Registered Nurse (RN) Utilization Review Jobs

RN Utilization Review Full-time
Molina Healthcare

Care Review Clinician (RN) Remote (Must reside in Mississippi)

Molina Healthcare Jackson, MS
JOB DESCRIPTION Job Summary Provides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines. • Analyzes clinical service requests from members or providers against evidence based clinical guidelines. • Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. • Conducts reviews to determine prior authorization/financial responsibility for Molina and its members. • Processes requests within required timelines. • Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner. • Requests additional information from members or providers as needed. • Makes appropriate referrals to other clinical programs. • Collaborates with multidisciplinary teams to promote the Molina care model. • Adheres to utilization management (UM) policies and procedures. Required Qualifications • At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience. • Registered Nurse (RN). License must be active and unrestricted in state of practice. • Ability to prioritize and manage multiple deadlines. • Excellent organizational, problem-solving and critical-thinking skills. • Strong written and verbal communication skills. • Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications • Certified Professional in Healthcare Management (CPHM). • Recent hospital experience in an intensive care unit (ICU) or emergency room. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $23.76 - $51.49 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
RN Utilization Review Telehealth Full-time
Centene

Clinical Review Nurse-Concurrent Review

Centene New York, NY
$27.02 - $48.55 / hour
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. ***Applicants must have and maintain active New York State (NYS) RN licensure to be considered. The standard fully remote work schedule is Monday through Friday, 8:30 a.m. to 5:00 p.m. with the potential for weekend and/or holiday coverage based on business needs.*** Position Purpose: Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member. Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines Reviews member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities Collaborates with care management on referral of members as appropriate Performs other duties as assigned. Complies with all policies and standards Education/Experience: Requires graduation from an accredited school of nursing or a Bachelor’s degree in Nursing (BSN), along with 2–4 years of related nursing experience. A minimum of 2 years of acute care experience is required. Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. License/Certification: LPN - Licensed Practical Nurse - State Licensure required NYS RN Licensure Strongly Preferred Pay Range: $27.02 - $48.55 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
RN Outpatient Utilization Review Outpatient Full-time
IU Health

Registered Nurse – Outpatient – Urology – Ambulatory Referral Review

IU Health Indianapolis, IN
Overview Part and Full-time roles are eligible for a $30,000 sign-on bonus — apply today to learn more! We are seeking an individual with a minimum of one year of RN experience for this role. Are you an upcoming nurse graduate or recent nurse graduate? Please apply through our pipeline requisition here: https://iuhealth.org/applyrn . This pipeline requisition allows the IU Health Talent Acquisition team to pair upcoming & recent nurse graduates with the best opportunities available to them based on their unique skillset and interests. Thanks for your interest in joining the team! IU Health is seeking expert RN's who will have the opportunity to collaborate with the brightest minds in medicine. At IU Health, you will develop in significant ways, advancing healthcare for all! Being an IU Health nurse means building a professional nursing career designed with competitive benefits, a culture that accepts your outstanding strengths, and supports your personal and professional goals. If you are seeking an organization where you can engage expertly, develop clinical expertise, embrace learning, cultivate new relationships, and fuel your spirit of inquiry, apply today! Position Overview: Join our dynamic healthcare team as a Registered Nurse specializing in Ambulatory Referral Review, supporting the Urology service line. This innovative role leverages your clinical expertise to coordinate and manage patient care referrals from an off-site, system-wide call center. Working Monday through Friday during the day shift with flexible hours, this remote/hybrid position offers a balanced work environment with comprehensive training to ensure your success. Work Environment: This position is primarily remote, with initial hybrid training to ensure seamless onboarding and integration into the team. Key Responsibilities: Utilize the nursing process (assessment, diagnosis, outcome identification, planning, implementation, and evaluation) to review inbound patient care referrals efficiently and accurately. Analyze electronic health records, test results, and clinical documentation in accordance with specialty care protocols and scheduling workflows. Assess patient acuity and prioritize scheduling based on clinical needs. Collaborate closely with specialty physicians and interdisciplinary teams to ensure patients receive timely, appropriate care. Maintain adherence to organizational policies, ensuring quality and compliance in referral management. Qualifications: Associate's Degree is required. Bachelor's Degree is preferred. Requires 0-3 years of relevant experience. 2+ years of Urology experience preferred. Requires that the RN has graduated from a nationally accredited nursing program. Requires an active Registered Nurse (RN) license in the state of Indiana or an active Nurse Licensure Compact (NLC) RN license. Requires basic life support (BLS) certification through the AHA annually. Other advanced life support certifications may be required per unit/department specialty according to patient care policies. Requires the ability to assess patients without face-to-face interaction. Why Join Us? Be part of a forward-thinking healthcare organization dedicated to delivering patient-centered care. This role offers an excellent opportunity to utilize your nursing skills in a specialized, fast-paced environment while enjoying the flexibility of remote work.
RN Utilization Review Full-time
New York State

