Registered Nurse (RN) Utilization Review Jobs

RN Utilization Review Telehealth
Devoted Health

Clinical Guide Part A: (UM) Utilization Management Nurse

Devoted Health
$82,680 - $96,460 / year
Job Description A bit about this role: The Clinical Guide Part A will be part of the Utilization Management team, responsible for inpatient, behavioral health, and/or post-acute authorization review in alignment with CMS and Medicare Advantage regulations. Reviews medical records to evaluate the medical necessity and appropriateness of requested inpatient and/or post-acute services in accordance with established clinical criteria and CMS guidelines. Schedule: This is a full-time, remote position working five 8-hour days. We are hiring for several schedules: Tuesday – Saturday, 9:00 AM – 6:00 PM ET Sunday – Thursday, 9:00 AM – 6:00 PM ET Monday – Friday, 11:00 AM – 8:00 PM ET Monday – Friday, 9:00 AM – 6:00 PM ET We'll ask about your schedule preference during the process and will do our best to match it. Because we are 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. Most schedules include one weekend day. Weekend and later-day coverage is a core part of how our Utilization Management team meets CMS turnaround requirements. Your Responsibilities and Impact will include: Review Medical Records: Conduct prospective (pre-service), concurrent, and retrospective utilization review to evaluate medical necessity, appropriate level of care (Inpatient vs. Observation), and post-acute services in accordance with established clinical criteria and CMS guidelines. Evaluate Treatment Plans: Assess the appropriateness, timing, and setting of requested services, ensuring alignment with medical necessity criteria and Medicare Advantage requirements. Recommend alternative levels of care when clinically appropriate. Inpatient & Behavioral Health Review: Perform initial, concurrent, and discharge reviews for inpatient and behavioral health admissions. Ensure admission status accuracy and regulatory compliance with CMS timeliness (TAT) standards. Post-Acute Review: Conduct initial authorization and concurrent review for post-acute services (SNF, LTACH, ARU, Home Health), evaluating ongoing medical necessity and appropriate length of stay. Issue NOMNC when coverage criteria are no longer met. Medical Director Collaboration: Refer cases that do not meet criteria to the Medical Director for secondary review and final determination. Prepare clinical summaries and coordinate peer-to-peer (P2P) discussions. Manage authorization reopen requests as appropriate. Resource Stewardship: Monitor utilization of inpatient and post-acute services to promote appropriate resource use while maintaining high-quality, member-centered care. Regulatory & Documentation Compliance: Maintain accurate, defensible documentation of all determinations. Ensure adherence to CMS regulations, Medicare Advantage requirements, and internal compliance standards. Required skills and experience: Unrestricted RN license with a minimum of 4 years of clinical experience 3+ years in utilization review, utilization management, case management, discharge planning, care coordination, or clinical appeals — in a health plan, hospital, or post-acute setting Familiarity with CMS regulations and Medicare Advantage requirements, or comparable payer coverage experience Experience escalating cases that don't meet criteria, including preparing clinical summaries for physician review Ability to work one of the posted schedules, including a weekend day for most schedules; flexibility across more than one schedule preferred. Able to work in a fast paced environment that is constantly evolving. Desired skills and experience: Experience with AI/LLM Certified in InterQual #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.
RN Utilization Review Telehealth
Devoted Health

Clinical Guide Part A: (UM) Utilization Management Nurse

Devoted Health
$82,680 - $96,460 / year
Job Description A bit about this role: The Clinical Guide Part A will be part of the Utilization Management team, responsible for inpatient, behavioral health, and/or post-acute authorization review in alignment with CMS and Medicare Advantage regulations. Reviews medical records to evaluate the medical necessity and appropriateness of requested inpatient and/or post-acute services in accordance with established clinical criteria and CMS guidelines. Schedule: This is a full-time, remote position working five 8-hour days. We are hiring for several schedules: Tuesday – Saturday, 9:00 AM – 6:00 PM ET Sunday – Thursday, 9:00 AM – 6:00 PM ET Monday – Friday, 11:00 AM – 8:00 PM ET Monday – Friday, 9:00 AM – 6:00 PM ET We'll ask about your schedule preference during the process and will do our best to match it. Because we are 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. Most schedules include one weekend day. Weekend and later-day coverage is a core part of how our Utilization Management team meets CMS turnaround requirements. Your Responsibilities and Impact will include: Review Medical Records: Conduct prospective (pre-service), concurrent, and retrospective utilization review to evaluate medical necessity, appropriate level of care (Inpatient vs. Observation), and post-acute services in accordance with established clinical criteria and CMS guidelines. Evaluate Treatment Plans: Assess the appropriateness, timing, and setting of requested services, ensuring alignment with medical necessity criteria and Medicare Advantage requirements. Recommend alternative levels of care when clinically appropriate. Inpatient & Behavioral Health Review: Perform initial, concurrent, and discharge reviews for inpatient and behavioral health admissions. Ensure admission status accuracy and regulatory compliance with CMS timeliness (TAT) standards. Post-Acute Review: Conduct initial authorization and concurrent review for post-acute services (SNF, LTACH, ARU, Home Health), evaluating ongoing medical necessity and appropriate length of stay. Issue NOMNC when coverage criteria are no longer met. Medical Director Collaboration: Refer cases that do not meet criteria to the Medical Director for secondary review and final determination. Prepare clinical summaries and coordinate peer-to-peer (P2P) discussions. Manage authorization reopen requests as appropriate. Resource Stewardship: Monitor utilization of inpatient and post-acute services to promote appropriate resource use while maintaining high-quality, member-centered care. Regulatory & Documentation Compliance: Maintain accurate, defensible documentation of all determinations. Ensure adherence to CMS regulations, Medicare Advantage requirements, and internal compliance standards. Required skills and experience: Unrestricted RN license with a minimum of 4 years of clinical experience 3+ years in utilization review, utilization management, case management, discharge planning, care coordination, or clinical appeals — in a health plan, hospital, or post-acute setting Familiarity with CMS regulations and Medicare Advantage requirements, or comparable payer coverage experience Experience escalating cases that don't meet criteria, including preparing clinical summaries for physician review Ability to work one of the posted schedules, including a weekend day for most schedules; flexibility across more than one schedule preferred. Able to work in a fast paced environment that is constantly evolving. Desired skills and experience: Experience with AI/LLM Certified in InterQual #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.
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.
RN Utilization Review Full-time
UF Health

RN, Utilization Management| Day |Full Time

UF Health The Villages, FL
Overview Make an impact by supporting the right care at the right time through utilization management excellence. 💻 Work Style: Onsite 📍 Location: Gainesville, FL 🕒 FTE: Full-Time (1.0FTE) ⏰ Schedule: ( Days-TBD) 8:00 PM – 6:30PM Plays a critical role in evaluating patient medical records to ensure the necessity and appropriateness of healthcare services. Involves coordinating with healthcare providers to maintain compliance with utilization management guidelines and optimizing treatment plans for effective patient care and resource utilization. Requires clear communication of authorization decisions and ongoing monitoring to support timely discharge planning. Analyzes utilization data to identify trends and collaborates with interdisciplinary teams to enhance care coordination while ensuring accurate documentation Responsibilities Key Responsibilities Evaluates patient medical records to determine the medical necessity and appropriateness of healthcare services. Coordinates with healthcare providers and care teams to ensure compliance with utilization management guidelines and payer requirements. Supports effective treatment planning, patient care coordination, and appropriate resource utilization. Communicates authorization decisions and utilization determinations while supporting timely discharge planning efforts. Analyzes utilization management data and trends to identify opportunities for improved care coordination and operational efficiency. Collaborates with interdisciplinary teams to ensure accurate documentation, regulatory compliance, and quality patient outcomes. Qualifications Education & Licensure Registered Nurse (RN) with a current Florida nursing license required. Experience & Skills Minimum of three (3) years of experience in utilization review, utilization management, or case management required. Knowledge of healthcare utilization guidelines, payer requirements, and regulatory compliance standards. Experience evaluating medical necessity, treatment plans, and appropriate levels of care. Strong communication and collaboration skills related to authorization determinations and care coordination. Demonstrated ability to analyze utilization data, identify trends, and support patient care and discharge planning initiatives.
RN Utilization Review Telehealth Full-time
Mass General Brigham

