Registered Nurse (RN) Utilization Review Jobs

RN Utilization Review Full-time
Munson Healthcare

Utilization Review Specialist (RN)

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. 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 Full-time
Valley Children's Healthcare

Utilization Management Registered Nurse

Valley Children's Healthcare Madera, CA
$60.15 - $85.81 / hour
Job Summary: The Utilization Management Nurse supports the case management department by providing a variety of utilization management functions including but not limited to daily screening of patient admission relative to specified criteria, active involvement in denial management, acting as a resource to staff regarding clinical criteria, communication with payors to address concerns and other duties as assigned. The Utilization Management Nurse will work collaboratively with the Utilization Nurse Program Coordinator to ensure compliance with regulatory, organizational and department requirements. The Utilization Review Nurse will receive direction from the Utilization Review Program Coordinator for daily and long term tasks and projects. Qualifications: Schedule Full-time 9 shifts per two-week pay period Shift: 11:00 a.m. – 7:30 p.m. with rotating weekend coverage Hybrid Position – Primarily remote/work-from-home, with an expectation to be on-site at least once per month, or more frequently as business needs or projects require. Candidates must reside locally and be able to commute to the worksite as needed. Education Associates Degree Nursing (required) Bachelors Degree Nursing or related field (preferred) Licenses and Certifications RN - Registered Nurse License - CA-BRN - California Board of Registered Nursing (required) Work Experience Minimum three (3) years Full time equivalent RN experience in an acute care hospital. (required) Pediatric experience and experience in Case Management and/or Utilization Review. (preferred) Skills and Abilities Knowledge of UM regulations. Knowledge of private and public payer reimbursement practices and procedures. Excellent organizational and communication skills and ability to work with a variety of health care professionals. Ability to work independently. Computer Skills Proficiency with word processing, spreadsheets and database software. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed above 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. Compensation Range: $60.15 - $85.81 Workshift: Day (United States of America) Position Exempt: No FTE %: 90 Scheduled Weekly Hours: 36 Daily Hours: 8 Have Questions? Call Recruitment Services at 559-353-7071 or email us at recruiting@valleychildrens.org Disclaimer: Final compensation will be dependent upon skills and experience.
RN Utilization Review Outpatient Full-time
CentralCare Inc

Registered Nurse- Utilization Management

CentralCare Inc San Antonio, TX
Join our team at Lackland Air Force Base and become part of a mission-driven healthcare team dedicated to providing exceptional support to active-duty service members, retirees, and their families. If you're looking for a rewarding career with excellent benefits and the opportunity to serve those who serve our nation, we'd love to hear from you! Registered Nurse –Utilization Management - Lackland AFB Location: San Antonio, TX Degree/Education Requirements: Bachelor of Science in Nursing Graduate from a college or university accredited by National League for Nursing Accrediting Commission (NLNAC), or The Commission on Collegiate Nursing Education (CCNE). Required Experience: Three years of experience in nursing Must have knowledge of medical privacy and confidentiality (Health Insurance Portability and Accountability Act [HIPAA]), and accreditation standards of Accreditation Association for Ambulatory Health Care (AAAHC) Must have a working knowledge of computer applications/software to include Diagnostic Related Grouping (DRGs). Must be able to collect clinical data from inpatient and outpatient sources; provide documentation for appeals or grievance resolution; apply critical thinking skills and expertise in resolving complicated healthcare, social, interpersonal, and financial patient situations; Licensure/Registration: Current, full, active, and unrestricted license to practice as a Registered Nurse. Job Responsibilities.: Coordinate patient care in collaboration with a wide array of healthcare professionals. Ensure compliance with standards of care and practice in accordance with all established policies, procedures, and guidelines used in the MTF. Direct and supervise care provide by other healthcare professionals Make referral appointments and arrange specialty care as appropriate. Conduct research in support of improved practice and patient outcomes. Develops and implements a comprehensive Utilization Management plan/program in accordance with the facility's goals and strategic objectives. Performs data/metrics collection on identified program areas; analyzes and trends results, including over- and underutilization of healthcare resources. Identifies areas for improvement and cost containment. Reports utilization patterns Analyzes medical referrals/appointments and general hospital procedures and regulations by monitoring specialty care referrals for appropriateness, covered benefits, and authorized surgery/medical procedures, laboratory, radiology, and pharmacy. Performs medical necessity review for planned inpatient and outpatient surgery; and performs concurrent review to include length of stay (LOS) for the facility's inpatients using appropriate criteria. Reviews previous and present medical care practices for patterns; trends incidents of under or over- utilization of resources incidental to providing medical care. Acts as referral approval authority for designated referrals Verifies eligibility of beneficiaries using Defense Eligibility Enrollment Reporting System (DEERS). Obtains pertinent information from patients/callers and updates data MHS Genesis, local referral database, and other office automation software programs. Make a Difference Where It Matters Join Central Care Incorporated at Lackland AFB and make a difference—one patient at a time. About Central Care Inc. Central Care Incorporated is an equal opportunity employer. We encourage applications from candidates of all backgrounds and experiences to apply.
RN Home Health Utilization Review Home Health Full-time
St. Peter's Health Partners

Registered Nurse (RN) Coder OASIS Review - Eddy Visiting Nurse and Rehab Association

St. Peter's Health Partners Troy, NY
$36 - $47.52 / hour
Employment Type: Full time Shift: Day Shift Description: Come join the satisfied, long-term staff of this 5 out of 5 Star Agency. There’s not a local agency that compares to us! Eddy Visiting Nurse and Rehab Association has a rewarding opportunity for a per diem, part time, or full time Registered Nurse (RN) CODER/OASIS Reviewer to join our interdisciplinary Home Care team! Flexibility to work remote What you will do: The role of the coding/OASIS position is to code and complete OASIS reviews on SOC, ROC, and RECERTS, meeting Coding and OASIS guidelines. We take pride in our job at EVNRA working closely with the clinical team to achieve a 5 Star - Top 6% in the country. Requirements: Valid NYS Registered Nurse license Must have current HCS-D Must have either current HCS-O or COS-C (preferred). COS-C Certification would have to be obtained within a year of hire if missing. Must have one year of previous experience in the health care field. Additional experience working with seniors and/or in home care field preferred. Offering flexible shift and shift length options! Apply now for more information! Pay Range:$36.00 - $47.52 Pay is based on experience, skills, and education. Exempt positions under the Fair Labor Standards Act (FLSA) will be paid within the base salary equivalent of the stated hourly rates. The pay range may also vary within the stated range based on location. Our Commitment Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.
RN Utilization Review
L.A. Care Health Plan