Registered Nurse 3 - Utilization

New York State Albany, NY
$47 - $53 / hour
Description Duties Description To be discussed at time of interview. Qualifications Minimum Qualifications Possession of a license and current registration as a registered professional nurse in New York State; and three years of post-licensure clinical nursing experience of which one year was in utilization review and/or discharge planning. Substitution: a bachelor's degree in nursing can substitute for one year of post-licensure clinical nursing experience; and a master's degree in nursing can substitute for two years of post-licensure clinical nursing experience. Additional Comments Please include a copy of your NYS Registration License when submitting a resume
RN Utilization Review Telehealth Full-time
Elevance Health

Clinical Review Nurse I

Elevance Health Indianapolis, IN
Anticipated End Date: 2026-06-17 Position Title: Clinical Review Nurse I Job Description: Clinical Review Nurse I Location: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. *Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless accommodation is granted as required by law. Wellpoint Federal, a subsidiary of Elevance Health, brings deep industry expertise and healthcare service capabilities to support federal programs. The organization delivers solutions across claims administration, data, and care delivery to help address complex challenges and improve health outcomes for federal populations. The Clinical Review Nurse I is responsible for reviewing and making medical determinations as to whether a claim meets the benefits the member carries. How you will make an impact: Review prior authorization requests and supporting clinical documentation to determine medical necessity and benefit coverage. Apply strong clinical judgement, evidence-based guidelines, and medical policies to make accurate and timely authorization decisions. Identify requests requiring additional clinical information and collaborate with providers to obtain additional information or necessary documentation, as needed. Partner with internal clinical and operational teams to support consistent, high-quality clinical review decisions. Escalate complex cases to the prior authorization leadership and physician reviewers in accordance with established policies and workflows Minimum Requirements: Requires AS in nursing and minimum of 1 year of clinical experience; or any combination of education and experience, which would provide an equivalent background. This position is part of our Wellpoint Federal division which, per CMS TDL 190275, requires foreign national applicants meet the residency requirement of living in the United States at least three of the past five years. Preferred Skills, Capabilities, and Experiences: Current unrestricted RN license required. BS in nursing preferred. The ability to comprehend medical policy and criteria to clearly articulate health information is strongly preferred. Medicare Part A experience is preferred. Prior authorization experience is preferred. Medical Review experience is preferred. Job Level: Non-Management Exempt Workshift: 1st Shift (United States of America) Job Family: MED > Licensed Nurse Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health. Who We Are Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. How We Work At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business. We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few. Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws. Elevance Health is an Equal Employment Opportunity employer, and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process should submit the following form: Accessibility Accommodation Request Form and a member of the team will be in contact. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act. Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration . NOTE: Workday keeps job postings active through 11:59:59 PM on the day before the listed end date. Example: If the end date is 3/13, the posting will automatically come down on 3/12 at 11:59:59 PM. In other words — the job is posted until 3/13, not through 3/13.
RN Utilization Review Full-time
Hillcrest HealthCare System