Utilization Management Nurse, Out of Network

Mass General Brigham Assembly Square, MA
$90,000 - $107,000 / year
Site: Mass General Brigham Health Plan Holding Company, Inc. Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham. Job Summary Given equity, this position will pay somewhere between $90,000 to $107,000 annually. Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham, we are at the forefront of transformation with one of the world’s leading integrated healthcare systems. Together, we are providing our members with innovative solutions centered on their health needs to expand access to seamless and affordable care and coverage. Our work centers on creating an exceptional member experience – a commitment that starts with our employees. Working with some of the most accomplished professionals in healthcare today, our employees have opportunities to learn and contribute expertise within a welcoming and supportive environment that embraces their unique and varied backgrounds, experiences, and skills. We are pleased to offer competitive salaries and a benefits package with flexible work options, career growth opportunities, and much more. The UM Nurse will support network adequacy review and authorization activities for members enrolled in ACO, HMO, and EPO products who require planned inpatient or outpatient services from out-of-network providers. Utilizing clinical knowledge, the UM Nurse will review prior authorization requests, assess medical necessity and benefit coverage, render approval decisions within scope, determine when physician review is required, and complete determinations following physician review. The ideal candidate will have prior authorization experience in a managed care setting and possess strong commercial health plan knowledge. Essential Functions: • Expertise in clinical review for prospective, concurrent, retrospective utilization management reviews utilizing Interqual ®, company policies and procedures, and other resources as determined by review, including physician reviews as needed for all lines of business as per departmental needs • Review authorization requests for medical services, including making initial eligibility and coverage determinations, screening for medical necessity appropriateness, determining if additional information is required, and referral to correct programs within Mass General Brigham Health Plan as needed. • Manage incoming requests for procedures and services including patient medical records and related clinical information. • Strong working knowledge of commercial, self-insured, fully insured, and limited network plans. • Adherence to program, departmental, and organizational performance metrics, including productivity. • Excellent verbal and written communication skills. • Excellent problem-solving and customer service skills. • Would need to be available for “on call” for a minimum of once per month with the possibility of that increasing depending on staff availability; Approximately 6 months after hire. • Must be self-directed and highly motivated with an ability to multitask. • Develop and maintain effective working relationships with internal and external customers • Hold self and others accountable to meet commitments. • Sound decision-making and time management skills. • Proactive in areas of professional development, personally and for the department. • Persist in accomplishing objectives to consistently achieve results despite any obstacles and setbacks that arise. • Build strong relationships and infrastructures that designate Mass General Brigham Health Plan as a people-first organization. • Proficient with Microsoft Word, Excel, Outlook, McKesson InterQual ®, Outlook, SharePoint, PC based operating system, and web-based phone system. Qualifications Education Associate's Degree Nursing required or Bachelor's Degree Nursing preferred Licenses and Credentials Massachusetts Registered Nurse (RN) license required ​ Experience At least 2-3 years of utilization review experience is highly preferred Experience using Interqual or Milliman is highly preferred At least 1-2 years of experience in a payer setting is highly preferred At least 1-2 years of experience in an acute care setting is highly preferred Knowledge, Skills, and Abilities Demonstrate Mass General Brigham Health Plan’s core brand principles of always listening, challenging conventions, and providing value Strong aptitude for technology-based solutions. Embrace opportunities to take the complexity out of how we work and what we deliver. Listen to our constituents, learn, and act quickly in our ongoing pursuit of meaningful innovation Current in healthcare trends. Ability to inject energy, when and where it’s needed. Exercise self-awareness; monitor impact on others; be receptive to and seek out feedback; use self-discipline to adjust to feedback. Be accountable for delivering high-quality work. Act with a clear sense of ownership. Bring fresh ideas forward by actively listening to and working with employees and the people we serve. Communicate respectfully and professionally with colleagues Strong EQ; exercises self-awareness; monitors impact on others; is receptive to and seeks out feedback; uses self-discipline to adjust to feedback. Knowledge, Skills, and Abilities Demonstrate Mass General Brigham Health Plan’s core brand principles of always listening, challenging conventions, and providing value Strong aptitude for technology-based solutions. Embrace opportunities to take the complexity out of how we work and what we deliver. Listen to our constituents, learn, and act quickly in our ongoing pursuit of meaningful innovation Current in healthcare trends. Ability to inject energy, when and where it’s needed. Exercise self-awareness; monitor impact on others; be receptive to and seek out feedback; use self-discipline to adjust to feedback. Be accountable for delivering high-quality work. Act with a clear sense of ownership. Bring fresh ideas forward by actively listening to and working with employees and the people we serve. Communicate respectfully and professionally with colleagues Strong EQ; exercises self-awareness; monitors impact on others; is receptive to and seeks out feedback; uses self-discipline to adjust to feedback. Additional Job Details (if applicable) Working Conditions Would need to be available for “on call” for a minimum of once per month with the possibility of that increasing depending on staff availability; Approximately 6 months after hire. This is a remote role with occasional onsite team meetings in Somerville, MA. Monday through Friday, eastern business hours required Remote workdays require a stable, secure, quiet, and HIPAA-compliant workspace. This will be confirmed via Microsoft Teams video for all employees Given equity, this position will pay somewhere between $90,000 to $107,000 annually. Remote Type Remote Work Location 399 Revolution Drive Scheduled Weekly Hours 40 Employee Type Regular Work Shift Day (United States of America) Pay Range $58,656.00 - $142,448.80/Annual Grade 98TEMP At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package. EEO Statement: 8925 Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran’s Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642. Mass General Brigham Competency Framework At Mass General Brigham, our competency framework defines what effective leadership “looks like” by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.
RN Utilization Review Telehealth
L.A. Care Health Plan

Utilization Management Admissions Liaison RN II (Nights)

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 Utilization Review
Health & Hospital Corporation

QUALITY REVIEW NURSE SPECIALIST

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 Assists the Vice President of Long Term Care and other department personnel in the review and analysis of care and services provided by 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
Lexington Medical Center