Utilization Management Admissions Liaison RN II

L.A. Care Health Plan Los Angeles, CA
$88,854 - $142,166 / year
Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job Summary The Utilization Management (UM) Admissions Liaison RN II is primarily responsible for receiving/reviewing admission requests and higher level of care (HLOC) transfer requests from inpatient facilities within regular timelines. Reviews clinical data in real-time and post admission to issue a determination based on clinical criteria for medical necessity. Assures timely, accurate determination and notification of admission and inter-facility transfer requests. Generates approval, modification, and denial communications for inpatient admission requests. Actively monitors for appropriate level of care (inpatient vs. observation) admission in the acute setting. Works with UM leadership, including the Utilization Management Medical Director, on requests where determination requires extended review. Collaborates with the inpatient care team for facilitation/coordination of patient transfers between acute care facilities. Acts as a department resource for medical service requests/referral management and processes. Actively participates in the discharge planning process, including providing clinical review and authorization for alternate levels of care, home health, durable medical equipment, and other discharge needs. Provides support to the inpatient review team as necessary to ensure timely processing of concurrent reviews. Duties Provides the primary clinical point of contact for inpatient acute care hospitals requesting Inpatient care/post-stabilization admission requests, Higher level of care transfers and other emergent transfers or needs. Ensures appropriate determination for admission requests/HLOC transfers based on clinical data presented and established criteria/guidelines, escalating to the medical director if needed. Triages and assesses members for admission needs, including, but not limited to, bed and accepting physician availability. (40%) Establishes and maintains ongoing communication with internal stakeholders and external customers while securing the L.A. Care member's admission or inter-facility transfer. Interfaces with physicians, house supervisors, and other hospital delegates to ensure that telephone triage results in appropriate patient placement. (10%) Applies clinical expertise and the nursing process to triage and prioritize admission acuity, servicing as an expert clinical resource for patient placement while utilizing medical knowledge and experience to facilitate consensus-building and development of satisfactory outcomes (10%) Continually seeks new ways to improve processes and increase efficiencies. Takes the initiative to communicate recommendations to UM Leadership. (5%) Completes all inpatient and discharge planning requests appropriately and timely including, but not limited to: Skilled nursing facility, outpatient needs (home health, physical therapy, infusion), and case management referrals (5%) Performs prospective, concurrent, post-service, and retrospective claim medical review processes. Utilizes clinical judgement, independent analysis, critical-thinking skills, detailed knowledge of medical policies, clinical guidelines and benefit plans to complete reviews and determinations within required turnaround times specific to the case type. Identifies requests needing medical director review or input and presents for second level review (20%) Performs other duties as assigned. (10%) Duties Continued Education Required Associate's Degree in NursingEducation Preferred Bachelor's Degree in NursingExperience Required: Minimum of 7 years of clinical experience in an acute hospital setting. Previous experience to have a strong understanding of Utilization Management/Case Management practices including, but not limited to, placement (with level of care) criteria (MCG, InterQual), concurrent review, and discharge planning. Preferred: Consistent Critical Care experience (Emergency Department, Intensive Care, Labor & Delivery) background highly desirable. Experience in bed placement decision-making highly desirable. Skills Required: Must be computer literate, with expertise in Outlook, Word, Excel, PowerPoint. Provision of excellent customer service required due to frequent communication with providers and other members of the interdisciplinary team Knowledge of personal computer, keyboarding, and appropriate software to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment. Prepare clear, comprehensive written and oral reports and materials. Excellent time management and priority-setting skills. Maintains strict member confidentiality and complies with all HIPAA requirements. Strong verbal and written communication skills. Preferred: Knowledge of National Committee for Quality Assurance (NCQA) requirements for Utilization Management or CM. Knowledge of Department of Health Care Services (DHCS) or Centers for Medicare and Medicaid Services(CMS) requirements for health plan compliance with UM or CM. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California LicenseLicenses/Certifications Preferred Certified Case Manager (CCM)American Case Management Association (ACM)Required Training Physical Requirements LightAdditional Information Required: Attend mandatory department trainings as scheduled Financial Impact: Management of all medical services has a tremendous potential impact on the cost of health care and budget. This position manages determinations to ensure services requested are medically appropriate and provided in the most cost effective manner without compromising quality healthcare delivery. Types of Shift: Day (7:00am - 3:30pm), Evening (3:00pm -11:30 pm), Night (11:00pm -7:30am). Float (Varies)* *All possible shifts. 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 Outpatient Utilization Review Outpatient
L.A. Care Health Plan

Utilization Management Nurse Specialist RN II (Outpatient)

L.A. Care Health Plan Los Angeles, CA
$88,854 - $142,166 / year
Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job Summary The Utilization Management Nurse Specialist RN II facilitates, coordinates, and approves medically necessary referrals that meet established criteria. Assures timely and accurate determination and notification of referrals and reconsiderations based on the referral determination status. Generates approval, modification and denial communications, to include member and provider notification of referral determination. Actively monitors for admissions in any inpatient setting. Performs telephonic and/or onsite admission and concurrent review, and collaborates with onsite staff, physicians, providers, member/family interaction to develop and implement a successful discharge plan. Works with the UM Manager and Physician Advisor on case reviews for pre-service, concurrent, post-service and retrospective claims medical review. Monitors and oversees the collection and transfer of data (medical records) and referral requests by Providers. Acts as a department resource for medical service requests /referral management and processes. Receives incoming calls from providers, professionally handles complex calls, researches to identify timely and accurate resolution steps. Follows up with caller to provide response or resolution steps. Answers all inquiries in a professional and courteous manner. Duties Promote and support team engagements, programs and activities to create and ensure a positive and productive workplace environment. Perform telephonic and/or onsite admission and concurrent review, and collaborates with onsite staff, physicians, providers, the member and significant others to develop and implement a successful discharge plan. Process, finalize and facilitate inbound requests that are received from providers. Generate appropriate member and provider communication for all determinations within the required timelines as defined by the most current department policy. Facilitate/review requests for Higher level of care or skilled nursing/discharge planning needs. Research for appropriate facilities, specialty providers and ancillary providers to utilize for all lines of business. Identification of potential areas of improvement within the provider network. Identify and initiate referrals for appropriate members to the various L.A. Care programs/processes and external community based programs or Linked and Carve Out Services (e.g. DDS/CCS/MH). Potential quality of care/potential fraud issues are identified and documented per L.A. Care policy. High risk/high cost cases and reports are maintained and referred to the Physician Advisor/UM Director. Document in platform/system of record. Utilize designated software system to document reviews and/or notes. Receive incoming calls from providers, professionally handle complex calls, research to identify timely and accurate resolution steps. Follow up with caller to provide response or resolution steps. Answer all inquiries in a professional and courteous manner. Perform other duties as assigned. Duties Continued Education Required Associate's Degree in NursingEducation Preferred Bachelor's Degree in NursingExperience Required: At least 5 years of varied RN clinical experience in an acute hospital setting. At least 2 years of Utilization Management/Case Management experience in a hospital or HMO setting . Preferred: Managed Care experience performing UM and CM at a medical group or management services organization. Experience with Managed Medi-Cal, Medicare, and commercial lines of business. Skills Required: Must be computer literate, with expertise in Outlook, Word, Excel, PowerPoint. Effectively utilizes computer and appropriate software and interacts as needed with L.A. Care Information System. Knowledge of personal computer, keyboarding, and appropriate software to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment. Prepare clear, comprehensive written and oral reports and materials. Provision of excellent customer service required due to frequent communication with providers and other members of the interdisciplinary team Excellent time management and priority-setting skills. Maintains strict member confidentiality and complies with all HIPAA requirements. Strong verbal and written communication skills. Preferred: Knowledge of National Committee for Quality Assurance (NCQA) requirements for Utilization Management or Care Management (CM). Knowledge of Department of Health Care Services (DHCS) or Centers for Medicare and Medicaid Services(CMS) requirements for health plan compliance with UM or CM. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California LicenseLicenses/Certifications Preferred Certified Case Manager (CCM)Required Training Physical Requirements LightAdditional Information May work on occasional weekends and some holidays depending on business needs. 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 Home Health Full-time
VNS Health