Registered Nurse / RN Peer Review Coordinator

Hillcrest HealthCare System Tulsa, OK
Join our team as a day shift, full-time, Peer Review Coordinator RN in Tulsa, OK. Why Join Us? Thrive in a People-First Environment and Make Healthcare Better Thrive: We empower our team with career growth opportunities, tuition assistance, and resources that support your wellness, education, and financial well-being. People-First: We prioritize your well-being with paid time off, comprehensive health benefits, and a supportive, inclusive culture where you are valued and cared for. Make Healthcare Better: We use advanced technology to support our team and enhance patient care. Get to Know Your Team: Hillcrest Medical Center is a 656-bed hospital that includes The Alexander Burn Center, The Peggy V. Helmerich Women’s Health Center, Kaiser Rehabilitation Center, the latest technology for the treatment of cancer, and the Oklahoma Heart Institute. The Peer Review Coordinator will manage the peer review process from acceptance of cases for peer review, facilitating first level screening if applicable, preparation of case review documents, and documentation of peer review results, production of reports and maintenance of the peer review database. Job Requirements: Minimum of five years in an acute hospital setting Oklahoma RN licensure Preferred Job Requirements: CPHQ
RN Utilization Review Full-time
Confluence Health

Nurse Utilization RN

Confluence Health Wenatchee, WA
$44.64 - $71.24 / hour
Salary Range $44.64 - $71.24 Overview Located in the heart of Washington, we enjoy open skies, snow-capped mountains, and the lakes and rivers of the high desert. We are the proud home of orchards, farms, and small communities. Confluence Health actively supports the communities we serve and their quality of life through our community support program and through our individual efforts as involved community members. Full Time Employees of Confluence Health receive a wide range of benefits in addition to compensation. Medical, Dental & Vision Insurance Flexible Spending Accounts & Health Saving Accounts Paid Time Off Generous Retirement Plans Life Insurance Long-Term Disability Gym Membership Discount Tuition Reimbursement Employee Assistance Program Adoption Assistance Shift Differential For more information on our Benefits & Perks, click here! Summary Performs utilization review in accordance with all state mandated regulations. Maintains compliance with regulation changes affecting utilization management. Reviews patients records and evaluates patient progress. Performs continuing review on medical records and identification and need of on-going hospitalization. Obtains and reviews necessary medical reports and subsequent treatment plan requests. Conducts reviews and validates physician's orders, reports progress and unusual occurrences on patients. Ensures appropriate and cost-effective healthcare services to patients. Documents review information in computer. Monitors all Outpatient in a Bed & Inpatient surgeries for correct status. Reviews the insurance prior authorizations for correct status. Uses the Medicare Inpatient Only list of surgery CPT codes for correct status/class to ensure reimbursement for surgeries. Reviews all denials from insurance companies for correct status/class. Pursues peer to peer discussions between our hospitalists and insurance MD, reconsideration, appeal, administrative rate, or change in status/class. Position Reports To: Director of Utilization Management Essential Functions Prepares and organizes initial and continued stay utilization reviews. Complete admission review per MCG guidelines. Coordinates provider certification of Medicare inpatient hospital stays as required in the Medicare Benefit Manual, Final Rule etc. Utilizes clinical information located in the patient record to support patient status decisions and recommendations. Documents this information in MCG. Collaborates with other departments regarding review results. Issues MOON letters to patients per Medicare guidelines to notify them of their Observation status and billing of Medicare Part B. Communicates to care management staff when payers deny the patient stay. Complies with Medicare and other regulations for second level review by the UR Committee, notification of patient, physician, and hospital of particular