Utilization Review Specialist RN PRN

Lexington Medical Center West Columbia, SC
Utilization Management Dept. PRNAny Variable Lexington Health is a comprehensive network of care that includes six community medical and urgent care centers, nearly 80 physician practices, more than 9,000 health care professionals and Lexington Medical Center, a 607-bed teaching hospital in West Columbia, South Carolina. It was selected by Modern Healthcare as one of the Best Places to Work in Healthcare and was first in the state to achieve Magnet with Distinction status for excellence in nursing care. Consistently ranked as best in the Columbia Metro area by U.S. News & World Report, Lexington Health delivers more than 4,000 babies each year, performs more than 34,000 surgeries annually and is the region's third largest employer. Lexington Health also includes an accredited Cancer Center of Excellence, the state’s first HeartCARE Center, the largest skilled nursing facility in the Carolinas, and an Alzheimer’s care center. Its postgraduate medical education programs include family medicine and transitional year residencies, as well as an informatics fellowship.Job Summary Performs admission and concurrent stay medical record review to determine appropriateness of admission, continued stay, and setting. Follows patient throughout hospitalization collaborating with attending physician and other health care providers. Communicates with third party payors to obtain authorization. Contributes to appropriate throughput and length of stay. Assists with denial management. Reviews physician medical record documentation and consults with physicians regarding completeness. Minimum Qualifications Minimum Education: ADN, Diploma Nursing Degree, or Bachelor of Science in Nursing Minimum Years of Experience: 3 Years of experience in an acute care hospital setting Substitutable Education & Experience: None. Required Certifications/Licensure: Registered Nurse currently licensed in the State of South Carolina Required Training: None. Essential Functions Works in a cooperative manner, which fosters favorable relations between employees and patients, patients' families, visitors, fellow employees, and the medical staff. Accepts chain of command, supervision, and constructive criticism. Exhibits commitment and pride through personal example by positively speaking about LMC, the department, employees and guests. Contributes to teamwork and creates harmonious, effective and positive working relationships with others. Respects, understands, and responds with sensitivity to employees and guests by treating others as one would wish to be treated. Resolves conflicts and problems-solves by remaining calm when confronted, attempting to identify solutions or referring person to appropriate authority and attempting to deliver more than is expected. Exhibits telephone courtesy by: Answering promptly with name and department. Speaking with pleasant tone while focusing on caller. Transferring calls correctly and promptly. Attending to calls on hold in a timely manner. Maintains confidentiality by: Discouraging gossip. Using discretion when discussing patient, work, or LMC-related information with others. Utilizes the service recovery process to resolve complaints (GIFT). Demonstrates competence in providing duties within role. Demonstrates competence to provide developmentally appropriate planning/review for patients of all age groups. Identifies need for professional growth and seeks appropriate professional development opportunities attaining a minimum of 15 hours of continuing education in topics related to the role annually. Serves as role model for other members of the health care team. Demonstrates receptiveness to change and flexibility in meeting department needs. Assists in orientation and training of staff. Performs admission and continued stay medical record review to gather information to support medical necessity of the admission and communicate with third party payors. Performs timely review of admissions utilizing InterQual criteria to assess for appropriate level of care assignment. Reviews both inpatient admissions and patients placed in Observation. Incorporates applicable governmental regulatory guidelines in effect for Medicare and/or Medicaid admissions. Submits clinical data to third party payors and documents authorization in electronic medical record system. Performs continued stay reviews based on intensity of service, clinical response to care, expected length of stay and readiness for discharge, or at intervals which correspond to authorized days. Refers Observation or Inpatient admissions that lack documented medical necessity for the stay to the Physician Advisor and completes any needed follow through to ensure correct level of care and billing based on the Physician Advisor’s determination. Documents pertinent clinical data on worksheets. Ensures regulatory compliance and revenue integrity utilizing appropriate billing policies. Certifies Medicare admission utilizing established admission screening criteria. Duties & Responsibilities Applies appropriate condition codes and modifiers in electronic medical record system to communicate accurate claims information for billing. Documents denial information in electronic medical record system including attempts at resolution/overturning of the denial. Provides all payor communication to be scanned into the system for use in appeals. Maintains good working relationships with other departments within the revenue cycle. Conveys and receives information efficiently to and from third party payors, physicians, patients/families, physician practices, other members of the health care team, and other external agencies. Respects patient confidentiality and uses discretion in all interactions regarding patient protected health information. Consults with attending physician when documentation in the medical record does not support admission or continued stay and seeks to ensure completeness of all clinical documentation. Functions as liaison between the Physician Advisor and the attending physician. Serves as a resource to physicians, patients, physician practices, and other members of the health care team regarding issues related to patient classification and reimbursement. Issues letters of non-coverage in cases where the admission or continued stay is not certified, as necessary. Ensures patient/family notification of Observation status and documents in electronic medical record. Communicates insurance authorization information to physician's office as requested. Communicates with case management triad regarding reimbursement issues. Uses appropriate channels for reporting progress or concerns. Participates in making appropriate and efficient discharge plans for patients on assigned areas. Consults with members of the health care team effectively and efficiently regarding patient discharge plans. Manages inpatient Medicare discharge expedited appeals process through the QIO. Notifies attending physician and other members of the health care team of inappropriate admissions, denials, end of authorized days, or other factors that have a reimbursement impact. Consults Physician Advisor in cases where patient demonstrates readiness for discharge, but there is no documented intent to discharge. Identifies and documents potentially avoidable days in electronic medical record system. Assist Social Work staff to coordinate/obtain authorization for post acute services as needed. Identifies opportunities for improvement and coordinates/participates in the development and implementation of action plans to make improvements. Participates in unit discharge planning activities and in interdisciplinary patient care conferences. Indentifies abnormal patterns of utilization and refers to Manager/Director. Recommends changes to system/processes to eliminate identified problems. Represents department on various committees/taskforces. Adapts to change in timely and positive manner. Strives to meet department and hospital goals. Performs all other duties as assigned by authorized personnel or as required in an emergency (e.g., fire or disaster). We are committed to offering quality, cost-effective benefits choices for our benefit eligible employees and their families: Day ONE medical, dental and life insurance benefits Health care and dependent care flexible spending accounts (FSAs) Employees are eligible for enrollment into the 403(b) match plan day one. LHI matches dollar for dollar up to 6%. Employer paid life insurance – equal to 1x salary Employee may elect supplemental life insurance with low cost premiums up to 3x salary Adoption assistance LHI provides its full-time employees employer paid short-term disability and long-term disability coverage after 90 days of eligible employment Tuition reimbursement Student loan forgiveness Equal Opportunity EmployerIt is the policy of Lexington Health to provide equal opportunity of employment for all individuals, and to remain compliant with applicable state and federal laws and regulations. Lexington Health strives to provide a discrimination-free environment, and to recruit, select, on-board, and employ all employees without regard to race, color, religion, sex, age, disability, national origin, veteran status, or pregnancy, childbirth, or related medical conditions, including but not limited to, lactation. Lexington Health endeavors to upgrade and promote employees from within the hospital where possible and consistent with the employee’s desires and abilities and the hospital’s needs.
RN Utilization Review Full-time
Albany Medical Center

Utilization Review Nurse

Albany Medical Center Albany, NY
$77,075 - $119,466 / year
Department/Unit: Care Management/Social Work Work Shift: Day (United States of America) Salary Range: $77,075.00 - $119,466.00 Responsible for Utilization Management, Quality Screening and Delay Management for assigned patients. • Completes Utilization Management and Quality Screening for assigned patients. • Applies MCG criteria to monitor appropriateness of admissions and continued stays, and documents findings based on Departmental standards. • While performing utilization review identifies areas for clinical documentation improvement and contacts appropriate department. • Identifies at-risk populations using approved screening tool and follows established reporting procedures. • Monitors LOS and ancillary resource use on an ongoing basis. Takes actions to achieve continuous improvement in both areas. • Refers cases and issues to Medical Director and Triad Team in compliance with Department procedures and follows up as indicated. • Communicates covered day reimbursement certification for assigned patients. • Discusses payor criteria and issues and a case-by-case basis with clinical staff and follows up to resolve problems with payors as needed. • Uses quality screens to identify potential issues and forwards information to the Quality Department. • Demonstrates proper use of MCG and documentation requirements through case review and inter-rater reliability studies. • Facilitates removal of delays and documents delays when they exist. Reports internal and external delays to the Triad Team. • Collaborates with the health care team and appropriate department in the management of care across the continuum of care by assuring communication with Triad Team and health care team. Minimum Qualifications: • Registered nurse with a New York State current license. • Associate's degree required. Bachelor's degree preferred. • Minimum of three years clinical experience in an assigned service. • Recent experience in case management, utilization management and/or discharge planning/home care in a high volume, acute care hospital preferred. PRI and • Case Management certification preferred. • Assertive and creative in problem solving, critical thinking skills, systems planning and patient care management. • Self-directed with the ability to adapt in a changing environment. • Basic knowledge of computer systems with skills applicable to utilization review process. • Excellent written and verbal communication skills. • Working knowledge of MCG criteria and ability to implement and utilize. • Understanding of Inpatient versus Outpatient surgery and ICD10-Coding (preferred) and Observation status qualifications. • Ability to work independently and demonstrate organizational and time management skills. • Strong analytic, data management and PC skills. • Working knowledge of Medicare regulatory requirements, Managed Care Plans Thank you for your interest in Albany Med Health System!​ Albany Med Health System is an equal opportunity employer. This role may require access to information considered sensitive to Albany Med Health System, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that: Access to information is based on a “need to know” and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Med Health System policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification.
RN Utilization Review Full-time
Cottage Health