Utilization Management RN - Utilization Management

VNS Health New York, NY
$85,000 - $106,300 / year
Overview Assesses member needs and identifies solutions that promote high quality and cost-effective health care services. Manages providers, members, team, or care manager generated requests for medical services and renders clinical determinations in accordance with healthcare policies as well as applicable state and federal regulations. Delivers timely notification detailing clinical decisions. Coordinates with management, subject matter experts, physicians, member representatives, and discharge planners in utilization tracking, care coordination, and monitoring to ensure care is appropriate, timely and cost effective. Works under general supervision. What We Provide Referral bonus opportunities Generous paid time off (PTO), starting at 30 days of paid time off and 9 company holidays Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life and Disability Employer-matched retirement saving funds Personal and financial wellness programs Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care Generous tuition reimbursement for qualifying degrees Opportunities for professional growth and career advancement Internal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities. What You Will Do Conducts comprehensive review of all components related to requests for services which includes a clinical record review and interviews with members, clinical staff, medical providers, paraprofessional staff, caregivers and other relevant sources as necessary. Examines standards and criteria to ensure medical necessity and appropriateness of admissions, treatment, level of care and lengths of stay. Performs prior authorization and concurrent reviews to ensure extended treatment is medically necessary and being conducted in the right setting. Reviews requests for outpatient and inpatient admission; approves services or consults with medical directors when case does not meet medical necessity criteria. Ensures compliance with state and federal regulatory standards and VNS Health policies and procedures. Participates in case conferences with management. Identifies opportunities for alternative care options and contributes to the development of patient focused plan of care to facilitate a safe discharge and transition back into the community after hospitalization. Reviews covered and coordinated services in accordance with established plan benefits, application of evidenced based medical criteria, and regulatory requirements to ensure appropriate authorization of services and execution of the plan’s fiduciary responsibilities. Identifies and provides recommendations for improvement regarding department processes and procedures. Maintains current knowledge of organizational or state-wide trends that affect member eligibility and the need for issuance of Determination Notices Improves clinical and cost-effective outcomes such as reduction of hospital admissions and emergency department visits through on-going member education, care management and collaboration with IDT members. Provides input and recommendations for design and development of, processes and procedures for effective member case management, efficient department operations, and excellent customer service. Maintains accurate record of all care management. Maintains written progress notes and verbal communications according to program guidelines. Verifies that all aspects of the clinical record are in agreement with the member’s clinical and functional status. Utilizes VNS Health and state approved assessment and documentation as well as interviews with members, family, and care providers in decision-making. Performs annual clinical co-visits for nurses as well as two initial co-visits during the first six months for new hires as follows: one within first three weeks and a second within the first six months. Provides feedback to therapist and management; assists in development of plans to address improvement needs as appropriate. For Utilization Management Only: Issues Determinations, Notices of Action, and other forms of communication to members and providers which communicate VNS Health’s determinations. Ensures all records/logs related to decision requests, Notices of Action, and other communications required by state or federal regulations are saved in the Utilization Management System. Reviews, evaluates and determines the appropriateness of requests, utilize the most appropriate clinical care guidelines based on clinical practice guidelines. Adheres to all federal and regulatory requirements. Evaluates and analyzes care and utilization trends/issues and identifies opportunities for better coordination of members’ care. Qualifications Licenses and Certifications: Current license to practice as a Registered Professional Nurse in New York State required. Certified Case Manager preferred Education: Associate's Degree in Nursing required. Bachelor's Degree or Master’s degree in nursing preferred Work Experience: Minimum two years of experience with strong cost containment /case management background or two years acute inpatient hospital experience in chronic or complex care required Must have experience and qualifications demonstrating knowledge of working with the LTSS eligible population. preferred Knowledge of Medicare and Medicaid regulations required Excellent organizational and time management skills, interpersonal skills, verbal and written communication skills. Working knowledge of Microsoft Excel, Power-Point, and Word and strong typing skills required Knowledge of Medicaid and/or Medicare regulations required Knowledge of Milliman criteria (MCG) preferred For UM Only: Experience must be with a Managed Care Organization or Health Plan. For SelectHealth ETE Only: Experience in Public Health programming, delivery and evaluation preferred Experience working with community-based organizations in underserved communities preferred Pay Range USD $85,000.00 - USD $106,300.00 /Yr. About Us VNS Health has been committed to meeting the needs of New Yorkers for over 130 years. We’re one of the largest nonprofit home- and community-based health care organizations in the country, and today, more than 11,500 team members work together to make a difference in the lives of more than 99,000 patients and members on any given day.
RN Utilization Review
Health & Hospital Corporation

QUALITY REVIEW NURSE (RN)

Health & Hospital Corporation Indianapolis, IN
Health and Hospital Corporation is an organization that celebrates diversity, and seeks to employ a diverse workforce. We actively encourage all individuals to apply for employment and to seek advancement opportunities. Health and Hospital Corporation also provides reasonable accommodations to qualified individuals with disabilities as required by law. For additional questions please contact us at: hrmail@hhcorp.org. Job Role Summary The Quality Review Registered Nurse (RN) position assists the Vice President of Long Term Care and other department personnel in the review and analysis of care and services provided by Health and Hospital Corporation (HHC) owned nursing homes and licensed residential facilities. Performs on site and office review of various clinical resident care services and nursing management operations at the long term care facilities and prepares related reports for the long term care department, individual facilities and the contract management company. Assists in the analysis of various aspects of nursing home operations using professional standards of practice and industry benchmarks and in the preparation of reports for the HHC Board of Directors’ Planning Committee. This position is responsible for promoting health and wellbeing of long term care residents of Health and Hospital Corporation Marion County nursing facilities by promoting preventive, therapeutic, and supportive care based on standards of practice and in compliance with all applicable regulatory requirements.Essential Duties Responsibility 1: 70% Performs quality review oversight visits to HHC owned nursing homes and retirement communities as assigned. May serve as a member of a quality review team or at times may visit assigned facilities as the sole representative from the HHC Long Term Care Department. Maintains a professional and supportive role when interacting with the nursing home and licensed residential facility staff providing helpful observations and suggestions. Performs various auditing/review activities during the site visits including but not limited to: medication administration observations, wound care and treatment administration, personal care services, meal service, clinical record reviews and review of nursing management records. At times may assist the other members of the quality review team to complete their assigned tasks. Other review tasks may include: resident or family interviews, review of quality assurance records, in-service training records, personnel files, incident report logs, professional facility consultant reports and other records as assigned. Must be knowledgeable and mindful of potential liability and other risk management issues and methods for taking appropriate preventative or corrective action. Participates in the exit conferences held with facility management and the quality reviewers and provides summary information regarding significant observations during the facility visit including specific resident and employee identification when possible. When requested, participates in taking notes at the exit conference for exit conference reports. Prepares a written site visit report following each facility visit in cooperation with other quality review team members who participated in the facility visit. Reviews report for accuracy, and clarity. Distributes reports in a confidential manner to all parties and maintains HHC records. Assures the retention and confidentiality of all data materials from facility visits and forwards to the department Executive Assistant for proper storage/retention. Responsibility 2: 30% Participates in the compilation and completion of quarterly and other reports prepared for the HHC Board of Directors’ Planning Committee. May attend HHC Planning Committee meetings as assigned to represent the Long Term Care Department or to present a special report. Assists in the completion and follow up of any requests or directives resulting form the Planning Committee meetings as assigned. Accepts phone calls from residents, family members and interested parties in the absence of other Long Term Care Department staff or as assigned. Receives concerns or information in a manner that reflects good customer service practices and prepares detailed written information for the Vice President’s review and processing. Attends community and professional association functions and meetings representing HHC Long Term Care division as requested. Participates in the development of educational materials and staff training programs relative to long term care. Assists in development of departmental policies, procedures and forms for use in the departmental functions. In the absence of the Executive Assistant, makes travel arrangements/reservations for department staff conducting out of town facility site visits. Must be able to communicate effectively in verbal and written communications and able to adhere to deadlines and interruptions and frequent assignment changes, etc. Must have good customer service skills for interacting with facility residents and personnel on site visits as well as the general public. Qualifications Graduate of an approved school of nursing (diploma, associate or B.S. degree). Access to own vehicle and current automobile insurance. 5 – 10 years of previous experience in long term care in a nursing management role. Knowledge of local/State/Federal laws and regulations applicable to state licensure of nursing homes and residential nursing facilities, federal regulations for skilled nursing homes and participation in Medicare and Medicaid programs, communicable disease control, and other applicable long term care requirements. Licenses/Certifications Required Licensed Registered Nurse (Indiana). Valid Indiana Driver’s license. Working Environment Unconfined sitting 75% Confined sitting 15% Standing or walking 10% Steady use of hands or fingers – Typing and filing 85% Lift, carry, etc. with arms and legs – Carrying small boxes to meetings 15% Ability to perform driving functions in normal course of work day with confined sitting for several hours at times. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.
RN Utilization Review Home Health Full-time
UnitedHealthcare