status changes. Follows the A/B Rebill flow maps as indicated. Ensures written notification to the patient, physician, and hospital when the final outcome of a second level review is A/B Rebill. Notifies patient accounts to hold submission of a bill when a case has been sent for second level review and the patient has been discharged. Notifies patient accounts to submit the bill when the results of the second level review is known, along with the results. Participates in tracking and monitoring second level reviews as directed. Adheres to Workflows and Process Maps specific to UM functions. Follows process flow maps and established workflows. Participates in standard work. Assist in identifying processes and procedure improvements to positively affect work flows. Issues Notices of Non-coverage according to policy and procedure. Complies with the various private contracts regarding review, pre-authorization, phone calls, deliver non-coverage letters as required and/or appeal denials. Provides Clinical information to payers as requested and per contract. Facilitates concurrent Peer to Peer discussions between providers when a payer denies all or part of a hospital stay when the denial occurs prior to discharge. Communicates the results of Peer to Peer discussions, if known, with business office and patient accounts. Tracks all discussions with payers in the appropriate billing system, according to facility. Assist with the process following an appeal of discharge, as outlined in the Important Message from Medicare. Provide requested clinical information to the QIO following a patient’s appeal of the discharge decision. Deliver a HINN-12 notification following a decision from the QIO to uphold a decision to discharge, according to procedure. Performs other duties as assigned. Demonstrate Standards of Behavior and adhere to the Code of Conduct in all aspects of job performance at all times. Qualifications Required: Associate's Degree in Nursing. Three (3) years experience in an acute care setting as a Health Care Professional with demonstrated expertise in specific clinical area. Current licensure in the state of Washington (RCW 18.88) or licensure through Multistate Nurse Licensure Compact (SSB 5499). Demonstrated skills in the areas of negotiation, communication (verbal and written), conflict, interdisciplinary collaboration, management, creative problem solving, and critical thinking. Knowledge of healthcare financing, community and organizational resources, patient care processes, and data analysis. Excellent verbal and written communication skills. Demonstrates flexibility via an ability to adapt to changing priorities and regulations. Must possess basic computer skills related to Windows navigation, email communication. Desired : Bachelor's Degree in Nursing (BSN) or related field. Accreditation in ACMA. Physical/Sensory Demands O = Occasional, represents 1 to 25% or up to 30 minutes in a 2 hour workday. F = Frequent, represents 26 to 50% or up to 1 hour of a 2 hour workday. C = Continuous, represents 51% to 100% or up to 2 hours of a 2 hour workday. Physical/Sensory Demands For This Position: Walking - O Sitting/Standing - C Reaching: Shoulder Height - O Reaching: Above shoulder height - O Reaching: Below shoulder height - O Climbing - O Pulling/Pushing: 25 pounds or less - O Pulling/Pushing: 25 pounds to 50 pounds - O Pulling/Pushing: Over 50 pounds - O Lifting: 25 pounds or less - O Lifting: 25 pounds to 50 pounds - O Lifting: Over 50 pounds - O Carrying: 25 pounds or less - O Carrying: 25 pounds to 50 pounds - O Carrying: Over 50 pounds - O Crawling/Kneeling - O Bending/Stooping/Crouching - F Twisting/Turning - O Repetitive Movement - C Working Conditions: Work is performed in a hybrid setting with remote work as well as in an office environment. Involves frequent contact with staff, leadership and practitioners. Work may be stressful at times. Job Classification: FLSA: Non-Exempt Hourly/Salary: Hourly Physical Exposures For This Position: Unprotected Heights - No Heat - No Cold - No Mechanical Hazards - No Hazardous Substances - No Blood Borne Pathogens Exposure Potential - No Lighting - Yes Noise - Yes Ionizing/Non-Ionizing Radiation – No Infectious Diseases - No
RN Manager/Supervisor Utilization Review Home Health Full-time
Personal Touch Home Aides of New York

