSW, LLP, TLLP, LPC, LMFT, etc.). A minimum of 2 years of post-graduate related experience in psychiatric or substance abuse treatment required. Hospital utilization review/utilization management experience preferred. Familiarity with manager health care process, medical terminology, experience in case management, discharge planning, and/or utilization review preferred. EEO Statement All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws. We believe that diversity and inclusion among our teammates is critical to our success. Avoid and Report Recruitment Scams We are aware of a scam whereby imposters are posing as Recruiters from UHS, and our subsidiary hospitals and facilities. Beware of anyone requesting financial or personal information. At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skill set and experience with the best possible career path at UHS and our subsidiaries. During the recruitment process, no recruiter or employee will request financial or personal information (e.g., Social Security Number, credit card or bank information, etc.) from you via email. Our recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc. If you suspect a fraudulent job posting or job-related email mentioning UHS or its subsidiaries, we encourage you to report such concerns to appropriate law enforcement. We encourage you to refer to legitimate UHS and UHS subsidiary career websites to verify job opportunities and not rely on unsolicited calls from recruiters.
RN Utilization Review Med-Surg Full-time
Emanate Health

Quality Review Nurse - Med Surg/DOU - Full Time - Days 8hr FPH

Emanate Health Glendora, CA
$54.63 - $84.67 / hour
Current Emanate Health Employees - Please log into your Workday account to apply Everyone at Emanate Health plays a vital role in the care we deliver. No matter what department you belong to, the work you do at Emanate Health affects lives. When you join Emanate Health, you become part of a team that works together to strengthen our communities and grow as individuals. On Glassdoor's list of "Best Places to Work" in 2021, Emanate Health was named the #1 ranked health care system in the United States, and the #19 ranked company in the country. Job Summary Provides expertise to the organization in the form of quality management review and performance improvement knowledge. Supports the hospital units and staff in preparation for surveys, clinical documentation review, regulatory needs and rounding on patients with discharge calls. Assists in the review process and peer education/correction. Psych - Provides expertise to the organization in the form of quality management review and performance improvement knowledge. Supports the Psychiatric unit and staff in preparation for surveys, clinical documentation review, regulatory needs and rounding on patients with discharge calls. Assists in the review process and peer education/correction. Job Requirements Minimum Education Requirement : BSN preferred. Minimum Experience Requirement : Minimum of three years of acute care experience. Excellent customer service skills required. Experience in Telemetry, DOU, or Neuroscience preferred Experience in MedSurg, Telemetry, Orthopedics, or Oncology preferred Minimum License Requirement : California RN license and BLS required. ACLS required within 90 days of hire or transfer. NIHSS Stroke Certification required within 90 days of hire or transfer. Delivering world-class health care one patient at a time. Pay Range: $54.63 - $84.67