Utilization Case Manager RN - In-Home Services - Milwaukee, WI

UnitedHealthcare Milwaukee, WI
$60,200 - $107,400 / year
At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us to start Caring. Connecting. Growing together. The Utilization Case Manager serves Milwaukee County with occasional coverage in surrounding counties. This position offers the flexibility to work from the office and at home with field-based work in the local community approximately 25% of the work week. This role requires you to reside within a commutable distance of Milwaukee, WI and surrounding areas. Primary Responsibilities Making outbound calls to assess members' current health status Conducting face to face assessments in the member's home Assisting members in identifying unmet needs Documenting assessment details and applying State guidelines to requests for services Documenting and tracking findings Identifying gaps or barriers in treatment plans Providing patient education to assist with self- management Interacting with Medical Directors on challenging cases Coordinating care for members Making referrals to outside sources Coordinating services as needed (home health, DME, etc.) Educating members on disease processes Encouraging members to make healthy lifestyle changes 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 Current, unrestricted RN license in the State of Wisconsin 2+ years of experience in a hospital setting, acute care, direct care experience or experience as a Home Health Case Manager Basic level of experience with Microsoft Office and other electronic medical record applications Reliable transportation to travel to member's homes within the geographical area Willing to travel up to 25% to member homes Preferred Qualifications Home Health Case Management experience Experience in utilization review, concurrent review and / or risk management Experience working with the needs of vulnerable populations who have chronic or complex bio-psychosocial needs Experience with the Personal Care Screening Tool (PCST) or the Long Term Care Functional Screen (LTCFS) A background in Medicaid / Medicare managed care Bilingual Spanish Bilingual Hmong 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 salary for this role will range from $60,200 - $107,400 annually based on full-time employment. We comply with all minimum wage laws as applicable. #UHCPJ At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission. UnitedHealth Group is 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 is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.
RN Utilization Review Telehealth Full-time
Penn Medicine

Full-Time Clinical Documentation Review Specialist-RN -Days-Fully Remote

Penn Medicine PA
Description Penn Medicine is dedicated to our tripartite mission of providing the highest level of care to patients, conducting innovative research, and educating future leaders in the field of medicine. Working for this leading academic medical center means collaboration with top clinical, technical and business professionals across all disciplines. Today at Penn Medicine, someone will make a breakthrough. Someone will heal a heart, deliver hopeful news, and give comfort and reassurance. Our employees shape our future each day. Are you living your life's work? Summary: The Clinical Documentation Review Specialist is responsible for collaborating with clinicians to assure accurate completion of documentation and development of effective plans of care to assure appropriate utilization and promote appropriate quality patient care and positive patient outcomes. Responsibilities: Documentation Improvement: Reviews clinical documentation for compliance with state, federal, and TJC regulations. Follows up with team for clarification if documentation is unclear. Identifies and documents delays. Collaborates with clinicians to assure accurate completion of documentation and development of effective plans of care. Elevates issues appropriately. Utilization Management: Collects and submits data as indicated. Quality Improvement and Risk Management: Reviews clinical reports for compliance with state, federal, and TJC regulations. Collects and submits data as indicated. Communicates with service line and clinical effectiveness team members. Works with department leadership to develop and implement solutions to issues identified. Credentials: RN (Required) Must have Pennsylvania RN Education or Equivalent Experience: Bachelor of Arts or Science (Required) Education Specialization: Must have BSN from an accredited school of nursing Equivalent Experience: •And 2+ years In Medicare regulations for OASIS, compliance, and coding and/or experience in home care criteria and processes. We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region. Penn Medicine employees are actively engaged and committed to our mission. Together we will continue to make medical advances that help people live longer, healthier lives. Live Your Life's Work We are an Equal Opportunity employer. Candidates are considered for employment without regard to race, ethnicity, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, age, disability, marital status, familial status, genetic information, domestic or sexual violence victim status, citizenship status, military status, status as a protected veteran or any other status protected by applicable law.
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
University of Rochester Medical Center

RN, Utilization Management

University of Rochester Medical Center Rochester, NY
$81,307 - $109,761 / year
As a community, the University of Rochester is defined by a deep commitment to Meliora - Ever Better. Embedded in that ideal are the values we share: equity, leadership, integrity, openness, respect, and accountability. Together, we will set the highest standards for how we treat each other to ensure our community is welcoming to all and is a place where all can thrive. Job Location (Full Address): 601 Elmwood Ave, Rochester, New York, United States of America, 14642 Opening: Worker Subtype: Regular Time Type: Full time Scheduled Weekly Hours: 40 Department: 500009 Utilization Management Work Shift: UR - Day (United States of America) Range: UR URCD 215 Compensation Range: $81,307.00 - $109,761.00 The referenced pay range represents the minimum and maximum compensation for this job. Individual annual salaries/hourly rates will be set within the job's compensation range, and will be determined by considering factors including, but not limited to, market data, education, experience, qualifications, expertise of the individual, and internal equity considerations. Responsibilities: Works collaboratively with various departments across the entire health care system to review clinical documentation, utilizing evidence based criteria to support medical necessity and appropriate level of patient care for services provided. Reports outcome trends and patterns to UM leadership to help identify educational opportunities and performance improvement initiatives across the health care continuum. Adapts to process changes and assists with education efforts that support ongoing improvement. ESSENTIAL FUNCTIONS Determines level of care per regulatory requirements. Provides level of care notifications to patients and families as needed. Works collaboratively with payers to ensure authorization for dates of service. Collaborates with HIM, providers, Financial Counseling and Patient Financial Services. Monitors all UM hold bills and unplanned readmission reports. Conducts initial and concurrent reviews, utilizing evidence based criteria through Interqual. Supports discharge appeal process. Responsible for departmental denials and appeal activity. Documents according to regulatory guidelines and UM RN workflow protocols. Conducts clinical documentation improvement efforts through query process. Meets productivity expectations established by UM department. Provides and supports ongoing educational needs for all UM customers. Other duties as assigned. MINIMUM EDUCATION & EXPERIENCE Associate's degree in Nursing and 3 years of acute hospital experience required Bachelor's degree in Nursing (BSN) preferred Or equivalent combination of education and experience Utilization Management experience preferred KNOWLEDGE, SKILLS AND ABILITIES Database experience including: Interqual, Sharepoint, eRecord, ePARC, Cobius preferred LICENSES AND CERTIFICATIONS RN - Registered Nurse - State Licensure and/or Compact State Licensure NYS Registered Nurse license upon hire required The University of Rochester is committed to fostering, cultivating, and preserving an inclusive and welcoming culture to advance the University’s Mission to Learn, Discover, Heal, Create – and Make the World Ever Better. In support of our values and those of our society, the University is committed to not discriminating on the basis of age, color, disability, ethnicity, gender identity or expression, genetic information, marital status, military/veteran status, national origin, race, religion, creed, sex, sexual orientation, citizenship status, or any other characteristic protected by federal, state, or local law (Protected Characteristics). This commitment extends to non-discrimination in the administration of our policies, admissions, employment, access, and recruitment of candidates, for all persons consistent with our values and based on applicable law.
RN Utilization Review Outpatient
Tampa General Hospital

Case Manager, RN- Utilization Review

Tampa General Hospital Tampa, FL
Case Manager, RN- Utilization Review Location: Tampa, Florida, United States Posted: Sep 10, 2026
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 ER Utilization Review Full-time
GBMC Healthcare