Utilization Management Case Manager Lead

Cottage Health Santa Barbara, CA
$63 - $97 / hour
Job Description Santa Barbara Cottage Hospital seeks a Utilization Management Case Manager Lead for their Care Management department responsible for providing education on current and updated regulatory compliance, orients and trains all new hires. Assists Manager of Case Management with meetings, audits, and other tasks assigned by the Manager of Case Management. QUALIFICATIONS: All job qualifications listed indicate the minimum level necessary to perform this job proficiently. Education: Required: Associate's Degree in Nursing (ADN). Preferred: Bachelor's Degree in Nursing (BSN). Certifications, Licenses, Registrations: Required: Current California Nursing license in good standing. Preferred: Certification in Case Management. Years of Related Work Experience: Required: 3 years as a case manager in an acute care setting. Other patient care experience may be considered. Preferred: 5 years of 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
Health & Hospital Corporation

LONG-TERM CARE QUALITY REVIEW NURSE ANALYST

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 Provides support to Vice President of Long Term Care and the Director of Quality Review gathering clinical data , formulating reports and conducting statistical analysis for the Long Term Care (LTC) Division. Managing datasets and provides data quality assurance and identifying needs to inform leadership in health-related decisions. Assists in collection of Capital related financial invoices from managing partner. Accompanies and participates as a member of the LTC Quality Review Team on site visits to the HHC Nursing Homes as assigned. Essential Duties Responsibility 1: 50%Collaborates with the Vice President and Director of Quality Review to design, conduct and interpret statistical analyses and determine quality indicators to monitor and report via the various data sources internal and external for the nursing homes and assisted living facilities owned and operated by HHC. Manages and maintains datasets, providing quality assurance and identifying needs for information to inform health related decisions. Assists in preparation of reports and presentations on Long Term Care issues and statistics for the HHC Long Term Care Committee to aide in the oversight of the HHC owned Long Term Care Facilities. Extracts and interprets data and reports in a format that a variety of LTC, financial and medical personnel can use. Assists in the completion and follow up of any requests or directives resulting from the LTC Committee meetings as assigned.Works with managing partner to obtain data analysis for review. Responsibility 2: 40%Participates as a member of the quality review team on assigned facility site visits.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. Prepares data for the quality review team prior to the facility site visits to assist in determining specific areas to review. Performs various auditing/review activities during the site visits as assigned. Assists in the preparation of a written site visit report following each facility visit in cooperation with other quality review team members Responsibility 3: 10%Must be detail oriented, able to adhere to deadlines, deal with frequent interruption and regular requests for assistance from department staff and have good customer service skills for addressing concerns and interacting with facility residents and personnel on site visits.Maintains confidentiality of all client records and information as specified by the Health Insurance Portability and Accountability Act of 1996 (HIPAA).Serve as a driver on facility site visits out of town when necessary, using a LTC Department Van or personal vehicle (with approval and appropriate mileage reimbursement).Other Duties and Responsibilities:Works with LTC Sr. Financial Analyst responsible for financial and quality analysis for LTC Division.Participates in the compilation, completion and distribution of quarterly and other reports prepared for the HHC Board of Directors Long Term Care Committee. Qualifications Registered nurse (RN)Experience with computerized health data analysis, and data managementKnowledge, Skills & Abilities Good judgment and discretion in communication (written, verbal and non-verbal).Must be able to prioritize work, meet deadlines, and work well under pressure. Flexibility to adjust to changing program/department needs and activities. Strong skills in programming, including data management and data analysis Statistical knowledge Excellent verbal and written skills. Must be proficient with Microsoft Office, Word, Excel, Power Point, Internet Explorer, and all usual and customary office equipment. Must possess the ability to work independently, and as part of a team. Must be able to display good customer service skills Must be able to take initiative and prioritize workload. Must be proficient in proof reading skills Working Environment MENTAL/VISUAL/PHYSICAL STRAIN: 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 – 15% Ability to perform driving functions in normal course of workday 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 Outpatient Other
Spectrum Healthcare Resources

Registered Nurse (RN) - Utilization Management

Spectrum Healthcare Resources San Antonio, TX
Job Description Spectrum Healthcare Resources has a potential opportunity for a Registered Nurse Utilization Management at Lackland AFB in San Antonio, TX. This contract position offers: Monday-Friday 730am-430pm Outpatient Clinic No Nights, Weekend or Holidays No On-Call Stable Patient Population Paid time off and paid holidays Benefits package including Medical, Dental, Vision and 401(k) and more… Requirements: Associate Degree of Nursing. Must possess a bachelor's degree in relevant health sciences or health informatics from an accredited university. Graduate from a college or university accredited by the ACEN or CCNE Active RN license in any state 2+ years of clinical and utilization management RN experience Basic Life Support Certification from American Heart Core Duties: Supports a comprehensive MTF Utilization Management plan/program as prescribed in the DoD Medical Management Guide and by the MTF Utilization Management Director. Actively and retrospectively reviews medical cases to confirm receipt of appropriate care, monitor for patterns/trends and develop action plan for areas requiring improvement. Reports on utilization patterns; briefs provider staff and executive staff. Maintains reports on which cases have been denied or received reduced third party payments and reports provider profiles to the MTF management for corrective action. Participates on multi-disciplinary teams to resolve recurring problems in the healthcare delivery process for care within or outside the MTF including referrals Research and Analysis: Investigate and resolve queries from MTF clinics by analyzing reports and data. Education and Training: Provide education and guidance on reporting systems and tools to ensure effective utilization by clinic staff. For More Information Contact: Melissa Powell 719-528-7965 Melissa_Powell@Spectrumhealth.com Company Overview: Spectrum Healthcare Resources (SHR) was established in 1988 to deliver systems and processes designed to meet the unique needs of Military and VA Health Systems. SHR is a leading organization that provides physician and clinical staffing and management services to United States Military Treatment Facilities, VA clinics and other Federal Agencies through various contracting vehicles. A Joint Commission Health Care Staffing Services firm, SHR is the military staffing division of TeamHealth, a Nationwide organization that serves 850 civilian and military hospitals with a team of 9,600 affiliated health care professionals. EOE/Disabled/Veterans Location : Location US-TX- Recruiter : Full Name: First Last Melissa Powell Direct phone number 719-528-7965 Recruiter : Email Melissa_Powell@spectrumhealth.com
RN Utilization Review Telehealth
L.A. Care Health Plan

Utilization Management Nurse Specialist 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 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 Manager/Supervisor Utilization Review Telehealth
L.A. Care Health Plan