(RN) Quality Review Manager- Registered Nurse

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

Utilization Management Claims Review Nurse RN II

L.A. Care Health Plan Los Angeles, CA
$88,854 - $142,166 / year
Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job Summary The Utilization Management (UM) Claims Review Nurse RN II is responsible for conducting clinical review of medical claims to ensure services were medically necessary, appropriately documented, accurately billed, and compliant with established clinical policies and regulatory standards. This position supports payment integrity initiatives through retrospective and pre-payment review processes, helps reduce unnecessary denials, and monitors for potential fraud, waste, and abuse (FWA). The UM Claims Review Nurse RN II collaborates closely with internal teams to ensure accurate adjudication and compliance. This position collaborates closely with internal stakeholders and external entities to support compliance with state, federal, and accreditation requirements. Duties Perform claims pre-payment review by supporting the Claims team in evaluating flagged claims prior to adjudication to ensure services are medically necessary, documentation supports billed services, coding is accurate and aligned with authorization when applicable, and unnecessary denials are reduced through accurate clinical validation. Conduct comprehensive retrospective reviews, applying established clinical criteria, policies, and regulatory guidelines to determine medical necessity and appropriateness of services rendered. Complete Provider Dispute Review (PDR) clinical evaluations for disputed claims requiring medical necessity scrutiny and clinical determination. Apply internal and external clinical policies, including those developed by the Clinical Policy team, to ensure compliance with guidelines intended to limit fraud, waste, and abuse (FWA). Ensure adherence to federal and state regulations, and accreditation standards. Monitor trends related to contested claims and identify potential FWA concerns; escalate findings in accordance with organizational compliance protocols. Collaborate with internal teams to support payment integrity initiatives. Provide clear, well-documented clinical rationales supporting approval, denial, or adjustment decisions. Maintain productivity and quality standards consistent with departmental expectations. Participate in audits, regulatory readiness activities, and quality improvement initiatives as assigned. Document review outcomes clearly and accurately within designated systems, ensuring audit readiness and traceability. Remain current with evolving clinical guidelines, coding standards, reimbursement methodologies, and regulatory requirements. Perform other duties as assigned. Duties Continued Education Required Associate's Degree in Nursing Education Preferred Bachelor's Degree in Nursing Experience Required: At least 5 years of experience in Clinical Nursing. At least 3 years of experience with Medi-Cal and Medicare in a managed care environment. Experience in performing and creating clinical documentation. Experience in regulatory compliance for a health plan. Preferred: Experience with Provider Dispute Review (PDR) processes. Experience applying clinical guidelines (e.g., InterQual, MCG, or internally developed criteria) in processes. Prior experience in payment integrity, compliance, or fraud, waste, and abuse (FWA) monitoring. Skills Required: Knowledge of medical necessity criteria, reimbursement principles, and managed care operation. Working knowledge of clinical policies. Working knowledge of CPT/HCPC Codes, and ICD-10. Proficient in claims processing systems and electronic medical record platforms. Strong problem-solving skills and the ability to identify discrepancies, assess risk, and recommend actionable solutions. Strong verbal and written communication skills. Ability to work independently with a high degree of initiative, organization, and self-direction. Ability to work effectively with diverse teams in cross-functional work groups. Ability to multitask, re-prioritize tasking, and streamline day-to-day operations. Familiarity with regulatory and accreditation standards (e.g., CMS, Medi-Cal, NCQA). Understanding of the managed care industry and market conditions. High organizational and time-management skills. Preferred: Strong analytical and investigative skills with the ability to synthesize clinical and claims information into clear, defensible determinations are highly valued. Advanced knowledge of medical necessity criteria tools such as InterQual or MCG. Extensive knowledge in claims reviews includes retrospective reviews, pre-payment claims review, and medical necessity determinations. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California License Licenses/Certifications Preferred Required Training Physical Requirements Light Additional Information Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. L.A. Care offers a wide range of benefits including Paid Time Off (PTO) Tuition Reimbursement Retirement Plans Medical, Dental and Vision Wellness Program Volunteer Time Off (VTO)
RN Utilization Review Telehealth Full-time
L.A. Care Health Plan