Utilization Review Nurse (Full-Time)

GBMC Healthcare Towson, MD
$68,281.18 - $110,274.20 / year
Under general supervision, provides consultative support to the admitting teams concerning patient status determinations and utilization of hospital resources facilitating quality, cost-effective patient outcomes for patients requiring hospital services. Works collaboratively with interdisciplinary staff internal and external to the organization facilitating appropriate status determinations through the utilization review process supporting quality, cost-effective patient outcomes. Responsible for analyzing clinical information and performing timely initial and concurrent reviews using InterQual screening software to identify appropriate medical necessity, length of stay, and level of care based upon evidence based clinical guidelines Education: Bachelor of Science in Nursing (BSN) OR Associate of Science in Nursing and currently enrolled in a BSN program with an expected graduation date within three (3) years. Licensure, Certifications: Current state of Maryland Registered Nurse license Bachelor of Science in Nursing (BSN) Certification in Utilization Management and/or Care Management highly desired. Experience: Five (5) years diversified, progressive experience in acute care and/or other settings within the continuum required. Two (2) years of Utilization Review and Case Management experience which includes utilization review processes and discharge planning, and working with Re-Admission Initiatives preferred. Skills: · Advanced knowledge of InterQual and/or MCG admission criteria · Knowledge of healthcare regulatory standards · Advanced skill in using computer software · Advanced skill in oral and written communication · Advanced skill in critical thinking · Ability to work independently and resolve complex problems · Ability to remain calm under pressure and intense time constraints · Ability to assess discharge needs for patients · Strong analytical and problem-solving skills · Strong interpersonal communication and influencing skills necessary to interact effectively with physicians, payers, regulatory agencies, staff, and other health professional · Strong organizational and time management skills · Ability to operate independently and balance multiple priorities · Proficiency in electronic medical record review Principal Duties and Responsibilities: Reviews available electronic medical records during the pre-admission process to determine appropriate patient status, optimizing correct patient classification and corresponding payer notifications. Reviews the appropriateness of admission and continued stay criteria for a defined group of patients Develops initial admission reviews for patients requiring hospital services and provides timely status recommendations to admitting providers a concurrent stay and/or discharge plan of care in accordance with departmental and payer clinical guidelines. Maintains a working knowledge of contractual and clinical criteria guidelines. Coordinates services with managed care companies and other third party payers. Discusses on-site reviewer issues with payer, either via the telephone or in person Assures timely utilization compliance with all payers who require authorizations and clinical submission. Demonstrates knowledge of reimbursement mechanisms. Considers patient’s financial resources for meeting healthcare needs (insurance reimbursement, managed care plans, entitlement programs, and personal resources). Participates as an active partner with physicians and interdisciplinary teams, providing education ancillary, and nursing staffregarding admission decisions including status determinations, financial and clinical outcomes, and documentation requirements and standards. Maintains current knowledge on all regulatory changes that affect care delivery or reimbursement of acute care services. Uses knowledge of national and local coverage determinations to appropriately advise physicians. Identifies system obstacles that affect patient outcomes and participates in interdisciplinary decisions and care of the patient. consults with interdisciplinary team members to address problems, and makes recommendations to problem solve. Assists with discharge planning, by preventing un-necessary hospital utilization, assist in the appropriate return of and placement of patients to post acute care, community based care and appropriate alternate levels of care. Demonstrates mastery in InterQual level of care guidelines. Possesses proficiency in utilization review systems, clinical support systems, and business support applications. Promotes use of evidence-based protocols to influence high quality and cost-effective care. Escalates clinically and financially complex cases to leadership, offering possible solutions through discussion and feedback. Engages regularly in formal and informal dialogue about quality; directly addressing concerns and promoting continuous improvement. Performs concurrent reviews and additional duties as assigned. All roles must demonstrate GBMC Values: Respect I will treat everyone with courtesy. I will foster a healing environment. Treats others with fairness, kindness, and respect for personal dignity and privacy Listens and responds appropriately to others’ needs, feelings, and capabilities Excellence I will strive for superior performance in every aspect of my work. I will recognize and celebrate the accomplishments of others. Meets and/or exceeds customer expectations Actively pursues learning and self-development Pays attention to detail; follows through Accountability I will be professional in the way I act, look and speak. I will take ownership to solve problems. Sets a positive, professional example for others Takes ownership of problems and does what is needed to solve them Appropriately plans and utilizes required resources for various job duties Reports to work regularly and on time Teamwork I will be engaged and collaborative. I will keep people informed. Works cooperatively and collaboratively with others for the success of the team Addresses and resolves conflict in a positive way Seeks out the ideas of others to reach the best solutions Acknowledges and celebrates the contribution of others Ethical Behavior I will always act with honesty and integrity. I will protect the patient. Demonstrates honesty, integrity and good judgment Respects the cultural, psychosocial, and spiritual needs of patients/families/coworkers Results I will set goals and measure outcomes that support organizational goals. I will give and accept help to achieve goals. Embraces change and improvement in the work environment Continuously seeks to improve the quality of products/services Displays flexibility in dealing with new situations or obstacles Achieves results on time by focusing on priorities and manages time efficiently Pay Range $68,281.18 - $110,274.20 Final salary offer will be based on the candidate's qualifications, education, experience and alignment with our organizational needs. Equal Employment Opportunity GBMC HealthCare and its affiliates are Equal Opportunity employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity and expression, age, national origin, mental or physical disability, genetic information, veteran status, or any other status protected by federal, state, or local law.
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 Salary Range: 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 Outpatient
Baptist Memorial Health Care

RN-Order/Medical Review

Baptist Memorial Health Care Memphis, TN
Overview Job Summary Coordinates precertification/authorization services for patients across the continuum of care, promoting quality care, and effective utilization of resources. Provides leadership when dealing with patient preauthorization functions, including inpatient and outpatient services. Coordinates efforts between departments to ensure accurate precertification, resulting in timely billing of claims. Some overtime and call back may be required. Reports to the Director of CPAC. Performs other duties as assigned. Job Responsibilities Job Responsibilities • Assesses and evaluates clinical and financial information available and recommends the most appropriate delivery of services, including level of care in order to optimize resource consumption and reimbursement. • Precertifies patient care services that require precertification, in a timely, efficient manner, in order to optimize reimbursement for the patient as well as health care providers. • Communicates recommendations, clinical information, and fiscal information to appropriate internal and external customers in order to facilitate optimal delivery of services and customer satisfaction. • Reviews orders for accuracy and medical necessity to facilitate delivery of services and appropriate reimbursement. • Addresses issues identified with retrospective reviews for all payers. • All outpatient procedures will be timely precerted when applicable. • Works to improve the QI/PI process. • Assumes responsibility for personal growth and development by attendance and / or participation in inservices and continuing education programs. • Completes assigned goals. Experience Description Minimum Required Preferred/Desired 3 years of clinical experience. Prefer experience in utilization/case management. Education Description Minimum Required Preferred/Desired Training Description Minimum Required Preferred/Desired Special Skills Description Minimum Required Preferred/Desired Advanced communication, conflict management, organizational and planning skills; advanced computer literacy skills. Prefer certification in CPHQ, CCM, ACM Licensure Description Minimum Required Preferred/Desired RN CCM;ACM
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 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: 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
North Star Behavioral Health

Utilization Review Nurse (RN)