Supervisor, Utilization Management RN

L.A. Care Health Plan Los Angeles, CA
$102,183 - $163,492 / year
Salary Range: $102,183.00 (Min.) - $132,838.00 (Mid.) - $163,492.00 (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 Supervisor of Utilization Management (UM) RN is responsible for executing the day-to-day operations of the UM department, and monitoring the Care Management (CM) staff’s responsibilities and activities. This includes, but not limited to, ensuring proper staffing and coverage; monitoring and evaluating departmental operations to ensure optimal efficiency, productivity, and effectiveness; documenting and appropriately addressing excellence or deviations in work, departmental, and organizational expectations; and conducting intermittent and annual performance evaluations. This role assists in triaging identified issues/problems and forming resolution within the scope of work/licensure. The Supervisor is a subject matter expert (SME) in Care/Case/Utilization Management and supporting regulations, policies, protocols, and procedures. This position serves as a formal and informal instructor, and escalates issues/concerns to the appropriate person when outside of their scope. This position is responsible in assisting with and development and maintenance of a successful and cohesive unit, with high level of productivity and accuracy to achieve the department's overall performance metrics. The Supervisor ensures all functions of the UM department are operating in accordance with the organization's mission, values and strategic goals, which are focused on quality care delivery and continuous improvement; and are provided in a manner that is responsive and sensitive to the needs of L.A. Care's culturally diverse membership. The position supports the UM Manager/Director. This role also assists UM Educator/Manager/Director in identification of training needs including, but not limited to, collaborating in development of programs, training materials, competency checklist, and orientation checklists necessary to meet education and training needs of UM staff. The position supervises all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports. Duties Ensures adequate/appropriate distributions of workforce, assignments and time off requests. Participates in the hiring and termination process providing recommendations with appropriate supporting documentation. Monitors of staff's performance including productivity and compliance with regulatory requirements, compliance with policies. Identifies, communicates and coaches to improve staff performance. Develops tools, job aids, and workflows to optimize the process flow, performance and productivity of the UM team. Completes intermittent and annual staff evaluations. Serves as the primary resource for all business-related questions/issues raised by staff; escalates to appropriate leader/team when necessary. Recommends and implements process improvement measures to achieve department's performance measures outcomes and goals. Plans and oversees UM activities according to model of care, program description and policy and procedures to provide timely, quality care and services to members. Maintains all assigned reporting responsibilities, conducts regular audits to ensure compliance with community, industry and organizational standards including regulatory requirements. Serves as a super-user on electronic programs and systems used by the department. Assists in the development of programs, workflows, tools, training materials, orientation checklists, and competency checklist necessary to meet educational needs. Trains new staff, remediation of seasoned staff and cross training as needed in specified business lines. Serves as a leader and role model as well as technical and informational resource for staff and peers. Duties Continued Fosters a culture that encourages employee contribution to ensure that the department maintains an environment in which quality flourishes. Services as member/resource/liaison to the Interdisciplinary Care Team. Recommends resources to improve performance standards in terms of Utilization Management. Collaborates with peers and colleagues within the organization to address process improvements, member's needs, department and organizational enhancements and communicate development as appropriate. Participates on internal and external committees as delegated or assigned. Serves as a consultant to other departments or organizations as needed. Responsible for the daily workflow and leading the work of assigned staff. This role will mentor, coach, act as a resource and provide feedback on performance of assigned staff. Performs other duties as assigned. Education Required Associate's Degree in NursingEducation Preferred Bachelor's Degree in NursingExperience Required: Minimum of 7 years of acute/clinical care experience. Minimum of 2 years of experience in Case/Care/Utilization Management in an acute care or health plan setting. Minimum of 3 years leading process, program, or staff or supervisory experience. Equivalency: Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement. Skills Required: Knowledge of state, federal and regulatory requirements in Care/Case/Utilization Management. Strong verbal and written communication skills. Computer literacy with proficiency with Microsoft Word, Excel, etc. and ability to learn core departmental computer systems and software. Excellent organizational, time management, and interpersonal skills. Must be detailed-oriented, energetic, and an enthusiastic team player. Must be able to work independently. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California LicenseLicenses/Certifications Preferred Required Training Physical Requirements LightAdditional Information Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. L.A. Care offers a wide range of benefits including Paid Time Off (PTO) Tuition Reimbursement Retirement Plans Medical, Dental and Vision Wellness Program Volunteer Time Off (VTO)
RN Utilization Review Outpatient Full-time
Prime Healthcare

Utilization Review RN

Prime Healthcare Ontario, CA
Overview Prime Healthcare is an award-winning health system headquartered in Ontario, California. Prime Healthcare operates 54 hospitals and has more than 360 outpatient locations in 15 states providing more than 3.0million patient visits annually. It is one of the nation’s leading health systems with over 60,000 employees and physicians. Twenty-one of the Prime Healthcare hospitals are members of the Prime Healthcare Foundation, a 501(c)(3) not-for-profit public charity. Prime Healthcare is actively seeking new members to join our corporate team! Responsibilities Responsible for the quality and resource management of all authorizations and referrals with the Prime Healthcare Employee EPO. Works on behalf of the advocate, promoting cost containment and demonstrates leadership to integrate the health care providers to achieve a perceived seamless delivery of care. The methodology is designed to facilitate and insure the achievement of quality, clinical and cost-effective outcomes and to perform a holistic and comprehensive review of the medical record for the medical necessity, intensity of service and severity of illness. Qualifications EDUCATION, EXPERIENCE, TRAINING Required qualifications: Minimum 7 years Post Graduate of an accredited school of nursing and a current state Registered Nurse license. Minimum 3 years RN Utilization Manager working for a Health Plan. At least 3 years of experience in utilization review, referrals, authorizations, denials and appeals. Current BCLS (AHA) certificate upon hire and maintain current. Knowledge of MCG Criteria and/or InterQual Criteria required. Experience and knowledge in basic to intermediate computer skills. Preferred qualifications: Five years acute care nursing experience preferred. Experience with self-funded health plan preferred. Pay Transparency Prime Healthcare offers competitive compensation and a comprehensive benefits package that provides employees the flexibility to tailor benefits according to their individual needs. Our Total Rewards package includes, but is not limited to, paid time off, a 401K retirement plan, medical, dental, and vision coverage, tuition reimbursement, and many more voluntary benefit options. Benefits may vary based on employment status, i.e. full-time, part-time, per diem or temporary. A reasonable compensation estimate for this role, which includes estimated wages, benefits, and other forms of compensation, is $71,760.00 to $104,000.00 on an annualized basis. The exact starting compensation to be offered will be determined at the time of selecting an applicant for hire, in which a wide range of factors will be considered, including but not limited to, skillset, years of applicable experience, education, credentials and licensure. Employment Status Full Time Shift Days Equal Employment Opportunity Company is an equal employment opportunity employer. Company prohibits discrimination against any applicant or employee based on race, color, sex, sexual orientation, gender identity, religion, national origin, age (subject to applicable law), disability, military status, genetic information or any other basis protected by applicable federal, state, or local laws. The Company also prohibits harassment of applicants or employees based on any of these protected categories. Know Your Rights: https://www.eeoc.gov/sites/default/files/2022-10/EEOC_KnowYourRights_screen_reader_10_20.pdf Privacy Notice Privacy Notice for California Applicants: https://www.primehealthcare.com/wp-content/uploads/2024/04/Notice-at-Collection-and-Privacy-Policy-for-California-Job-Applicants.pdf
RN Utilization Review Per Diem
Northern Nevada Health System

UTILIZATION REVIEW NURSE (RN), Case Management - Per Diem

Northern Nevada Health System Sparks, NV
Responsibilities When it comes to choosing a hospital, one thing is clear: quality and convenience count. Northern Nevada Medical Center's tradition of providing quality healthcare in a comfortable, accessible environment means peace of mind for the thousands of patients served by the hospital each year. Northern Nevada Medical Center is a 124-bed acute care hospital located on 23 hillside acres at 2375 E. Prater Way in Sparks, Nevada. Website: https://www.nnmc.com Job Summary: This Utilization Review Nurse (RN) is Per Diem on our Case Management Unit and offers a convenient schedule. The Northern Nevada Health System is seeking a Utilization Review Nurse (RN) who will be responsible for carrying out utilization management functions by planning, coordinating, and managing patient needs during hospitalization and throughout the continuum of care. Must be available to work weekends and holidays. Job Duties/Responsibilities: Conducts admission and continued stay reviews per guidelines to ensure medical necessity of level of care and hospitalization for multiple entities. Reviews medical record for presence of accurate placement orders reconciles variances with patient providers. Works collaboratively with attending providers, specialty providers, and physician advisors to ensure application of evidence-based guidelines for determining appropriate status. Collaborate with Patient Access team to ensure correct payer source for hospitalization and communication. 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 Requirements: Graduate of an accredited or NLN approved RN program. Current license as a RN in the State of Nevada required. Two (2) years of clinical experience in an acute care hospital setting with (1) year in an inpatient or outpatient case management setting required. Demonstrates compliance with hospital policies and procedures at all times. Demonstrates strong leadership, organization, communication and interpersonal skills. 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 Part-time
Capital Health