Utilization Management Clinical Quality Nurse Reviewer RN II

L.A. Care Health Plan Los Angeles, CA
$88,854 - $142,166 / year
Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job Summary The Utilization Management Clinical Quality Nurse Reviewer RN II, under the purview of the Utilization Management (UM) Department Leadership Team, is responsible for conducting and tracking targeted and random internal department documentation audits. This role ensures that UM practices and supporting documentation are compliant with all regulatory requirements. The Incumbent also serves as a Subject Matter Expert during external audits as well as leads pre- and post-audit preparation/follow-up. This position actively participates in the development and review of policies and procedures to certify compliance with regulatory guidelines and mandates. This position focuses on UM cases for all lines of business to identify areas of opportunity for increasing positive audit outcomes and improved service to L.A. Care’s membership. This position is responsible for identifying and monitoring staff (non-clinical, nurse, and physician) performance against key performance indicator trends that warrant recognition or remediation. This position performs data mining and analysis and creates reports on audit findings, as well as makes recommendations, to submit to the department's Quality Assurance Team and UM Management. Duties Facilitates the development, review, and revision of organizational and departmental process flows to ensure compliance with relevant regulatory, organizational, and departmental guidelines. Keenly focuses on practices and documentation of clinical staff, serving as a resource on state and federal industry mandates applicable to UM functions. Generates results of findings, enhances, and analyzes various reports related, but not limited to, quality and accuracy of case documentation. Works with department leadership to assess for all opportunities related to quality improvements. Compiles and presents quality report cards that measure adherence to quality and regulatory compliance. Keeps UM Leadership apprised of departmental and industry trends, deficiencies, and any potential risks, and collaborates with the team to develop and execute mitigation efforts. Serves as a consultant to the organization's Compliance team on an ad hoc basis. Performs other duties as assigned. Duties Continued Education Required Associate's Degree in Nursing Education Preferred Bachelor's Degree Master's Degree in Nursing Experience Required: At least 5 years of experience in Clinical Nursing. Minimum of 2 years of auditing clinical documentation. Active participation in at least two state regulatory audits and one federal regulatory audits. Previous experience with Medi-Cal and Medicare in a managed care environment and experience with mitigation planning and implementation. Preferred: Experience performing clinical documentation for a health plan. Active participation in at least three state regulatory audits, at least one National Committee for Quality Assurance (NCQA) audit and/or Centers for Medicare and Medicaid Services (CMS) audit. Background in teaching and/or clinical education. Skills Required: Superior verbal and written communication skills. Advanced computer proficiency in both Microsoft Word and Excel. Strong analytical and team building skills. Ability to work independently and be self-directed. Ability to work effectively with diverse team members. Strong problem-solving skills. Ability to multitask and streamline day-to-day operations. Ability to translate regulatory requirements into auditable tools. Preferred: Proven ability to lead successful performance improvement projects. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California License Licenses/Certifications Preferred Required Training Physical Requirements Light Additional Information Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. L.A. Care offers a wide range of benefits including Paid Time Off (PTO) Tuition Reimbursement Retirement Plans Medical, Dental and Vision Wellness Program Volunteer Time Off (VTO)
RN Utilization Review Full-time
Albany Medical Center