North Star Behavioral Health Augusta, GA
Responsibilities Lighthouse Care Center of Augusta is seeking a dedicated, compassionate Utilization Review Nurse, RN to add to our growing team. Lighthouse Care Center of Augusta Lighthouse Care Center of Augusta (LCCA) is a multi-discipline behavioral healthcare center that offers mental health services to the communities of surrounding Augusta, Georgia. The Lighthouse Care Center of Augusta is an acute and residential treatment facility providing balanced, top-notch clinical care to children, adolescents and young adults. We provide a carefully-structured and supportive environment, and our education program is accredited through the Georgia Accrediting Commission. Utilization Review Nurse, RN Under the direction of the Director of Utilization Management. Website: https://www.LighthouseCareCenters.com Job Duties/ Responsibilities: Review clinical content of medical records Participate in treatment team meetings Collaborate with physicians, therapist, nurses and pertinent staff on gathering the necessary data to communicate with insurance companies/authorizing entities to ensure initial precertification and continued authorization is achieved Utilization Review/Business Office Coordinator will ensure input of pre-certifications and continued stay reviews into Midas Follow-up on unfinished pre-certifications from the day before Coordinate with the treatment team on any follow-ups necessary Verify insurance coverage at the first of the month, and post patient payments into MS4 Trained in all aspects relative to timely gathering clinical criteria, communication of clinical criteria, and entry of supporting clinical criteria into computer based systems Additional job duties Benefit Highlights: Referral Bonus Program 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 Career development opportunities within UHS and its 300+ Subsidiaries Pet Insurance More information is available on our Benefits Guest Website: uhsguest.com 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. Qualifications Education and Experience: Registered Nurse (RN) preferred or License Professional Nurse (LPN) Current GA or Multistate Valid RN or LPN license Must have 2 years of experience in a psychiatric health care setting, delivery of care to psychiatric and/or chemically dependent patients and utilization review 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. 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 Telehealth
L.A. Care Health Plan

Utilization Management Nurse Specialist RN II

L.A. Care Health Plan CA
$88,854 - $142,166 / year
Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job Summary The Utilization Management Nurse Specialist RN II facilitates, coordinates, and approves medically necessary referrals that meet established criteria. Assures timely and accurate determination and notification of referrals and reconsiderations based on the referral determination status. Generates approval, modification and denial communications, to include member and provider notification of referral determination. Actively monitors for admissions in any inpatient setting. Performs telephonic and/or onsite admission and concurrent review, and collaborates with onsite staff, physicians, providers, member/family interaction to develop and implement a successful discharge plan. Works with the UM Manager and Physician Advisor on case reviews for pre-service, concurrent, post-service and retrospective claims medical review. Monitors and oversees the collection and transfer of data (medical records) and referral requests by Providers. Acts as a department resource for medical service requests /referral management and processes. Receives incoming calls from providers, professionally handles complex calls, researches to identify timely and accurate resolution steps. Follows up with caller to provide response or resolution steps. Answers all inquiries in a professional and courteous manner. Duties Promote and support team engagements, programs and activities to create and ensure a positive and productive workplace environment. Perform telephonic and/or onsite admission and concurrent review, and collaborates with onsite staff, physicians, providers, the member and significant others to develop and implement a successful discharge plan. Process, finalize and facilitate inbound requests that are received from providers. Generate appropriate member and provider communication for all determinations within the required timelines as defined by the most current department policy. Facilitate/review requests for Higher level of care or skilled nursing/discharge planning needs. Research for appropriate facilities, specialty providers and ancillary providers to utilize for all lines of business. Identification of potential areas of improvement within the provider network. Identify and initiate referrals for appropriate members to the various L.A. Care programs/processes and external community based programs or Linked and Carve Out Services (e.g. DDS/CCS/MH). Potential quality of care/potential fraud issues are identified and documented per L.A. Care policy. High risk/high cost cases and reports are maintained and referred to the Physician Advisor/UM Director. Document in platform/system of record. Utilize designated software system to document reviews and/or notes. Receive incoming calls from providers, professionally handle complex calls, research to identify timely and accurate resolution steps. Follow up with caller to provide response or resolution steps. Answer all inquiries in a professional and courteous manner. Perform other duties as assigned. Duties Continued Education Required Associate's Degree in NursingEducation Preferred Bachelor's Degree in NursingExperience Required: At least 5 years of varied RN clinical experience in an acute hospital setting. At least 2 years of Utilization Management/Case Management experience in a hospital or HMO setting . Preferred: Managed Care experience performing UM and CM at a medical group or management services organization. Experience with Managed Medi-Cal, Medicare, and commercial lines of business. Skills Required: Must be computer literate, with expertise in Outlook, Word, Excel, PowerPoint. Effectively utilizes computer and appropriate software and interacts as needed with L.A. Care Information System. Knowledge of personal computer, keyboarding, and appropriate software to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment. Prepare clear, comprehensive written and oral reports and materials. Provision of excellent customer service required due to frequent communication with providers and other members of the interdisciplinary team Excellent time management and priority-setting skills. Maintains strict member confidentiality and complies with all HIPAA requirements. Strong verbal and written communication skills. Preferred: Knowledge of National Committee for Quality Assurance (NCQA) requirements for Utilization Management or Care Management (CM). Knowledge of Department of Health Care Services (DHCS) or Centers for Medicare and Medicaid Services(CMS) requirements for health plan compliance with UM or CM. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California LicenseLicenses/Certifications Preferred Certified Case Manager (CCM)Required Training Physical Requirements LightAdditional Information May work on occasional weekends and some holidays depending on business needs. 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
Kern Medical