Utilization Review RN - PT - Day - Utilization Resource Mgmt Pennington NJ

Capital Health Hopewell, VA
$39.40 - $51.47 / hour
Capital Health is the region's leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advanced technology. Capital Health is a dynamic health care resource accredited by the DNV that includes two hospitals, an outpatient center, satellite ED, and an expansive network of primary and specialty care. Capital Health Medical Group is made up of more than 600 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region. Capital Health recognizes that attracting the best talent is key to our strategy and success as an organization. As a result, we aim for flexibility in structuring competitive compensation offers to ensure we can attract the best candidates. The listed pay range or pay rate reflects compensation for a full-time equivalent (1.0 FTE) position. Actual compensation may differ depending on assigned hours and position status (e.g., part-time). Pay Range: $39.40 - $51.47 Scheduled Weekly Hours: 20 Position Overview Performs a variety of utilization and resource management activities to promote quality, clinical and cost effective outcomes. Assesses patients treatment plans, communicates to third party payers, and collaborates with healthcare team members. Performs functions which help to optimize lengths of stay, utilize resources efficiently, and promote cost effective practices without negatively impacting patient care. Adheres to established standards, practices and procedures. MINIMUM REQUIREMENTS Education: Associate's degree in nursing. Graduate of an accredited school of nursing. CPHQ, CCM or CPUR preferred. Experience: Five years' clinical nursing and three years quality management, utilization review or discharge planning experience. Other Credentials: Registered Nurse - NJ Knowledge and Skills: Special Training: Basic computer skills including the working knowledge of Microsoft Office, UR software and EMR. Possesses familiarity with MCG guidelines. Mental, Behavioral and Emotional Abilities: Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form. Usual Work Day: 8 Hours Reporting Relationships Does this position formally supervise employees? No If set to YES, then this position has the authority (delegated) to hire, terminate, discipline, promote or effectively recommend such to manager. ESSENTIAL FUNCTIONS Performs chart review of identified patients to identify quality, timeliness and appropriateness of patient care. Conducts admission reviews for Medicare, Medicaid beneficiaries, as well as private insurers and self pay patients, based on appropriate guidelines. Uses these criteria guidelines to screen for appropriateness for inpatient level of care or observation services based on physician certification (physicians H&P, treatment plan, potential risks and basis for expectation of a 2 midnight stay). Refers cases as appropriate, to the UR physician advisor for review and determination. Gathers clinical information to conduct continued stay utilization review activities with payers on a daily basis. Performs concurrent and retrospective clinical reviews with various payers, utilizing the appropriate guidelines as demonstrated by compliance with all applicable regulations, policies and timelines. Adheres to CMS guidelines for utilization reviews as evidenced by utilization of the relevant guidelines and appropriate referrals to the physician advisor and the UR Committee. Identifies, develops and implements strategies to reduce length of stay and resource consumption. . Confers proactively with admitting physician to provide coaching on accurate level of care determinations at point of hospital entry. Keeps current on all regulatory changes that affect delivery or reimbursement of acute care services. Uses knowledge of national and local coverage determinations to appropriately advise physicians. Understands and applies federal law regarding use of Hospital Initiated Notice of Non-Coverage (HINN) and Lifetime Reserve Days letters. Identifies and records consistently any information on any progression of care or patient flow barriers using the Avoidable Days tool in Utilization software program. Consults with medical staff, care team and case managers as necessary to resolve immediate progression of care barriers through appropriate administrative and medical channels. Engages care team colleagues in collaborative problem solving regarding appropriate utilization of resources. Recognizes and responds appropriately to patient safety and risk factors. Represents Utilization Management at various committees, professional organizations an physician groups as needed. Promotes the use of evidence based protocols and or order sets to influence high quality and cost effective care. Identifies, develops and implements strategies to reduce lengths of stay and resource consumption in patient population. Participates in performance improvement activities. Promotes medical documentation that accurately reflects findings and interventions, presence of complication or comorbidities, and patient's need for continued stay. Identifies and records episodes of preventable delays or avoidable days due to failure of progression of care processes. Maintains appropriate documentation in Utilization software system on each patient to include specific information of all resource utilization activities. Participates actively in daily huddles, patient care conferences, and hospitalist or nurse handoff reports to maintain knowledge about intensity of services and the progression of care. Identifies potentially wasteful or misused resources and recommends alternatives if appropriate by analyzing clinical protocols. Performs other duties as needed. PHYSICAL DEMANDS AND WORK ENVIRONMENT Frequent physical demands include: Sitting , Standing , Walking Occasional physical demands include: Climbing (e.g., stairs or ladders) , Carry objects , Push/Pull , Twisting , Bending , Reaching forward , Reaching overhead , Keyboard use/repetitive motion , Talk or Hear Continuous physical demands include: Lifting Floor to Waist 15 lbs. Lifting Waist Level and Above 15 lbs. Sensory Requirements include: Accurate Near Vision, Accurate Far Vision, Accurate Color Discrimination, Accurate Depth Perception, Accurate Hearing Anticipated Occupational Exposure Risks Include the following: N/A This position is eligible for the following benefits: Medical Plan Prescription drug coverage & In-House Employee Pharmacy Dental Plan Vision Plan Flexible Spending Account (FSA) - Healthcare FSA - Dependent Care FSA Retirement Savings and Investment Plan Basic Group Term Life and Accidental Death & Dismemberment (AD&D) Insurance - Less than 10 years of service - $5,000 - 10+ years of service - $10,000 Supplemental Group Term Life & Accidental Death & Dismemberment Insurance Disability Benefits – Short Term Disability (STD) Employee Assistance Program Commuter Transit Commuter Parking Supplemental Life Insurance - Voluntary Life Spouse - Voluntary Life Employee - Voluntary Life Child Voluntary Legal Services Voluntary Accident, Critical Illness and Hospital Indemnity Insurance Voluntary Identity Theft Insurance Voluntary Pet Insurance Paid Time-Off Program The pay range listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future. When determining base salary and/or rate, several factors may be considered including, but not limited to location, years of relevant experience, education, credentials, negotiated contracts, budget, market data, and internal equity. Bonus and/or incentive eligibility are determined by role and level. The salary applies specifically to the position being advertised and does not include potential bonuses, incentive compensation, differential pay or other forms of compensation, compensation allowance, or benefits health or welfare. Actual total compensation may vary based on factors such as experience, skills, qualifications, and other relevant criteria.
RN Utilization Review Full-time
Connecticut Children's