Utilization Review Nurse - Part Time - Shift

Kern Medical Bakersfield, CA
$43.51 - $68.56 / hour
Kern Medical has been a community cornerstone since its founding in 1867. Today, we are an acute care teaching center with 222 beds, offering the only advanced trauma care between Fresno and Los Angeles. Kern Medical offers a range of primary, specialty, and multi-specialty services including high-risk pregnancy care, inpatient psychiatric services integrated with county mental health programs, and a growing network of outpatient clinics providing personalized patient-centered wellness care. Kern Medical cares for 15,500 inpatients and 125,000 clinic patients a year. Career Opportunities within Kern Medical include many benefits such as: New Hire Bonus : $6,000.00 New Hire Premium : +6% of base rate of pay, matched up to 6% if contributed to Deferred Compensation Plan. A Comprehensive Benefits Package : includes Holidays, Paid Time Off, Retirement, Medical, Dental, Vision and Life Insurance. Position: Utilization Review Nurse - Case Management Compensation: The estimated pay for this position is $43.5114 to $68.5608 per hour . The rates shown include a 6% premium pay (base= $-$ plus 6%). This reflects only a portion of the total compensation package for this position. Additional compensation may be available for this role through differentials, incentives, and bonuses. In addition, this position may be eligible for participation and company contributions into the Kern County Employees’ Retirement Plan. Distinguishing Characteristics: Positions in this classification are assigned to the Utilization Review division of Kern Medical Center. Incumbents perform clinically oriented medical chart reviews and other administrative tasks to meet the requirements of the medical center's utilization review plan, state and federal regulations, insurance company requirements for reimbursement and facility accreditation standards. The Utilization Review Nurse classification ranges from less experienced nurses, who will perform administrative tasks concerning Utilization Review and Discharge planning activities, to experienced nurses who will apply full working knowledge of applicable regulations and to develop knowledge of outside agencies and services to develop appropriate discharge plans. Essential Functions: Obtains and evaluates medical records for in-patient admissions to determine if required documentation is present. Obtains appropriate records as required by payor agencies and initiates Physician Advisories as necessary for unwarranted admissions. Conducts on-going reviews and discusses care changes with attending physicians and others. Formulates and documents discharge plans. Provides on-going consultation and coordination with multiple services within the hospital to ensure efficient use of hospital resources Identifies pay source problems and provides intervention for appropriate referrals Coordinates with admitting office to avoid inappropriate admissions. Coordinates with clinic areas in scheduling specialized tests with other health care providers, assessing pay source and authorizing payment under Medically Indigent Adult program as necessary. Reviews and approves surgery schedule to ensure elective procedures are authorized. Coordinates with correctional facilities to determine appropriate use of elective procedures, durable medical goods and other services. Answer questions from providers regarding reimbursement, prior authorization and other documentation requirements. Learns the documentation requirements of payor sources to maximize reimbursement to the hospital Initiates and completes Disease Related Groups (DRG's) for Medicare payment; answers questions from providers regarding reimbursement, prior authorization and other documentation requirements. Teaches providers the documentation requirements of payor sources to maximize reimbursement to the hospital. May assist in training of other Utilization Review Nurses. Keeps informed of patient disease processes and treatment modalities. Other Functions: Performs other job related duties as required. Employment Standards: Possession of a valid license as a Registered Nurse in the State of California AND Two (2) years of experience or its equivalent as a registered nurse in an acute care hospital, at least one of which was on a medical/surgical ward or unit. OR Possession of a valid license as a Registered Nurse in the State of California and two (2) years of experience as a Case Manager in an alternate medical setting such as a clinic or physician’s office performing utilization or discharge planning. Incumbents may be required to possess and maintain specific certificates competency based on unit specific requirements as a condition of employment. Appointees not possessing the American Heart Association Provider Basic Life Support (BLS) card at time of hire must successfully complete appropriate training and qualify for the RQI Provider certification within 60 days of employment. As a continued condition of employment, employee must maintain RQI Provider certification and competency. Knowledge of: Payor source documentation requirements and governmental regulations affecting reimbursement; knowledge of acute care nursing principles, methods and commonly used procedures; knowledge of common patient disease processes and the usual methods for treating them; knowledge of medical terminology, hospital routine and commonly used equipment; knowledge of acute hospital organization and the interrelationships of various clinical and diagnostic services; Ability to: Effectively evaluate the medical records of hospital admissions regarding continuing stay necessity, appropriateness of setting, delivered care, use of ancillary services and discharge plans; ability to assess and judge the clinical performance of physicians and other health professionals; ability to communicate documentation needs in an effective and tactful manner that promotes cooperation; ability to gather and analyze data and prepare reports and recommendations based thereon; ability to get along with physicians, other health providers, outside payor sources and the general public. Supplemental: A background check may be conducted for this classification. All Kern County employees are designated "Disaster Service Workers" through state and local laws (CA Government Code Sec.3100-3109 and Ordinance Code Title 2-Administration, Ch. 2.66 Emergency Services). As Disaster Service Workers, all County employees are expected to remain at work, or to report for work as soon as practicable, following a significant emergency or disaster. If position responsibilities require driving a personal vehicle, then possession of a current valid California Driver’s License and adherence to the Kern County Hospital Authority Vehicle Use and Driving Standard Policy (ENG-EC-119) is required. If position responsibilities require driving a vehicle owned, leased or rented by Kern Medical, then possession of a current valid California Driver’s license, a signed authorization for Release of Drivers Record Information and adherence to the Kern County Hospital Authority Vehicle Use and Driving Standard Policy (ENG-EC-119) is required.
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 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 Per Diem
Kaiser Permanente

Case Manager Utilization RN, Per Diem Day

Kaiser Permanente Bellflower, CA
Job Summary: Works collaboratively with an MD to coordinate and screen for the appropriateness of admissions and Continued stays. Makes recommendations to the physicians for alternate levels of care when the patient does not meet the medical necessity for Inpatient hospitalization. Interacts with the family, patient and other disciplines to coordinate a safe and acceptable discharge plan. Functions as an indirect caregiver, patient advocate and manages patients in the most cost effective way without compromising quality. Transfers stable non-members to planned Health care facilities. Responsible for complying with AB 1203, Post Stabilization notification. Complies with other duties as described. Must be able to work collaboratively with the Multidisciplinary team, multitask and in a fast pace environment. Essential Responsibilities: Plans, develops, assesses and evaluates care provided to members. Collaborates with physicians, other members of the multidisciplinary health care team and patient/family in the development, implementation and documentation of appropriate, individualized plans of care to ensure continuity, quality and appropriate resource use. Recommends alternative levels of care and ensures compliance with federal, state and local requirements. Assesses high risk patients in need of post-hospital care planning. Develops and coordinates the implementation of a discharge plan to meet patients identified needs; communicates the plan to physicians, patient, family/caregivers, staff and appropriate community agencies. Reviews, monitors, evaluates and coordinates the patients hospital stay to assure that all appropriate and essential services are delivered timely and efficiently. Participates in the Bed Huddles and carries out recommendations congruent with the patients needs. Coordinates the interdisciplinary approach to providing continuity of care, including Utilization management, Transfer coordination, Discharge planning, and obtaining all authorizations/approvals as needed for outside services for patients/families. Conducts daily clinical reviews for utilization/quality management activities based on guidelines/standards for patients in a variety of settings, including outpatient, emergency room, inpatient and non-KFH facilities. Acts as a liaison between in-patient facility and referral facilities/agencies and provides case management to patients referred. Refers patients to community resources to meet post hospital needs. Coordinates transfer of patients to appropriate facilities; maintains and provides required documentation. Adheres to internal and external regulatory and accreditation requirements and compliance guidelines including but not limited to: TJC, DHS, HCFA, CMS, DMHC, NCQA and DOL. Educates members of the healthcare team concerning their roles and responsibilities in the discharge planning process and appropriate use of resources. Provides patients with education to assist with their discharge and help them cope with psychological problems related to acute and chronic illness. Per established protocols, reports any incidence of unusual occurrences related to quality, risk and/or patient safety which are identified during case review or other activities. Reviews, analyses and identifies utilization patterns and trends, problems or inappropriate utilization of resources and participates in the collection and analysis of data for special studies, projects, planning, or for routine utilization monitoring activities. Coordinates, participates and or facilitates care planning rounds and patient family conferences as needed. Participates in committees, teams or other work projects/duties as assigned.
RN Utilization Review Full-time
Parkland Health (TX)

Registered Nurse - Care Coordinator - Utilization Review

Parkland Health (TX) Dallas, TX
Location: Parkland Support Serv Bldg A Shift- Days 6:00am- 4:30pm (10hrs) Work Hours: Monday- Friday with rotating weekends **This position will hybrid- must be okay with coming onsite** Employment Type: Full Time Primary Purpose Establishes and maintains an efficient, cost effective care management process by determining patient financial and medical eligibility, medical necessity, and by developing, implementing and monitoring individual patient plans of care and communicating these plans to patients, families, and Parkland staff to ensure quality patient care throughout the healthcare continuum and compliance with program/Parkland policies and procedures. Responsible for the maintaining the knowledge and skill set related to utilization review, care coordination, performance improvement and professional licensure and certification. Minimum Specifications Education Must be a graduate of an accredited school of Nursing. Experience Must have two (2) years of hospital or community based patient care nursing, preferably in assigned clinical area. Equivalent Education and/or Experience Certification/Registration/Licensure Must have current, valid RN license or temporary RN license from the Texas Board of Nursing; or, valid Compact RN license. Must have current healthcare provider BLS for Healthcare Providers certification from one of the following: American Heart Association American Red Cross Military Training Network Required Tests for Placement Skills or Special Abilities Provides care to assigned patient population in accordance with the current State of Texas Nursing Practice Act, established protocols, multidisciplinary plan of care, and clinical area specific standards. Must be able to communicate and collaborate effectively with a diverse group of patients, families and healthcare staff. Must be able to demonstrate a working knowledge of specific patient populations, and be able to demonstrate knowledge of disease processes affecting this group. Must be able to demonstrate a working knowledge of PC operations and the ability to use word processing software in a Windows environment. Must be able to demonstrate a working knowledge of the laws and regulations governing Medicare, Medicaid and community-based funding sources. Must be self-directed and capable of priority setting and problem solving. Must be able to demonstrate patient centered/patient valued behaviors. Responsibilities Conducts assessment of patients on assigned Care Coordination team to develop a case management plan of care. Gathers information from patient, physicians, other pertinent members of the healthcare team. Determines funding sources for patients and potential eligibility if appropriate. Plans and develops specific objectives, goals and actions designed to meet the patient's needs as identified through the assessment process. Utilizes hospital approved review criteria to ensure appropriate bed status. Identifies at-risk populations using approved screening tool and follows established reporting procedures. Ensures appropriate admission status is documented. Collaborates with all members of the multidisciplinary team and the patient to implement the plan of care. Monitors the patient's progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective. Communicates all financial counseling as appropriate. Addresses and resolves system barriers impeding diagnostic or treatment progress. Proactively identifies and resolves delays and obstacles to discharge. Ensures/maintains plan consensus from patient/family, physician, and payer. Serves as patient advocate to secure coverage for needed community services. Mobilizes resources and coordinates the effort to the health care team to achieve a positive patient transition to appropriate next level of care. Communicates plan of care to patient and their family providing updates and reassesses the plan of care to determine effectiveness. Completes appropriate coordinator management documentation. Evaluates the plan of care at appropriate intervals to determine effectiveness in meeting outcomes and goals. Works with nursing and other disciplines to ensure that discharge needs, including teaching, are met. Collaborates with the healthcare team to identify 'best' practices for achieving patient outcomes. Develops reporting mechanisms to communicate outcomes to physicians and other members of the health care team. Responsible for Utilization Management activities for assigned patients. Applies approved utilization criteria to monitor appropriateness of admissions and continued stays, and documents findings based on department standards. Monitors length of stay (LOS) and ancillary resource use on an ongoing basis and takes action to achieve continuous improvement in both areas. Monitors and addresses outcome variances. Identifies causes of outcome variances and implements actions to improve the variances. Seeks the most efficient, cost effective ways to provide appropriate care. Supports cost containment efforts through the recommendation of performance improvement opportunities by the health care team. Communicates with Care Management team to facilitate covered-day reimbursement certification and/or authorization for assigned patients. Discusses payer criteria and issues on a case-by-case basis with clinical staff and follows up to resolve problems with payers as needed. Transitions patients through the health care system based upon individual and patient population needs. Directs liaison activities to appropriately integrate the patient into the health care continuum including procuring of services, health promotion and counseling, disease prevention, health education and screening, and community resource linkage. Engages in special projects and serves on committees, as assigned. Requisition ID: 989858
RN Outpatient Utilization Review Outpatient
Devoted Health

Clinical Guide: (UM) Utilization Management Nurse (Outpatient Prior Authorization)

Devoted Health
$82,680 - $96,460 / year
Job Description A bit about this role: As a Clinical Guide on our Outpatient Utilization Management team, you’ll have the opportunity to make a difference in the lives of our members. You’ll be responsible for clinical review of outpatient authorization requests — applying evidence-based medical necessity criteria, CMS and Medicare Advantage requirements, and health plan policy to determine whether requested services are appropriate. Your decisions help members get the right care in the right setting, and help them navigate the healthcare system with confidence. Our ideal Clinical Guide is detail-oriented, solutions-focused, and comfortable making well-documented clinical judgments at pace. You’re someone who can hold accuracy and volume at the same time, and who is energized rather than unsettled by evolving policies and workflows. Schedule: This is a full-time, remote position working five 8-hour days, 40 hours per week. We are hiring for the following schedules: Monday – Friday, 10:00 AM – 7:00 PM ET Monday – Friday, 11:00 AM – 8:00 PM ET Sunday – Thursday, 10:00 AM – 7:00 PM ET We’ll ask about your schedule preference during the process and will do our best to match it. Because we’re filling a limited number of openings on each schedule, availability changes as roles are filled — so we ask that candidates be open to more than one schedule where possible. Your responsibilities and impact will include: Conduct timely, comprehensive clinical review of outpatient authorization requests, applying evidence-based medical necessity criteria, CMS and Medicare Advantage requirements, and health plan policies. Review requests across multiple authorization categories — including outpatient procedures, imaging, therapy, DME, and home health — each with its own criteria and resources. Determine the appropriateness of requested services and the appropriate setting of care, recommending clinically appropriate alternatives where relevant. Refer cases that do not meet criteria to the Medical Director for secondary review; prepare clinical summaries and support peer-to-peer discussions. Communicate with providers and internal teams to obtain additional clinical documentation and resolve open questions. Meet CMS turnaround time standards while maintaining accuracy across a high volume of requests. Maintain accurate, defensible documentation of every determination, in line with CMS regulations, Medicare Advantage requirements, and internal compliance standards. Apply clinical judgment on complex cases — gathering additional information and escalating when appropriate. Identify, document, and communicate potential quality assurance or risk management issues. Explain complex clinical and coverage information clearly to providers and internal partners. Required skills and experience: An unrestricted RN license with a minimum of 4 years of RN experience. Minimum 3 years of utilization management, utilization review, or prior authorization experience within a health plan, hospital, or post-acute setting. Knowledge and understanding of CMS guidelines and Medicare Advantage requirements. Experience escalating cases that do not meet criteria, including preparing clinical summaries for physician review. Comfort in a fast-paced environment with daily turnaround standards and frequently changing policies, criteria, and workflows. The ability to comfortably multi-task — you’ll be listening, talking, and typing at the same time. Desired skills and experience: Outpatient prior authorization experience — home health and DME a significant plus. Proficiency with technology, including Google Workspace and AI tools. The ability to break down complex information and adjust your approach to different audiences. Transparency in your work — what’s going well and what isn’t. A desire to change the healthcare experience: you love to serve and make a difference. #LI-DS1 #LI-Remote Salary Range: $82,680-$96,460 / year The pay range listed for this position is the range the organization reasonably and in good faith expects to pay for this position at the time of the posting. Once the interview process begins, your talent partner will provide additional information on the compensation for the role, along with additional information on our total rewards package. The actual base salary offered will depend on a variety of factors, including the qualifications of the individual applicant for the position, years of relevant experience, specific and unique skills, level of education attained, certifications or other professional licenses held, and the location in which the applicant lives and/or from which they will be performing the job. Our Total Rewards package includes: Employer sponsored health, dental and vision plan with low or no premium Generous paid time off $100 monthly mobile or internet stipend Stock options for all employees Bonus eligibility for all roles excluding Director and above; Commission eligibility for Sales roles Parental leave program 401K program And more.... *Our total rewards package is for full time employees only. Intern and Contract positions are not eligible. Founded in 2017, Devoted Health is on a mission to dramatically improve the health and well-being of older Americans by caring for everyone like they are family, and that includes our employees. Our robust and seamlessly integrated care platform merges advanced data and AI access with world-class clinical and service experiences to create a member experience that is unlike the industry norm. To continue building upon our mission, we want to bring together those who share our values, embrace change and advancement, and are enthusiastic about where we're going — all the while bringing their own unique qualities, experiences, and expertise, in hopes of further changing the healthcare experience. Devoted is an equal opportunity employer. We are committed to a safe and supportive work environment in which all employees have the opportunity to participate and contribute to the success of the business. We value diversity and collaboration. Individuals are respected for their skills, experience, and unique perspectives. This commitment is embodied in Devoted’s Code of Conduct, our company values and the way we do business. As an Equal Opportunity Employer, the Company does not discriminate on the basis of race, color, religion, sex, pregnancy status, marital status, national origin, disability, age, sexual orientation, veteran status, genetic information, gender identity, gender expression, or any other factor prohibited by law. Our management team is dedicated to this policy with respect to recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, employee activities and general treatment during employment.