Center for Care Coordination-Team Lead Utilization Review Nurse- Full Time

Connecticut Children's Hartford, CT
The Team Lead for Utilization Review (UR) is responsible for the day-to-day activities and oversight of the UR Nurses, under the guidance and support of the Manager of Case Management and Director of the Center. Provides leadership and direction around scheduling, supervision and daily operations, while looking strategically at how workflow and process improvement can optimize and improve the role of Case Management and patient/family care through the institution. Lead will identify challenges and systems issues that need to be elevated to the Manager and Center Leadership. Team Lead-20%: Daily clinical support and supervision of UR nurses. Scheduling for UR coverage. UR Policies and Procedure review and maintenance. Onboarding and support of new staff. Individual and team supervision / support following challenging cases. Work with Manager to establish and track metrics, data and initiatives that improve process UR Team Communications. Assists Manager in completing performance evaluations. Provides formal and informal support of members through engagement activities, team supervision and staff meetings. Develop and maintain effective and efficient processes for determining the defensible hospitalization status based on regulatory and reimbursement requirements of various commercial and government payers. -20% Performs chart review of assigned patients to identify quality, timeliness, and appropriateness of patient care. Conducts hospitalization reviews for Medicaid beneficiaries, as well as other insurers and self-pay patients, based on appropriate guidelines. Uses these criteria to screen for appropriateness of level of care based on medical record documentation. -9% Gathers clinical information to conduct continued stay utilization review activities with payers pursuant to department policies and procedures and the Utilization Review Plan. -5% Escalates cases as appropriate for secondary review. -5% Performs concurrent and retrospective clinical reviews utilizing the appropriate guidelines as demonstrated by compliance with all applicable regulations, policies, and timelines. -5% Adheres to CMS guidelines for utilization reviews as evidenced by utilization of the relevant guidelines and appropriate referrals for secondary review. Identifies, develops, and implements strategies to reduce length of stay and resource consumption in conjunction with discharge planning staff. -9% Identifies and consistently documents information on any progression of care or patient flow barriers using the designated electronic tool used to track avoidable days/delays. -2.5% Engages hospital case management and care team colleagues in collaborative problem solving regarding appropriate utilization of resources. -5% Represents Utilization Management at various committees, as needed. -.5% Identifies and records episodes of preventable delays or avoidable days due to failure of progression-of-care processes. 2 Maintains appropriate documentation in the Utilization software system on each patient to include specific information of all resource utilization activities. -10% Provides consultation and education to physicians and other qualified practitioners regarding medical record documentation necessary to support the ordered level of care. -5% Conveys benefit data and options, programs and other forms of assistance that may be available to the patient, and negotiates for services as indicated. -.5% Communicates pertinent reimbursement information to healthcare team while observing patient right to confidentiality. -1.0% Verifies in-network verses out-of-network benefits and communicates data to the patient and healthcare team as indicated. -.5% Collaborates with other members of The Center team to coordinate the right care, in the right setting, at the right time for CT Children’s patients. Identify gaps in care/resources and address issues that negatively impact access to care, services, and resources Function as a change agent, advocate, and resource person for family and healthcare team to identify and resolve performance improvement issues within the system. -5% Performs other job-related duties as assigned 0 Education and/or Experience Required: Education: Bachelor of Science in Nursing (BSN) Experience: 3 years’ nursing in a healthcare setting Education and/or Experience Preferred: Experience: Pediatric nursing experience Previous experience in Utilization Review Previous experience in Case Management or Discharge planning License and/or Certification Required: State of Connecticut Nursing License License and/or Certification Preferred: Case Management Certification. Knowledge, Skills and Abilities: Knowledge: Demonstrate working knowledge of how to interpret and apply medical care criteria. Knowledge of community resources, treatment options, home health availability, funding options and special programs. UR Team Lead has strong clinical skills and a well-developed knowledge of utilization management, with a focus on medical necessity determinations. Lead maintains current and accurate knowledge regarding commercial and government payers including regulatory requirements. Skills: Coordinates management of care for a specified patient population; follows patients throughout the continuum of care and ensures optimum utilization of resources, service delivery and compliance with hospital standards Provides ongoing support and expertise through comprehensive assessment, care planning, plan implementation and overall evaluation of individual patient needs. Skilled in the operation of the computer including proficiency in Microsoft Office Word, ability to use/update Excel spreadsheets and ability to navigate EPIC. Strong working knowledge of medical necessity tools such as InterQual® and Milliman Care Guidelines® and be proficient in medical record reviews. UR Lead will support process improvement activities and report key metrics to facility leadership as requested. The UR Lead will demonstrate an ability to effectively and efficiently manage a diverse workload in a fast-paced, rapidly changing regulatory environment. Lead will provide support to the hospital’s UM Committee as needed and collaborate with multiple leaders at various levels throughout the organization. Abilities: Self-directed/motivated, organized, diplomatic and team-oriented. Function in a high energy, fast moving environment. Maintain flexibility as determined by acuity of medical unit. Prioritize case load. Collaborate with various disciplines Communicate effectively and efficiently Prioritize and manage multiple tasks. Excellent written and verbal communication skills.
RN Utilization Review Full-time
Cameron Memorial Community Hospital

Registered Nurse Case Manager and Utilization Review

Cameron Memorial Community Hospital Angola, IN
Cameron Hospital is an independent, not-for-profit facility that proudly serves Angola and Steuben County. We’ve been a cornerstone of this community and the surrounding area in northeast Indiana dating back to 1926. Over the years, we’ve helped generation after generation of area residents enjoy better health and live comfortably. Today, Cameron Hospital has grown into something more than a simple community hospital. Filled with advanced equipment and skilled specialists, Cameron is a modern, high-tech facility that provides advanced diagnostics, a variety of specialties and cutting-edge treatment options that are combined with highly personalized and compassionate care. DEPARTMENT : Utilization Review JOB TITLE: Registered Nurse Case Manager and Utilization Review SHIFT : .8 FTE, 64 hours bi-weekly, Days, Rotating weekend coverage required. Essential Functions Assess all needs for referrals to include durable medical equipment, special needs equipment/services, ongoing specialty medical care, and institutional referrals such as transfers to rehabilitative or nursing home care. Collaborates with providers, other members of the healthcare team, and community agencies as needed to help facilitate the best discharge plan for the patient. Create individual and comprehensive case management and treatment plans. Follow case and quality management processes in compliance with regulatory guidelines and company procedures. Participates in Daily Collaborative Rounds. QUALIFICATIONS Three years of hospital clinical experience. Skills/Competencies Demonstrates clinical assessment skills, including assessing clients from pre-admission to post discharge. Comply with the Indiana Pre-Admission Screening/PASAAR program manual to complete designee duties as a discharge planner. Knowledge of available community resources and external agencies. Ensures timely and accurate completion of workload and clinical documentation. Education Required Bachelor's degree in nursing or higher . Associate degree Nurse currently enrolled in an accredited bachelor's program with a completion date of fewer than 12 months from hire. Licenses Requirements Licensed Registered Nurse in the State of Indiana Certification Required or Preferred None
RN Utilization Review Outpatient Other
Spectrum Healthcare Resources

Registered Nurse - Utilization Management

Spectrum Healthcare Resources Joint Base Andrews, MD
Job Description Spectrum Healthcare Resources has an opportunity for a Registered Nurse Utilization Management (UMRN) working at Joint Base Andrews in Washington, D.C. Requirements: Associates Degree of Nursing Current, full, active, and unrestricted license to practice as a Registered Nurse (Any State) Must have at least 36 months of total nursing experience in direct patient care clinical setting. Must have utilization management, utilization review or case management experience for 24 recent consecutive months Certified/certification eligible in relevant specialty, such as Certified Managed Care Nurse through the American Board of Managed Care Nurses, or Certified Informatics Nursing, Ambulatory Care Nursing, Medical-Surgical Nursing, or Nursing Case Management through the American Nurses Credentialing Center. Highly organized, self-directed worker able to function in a high-volume environment without distractions. Strong verbal and written communication skills. Proficient level of experience with Microsoft Office applications and strong technical aptitude. Work Schedule: Monday - Friday No nights and weekends 8 hours a day Company Overview: Spectrum Healthcare Resources (SHR) was established in 1988 to deliver systems and processes designed to meet the unique needs of Military and VA Health Systems. SHR is a leading organization that provides physician and clinical staffing and management services to United States Military Treatment Facilities, VA clinics and other Federal Agencies through various contracting vehicles. A Joint Commission Health Care Staffing Services firm, SHR is the military staffing division of TeamHealth, a Nationwide organization that serves 850 civilian and military hospitals with a team of 9,600 affiliated health care professionals. EOE/Disabled/Veterans Joseph Day Recruiter Direct: (314) 744-4138 424 S Woods Mill Rd | Suite 205 | Town & Country, MO 63017 Location : Location US-MD-Camp Springs Recruiter : Full Name: First Last Joseph Day Direct phone number 314-744-4138 Recruiter : Email joseph_day@spectrumhealth.com
RN Utilization Review Temporary
UF Health

RN, Utilization Management

UF Health FL
Overview Plays a critical role in evaluating patient medical records to ensure the necessity and appropriateness of healthcare services. Involves coordinating with healthcare providers to maintain compliance with utilization management guidelines and optimizing treatment plans for effective patient care and resource utilization. Requires clear communication of authorization decisions and ongoing monitoring to support timely discharge planning. Analyzes utilization data to identify trends and collaborates with interdisciplinary teams to enhance care coordination while ensuring accurate documentation and regulatory compliance. Responsibilities Evaluates patient medical records to ensure necessity and appropriateness of healthcare services. • Coordinates with healthcare providers to maintain compliance with utilization management guidelines. • Optimizes treatment plans for effective patient care and resource utilization. • Communicates authorization decisions clearly and supports timely discharge planning. • Analyzes utilization data to identify trends and improve care coordination. • Collaborates with interdisciplinary teams to ensure accurate documentation and regulatory compliance. Qualifications Required Education . Graduate from an accredited Nursing school Required experienc e: Registered Nurse (RN) license with 3+ years experience in utilization review or case management Necessary Skills • Knowledge of healthcare utilization guidelines and compliance • Experience evaluating medical necessity and treatment plans • Strong communication skills for authorization decisions • Ability to analyze utilization data and support care coordination License Requirement: Registered Nurse (RN) with a current Florida nursing license required.
RN Utilization Review Full-time
Parkland Health (TX)

Registered Nurse - Care Coordinator - Utilization Review

Parkland Health (TX) Dallas, TX
Location: Main Hospital Bldg - 1st Flr Shift- Days (10hrs) 7:30am-6pm 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: 988689
RN Utilization Review Outpatient Full-time
UF Health

RN, Utilization Management | Utilization Management| Day| Full Time

UF Health Tampa, FL
Overview The RN Utilization Managemen t plays a critical role in evaluating patient medical records to ensure the necessity and appropriateness of healthcare services. Involves coordinating with healthcare providers to maintain compliance with utilization management guidelines and optimizing treatment plans for effective patient care and resource utilization. Requires clear communication of authorization decisions and ongoing monitoring to support timely discharge planning. Analyzes utilization data to identify trends and collaborates with interdisciplinary teams to enhance care coordination while ensuring accurate documentation and regulatory compliance Responsibilities An incumbent in this position will • Evaluates patient medical records to ensure necessity and appropriateness of healthcare services. • Coordinates with healthcare providers to maintain compliance with utilization management guidelines. • Optimizes treatment plans for effective patient care and resource utilization. • Communicates authorization decisions clearly and supports timely discharge planning. • Analyzes utilization data to identify trends and improve care coordination. • Collaborates with interdisciplinary teams to ensure accurate documentation and regulatory compliance. Qualifications Required: Registered Nurse (RN) with a current Florida license required. • 3+ years experience in utilization review or case management • Knowledge of healthcare utilization guidelines and compliance • Experience evaluating medical necessity and treatment plans • Strong communication skills for authorization decisions • Ability to analyze utilization data and support care coordination Licensure/Certification/Registration: Registered Nurse (RN) with a current Florida license required.
RN Utilization Review Full-time
Silver Cross Hospital

Utilization Review Nurse

Silver Cross Hospital New Lenox, IL
$34.73 - $45.15 / hour
Silver Cross Hospital is an extraordinary place to work. We’re known for our culture of excellence and delivery of unrivaled experiences for our patients, their families, the communities we serve…and for each other. Come join us! It’s the way you want to be treated. Position Summary: Performs medical record review for severity of illness and intensity of service; liaison function with external review agencies to ensure compliance with regulations affecting financial reimbursement; identifies variance from established pathways Essential Duties and Responsibilities: Collects information from clinical medical record for severity of illness and intensity of service and documents such in clinical database Monitors all levels of care for appropriateness and communicates variance; evaluates plan of care to ensure it is based on accepted standards Provides information to external review organizations, documents pertinent communications Refers to designated physician advisor those patients not meeting criteria as well as quality of care concerns Maintains knowledge and incorporates current standards into practice Required Qualifications : Knowledge of clinical norms; excellent communication skills; critical thinking skills; organized and efficient time management skills Education and Training : Nurse, Registered (RN) licensure BSN preferred. 2-5 years previous Utilization Review experience preferred. Current CPR Relevant hospital nursing; hospital case management; insurance case management or utilization management experience preferred Work Shift Details: Days, Primarily remote; onsite orientation requirement; weekend and holiday rotation; on site requirement for meetings and mandatory training Department: CONTINUUM OF CARE Benefits for You At Silver Cross Hospital, we care about your health and well-being and that is why we work hard to provide quality and affordable benefit options for you and your eligible family members. Silver Cross Hospital and Silver Cross Medical Groups offer a comprehensive benefit package available for Full-time and Part-time employees which includes: · Medical, Dental and Vision plans · Life Insurance · Flexible Spending Account · Other voluntary benefit plans · PTO and Sick time · 401(k) plan with a match · Wellness program · Tuition Reimbursement Registry employees who meet eligibility may participate in our 401(k) Savings plan with a potential match. However, registry employees are ineligible for Health and Welfare benefits. The final pay rate offered may be more than the posted range based on several factors including but not limited to: licensure, certifications, work experience, education, knowledge, demonstrated abilities, internal equity, market data, and more. The expected pay for this position is listed below: $34.73 - $45.15
RN Utilization Review Telehealth Other
Devoted Health

Clinical Guide Part A: Utilization Management Nurse

Devoted Health
$85,000 - $95,000 / year
Job Description Schedule: The weekly schedule choice is either Monday - Friday 10am-7pm EST OR Tuesday - Saturday 9am-6pm EST A bit about this role: The Clinical Guide Part A will be part of the Utilization Management team, responsible for inpatient, behavioral health, and/or post-acute authorization review in alignment with CMS and Medicare Advantage regulations. Reviews medical records to evaluate the medical necessity and appropriateness of requested inpatient and/or post-acute services in accordance with established clinical criteria and CMS guidelines. Your Responsibilities and Impact will include: Review Medical Records: Conduct prospective (pre-service), concurrent, and retrospective utilization review to evaluate medical necessity, appropriate level of care (Inpatient vs. Observation), and post-acute services in accordance with established clinical criteria and CMS guidelines. Evaluate Treatment Plans: Assess the appropriateness, timing, and setting of requested services, ensuring alignment with medical necessity criteria and Medicare Advantage requirements. Recommend alternative levels of care when clinically appropriate. Inpatient & Behavioral Health Review: Perform initial, concurrent, and discharge reviews for inpatient and behavioral health admissions. Ensure admission status accuracy and regulatory compliance with CMS timeliness (TAT) standards. Post-Acute Review: Conduct initial authorization and concurrent review for post-acute services (SNF, LTACH, ARU, Home Health), evaluating ongoing medical necessity and appropriate length of stay. Issue NOMNC when coverage criteria are no longer met. Medical Director Collaboration: Refer cases that do not meet criteria to the Medical Director for secondary review and final determination. Prepare clinical summaries and coordinate peer-to-peer (P2P) discussions. Manage authorization reopen requests as appropriate. Resource Stewardship: Monitor utilization of inpatient and post-acute services to promote appropriate resource use while maintaining high-quality, member-centered care. Regulatory & Documentation Compliance: Maintain accurate, defensible documentation of all determinations. Ensure adherence to CMS regulations, Medicare Advantage requirements, and internal compliance standards. Required skills and experience: Unrestricted RN license with a minimum of 4 years of clinical experience. Minimum 3 years of Utilization Management or Inpatient UR experience within a health plan or hospital setting. Strong knowledge of CMS regulations and Medicare Advantage requirements. Experience preparing cases for Medical Director review Able to work in a fast paced environment that is constantly evolving. Desired skills and experience: Experience with AI/LLM Certified in InterQual #LI-Remote #LI-DS1 Salary Range: $85,000-$95,000 / 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.