Utilization Management Specialist (RN): Salary, 40hrs/week - DAYS

Albany Medical Center Albany, NY
$84,783 - $131,414 / year
Department/Unit: Care Management/Social Work Work Shift: Day (United States of America) Salary Range: $84,783.00 - $131,414.00 Under direction of the Manager of Utilization Management, the Utilization Management Specialist is responsible for the coordination, processing and tracking of all potential utilization concerns from the third party payors for Albany Medical Center; and to do other related work as required. This individual will act as a liaison with all payors and review agents, providing required acuity information regarding patients and issuing notice of non-coverage as appropriate. This position is also responsible for the processing of adverse determinations received from third party payors, coordinating with Patient Financials Services, Admitting/Access Operations, attending physicians, Medical Director and AMC Case Managers and R1 Physician advisory services. Requirements: Graduate of a professional academic nursing program in which a Diploma, Associate Degree or Baccalaureate Degree is conferred. Bachelor's degree preferred. A Bachelor’s Degree in a Health-related field is required. Registered nurse with a New York State current license A minimum of 5 years clinical experience in acute care setting with at least two years in case or utilization management. Skills and Knowledge: Knowledge of care delivery documentation systems and related medical record documents. Strong broad-based clinical knowledge and understanding of pathology/physiology. Excellent written and verbal communication skills and critical thinking skills. Experience with Milliman MCG, InterQual criteria, and knowledge of IPRO and retrospective review process. Ability to work independently and demonstrate organizational and time management skills. Computer literacy and familiarity with basic office equipment and software. Working knowledge of Medicare reimbursement system and coding structures preferred. Essential Duties & Responsibilities , including but not limited to: Mission, Core Values and Service Excellence: Contributes to the creation of a compassionate and caring environment for patients, families and colleagues through displays of kindness and active listening. Recognizes and appreciates that each employee’s work is valuable and contributes to the success of the Mission. Demonstrates excellence in daily work. Actively participates in performance and quality improvement activities and works toward enhancing customer/patient satisfaction. Exhibits positive service excellence skills to patients, visitors and coworkers by greeting others in a friendly manner, keeping customers/patients/colleagues informed about progress, delays and changes. Demonstrates effective teamwork by interacting in a positive manner with colleagues and creating a collaborative work environment. Initiates open communication, conveys positive intent, offers assistance. Contributes to a safe and secure environment for patients, visitors, colleagues by following established procedures and protocols, which address the needs of a diverse patient population and workforce. Demonstrates stewardship by thoughtful and responsible use of resources including maintaining a clean and hospitable environment, starting work on time, displaying a consciousness regarding costs, supplies and department finances. Demonstrates respect for individual differences of each person by acknowledging the essence of each person, appreciating and responding to unique, spiritual, personal and cultural backgrounds of patients, families and colleagues. Strategic and Operational Planning Supports the Manager in planning, organizing, directing of the Utilization Management services of AMC; and to do other related work as required. Participates in the development of departmental goals and develops plans to achieve those goals. Planning and Program Development Act as contact person for payors regarding utilization issues, i.e., carve outs, denials, downgrading and potential utilization concerns, providing required communication regarding patient acuity. Coordination of appeal of adverse determination, working with Service Case manager, Attending physician, Case manager, Medical Director, R1 Physician advisory services. for concurrent resolution of issue, prevention of retrospective denial and delay in payment for the institution. Maintain all correspondence and provide follow up with third party payors, commercial insurers, and IPRO. In conjunction with the service Case Manager, issue HINN notice and reinstatement to patients when indicated with focus on accuracy, timeliness, and diplomacy. Demonstrate in-depth knowledge of utilization criteria for Medicare, Medicaid, and private insurers. Delegates and coordinates the work of Utilization Review ASA support staff. Tracks denials and develops action plans to decrease bad debt. Maintain database of utilization issues and identify trends in payor activity through generation of statistical reports. Complete end of month reports. Educational Leadership Working knowledge of how to research changes in CMS and payor regulations and project impact of these changes on AMC and communicate this information. Demonstrates proper use of MCG and documentation requirements through case review and inter-rate reliability studies. Attends all mandatory hospital in-service education. Ability to analyze data and identify trends and project expected response to changes in health care reimbursement system. Hospital-wide Leadership Models AMC cares standards Demonstrates wiliness to participate in hospital wide initiatives. Patient Safety Assists in the development of policies and procedures, standards of care and practice, and in the monitoring processes in relations to those standards. Maintains complete confidentiality of patient information, in addition to hospital and individual physician practice pattern data. Provides information and in services as necessary to physicians and ancillary staff. Practices in an environmentally safe and healthy manner. 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 Part-time
Riverside Health System

Registered Nurse Peer Review-Labor Pool-Days

Riverside Health System Newport News, VA
Newport News, Virginia Labor Pool-Days Available The Peer Review Analyst is responsible for supporting activities related to the peer review process. The peer review process includes daily review of cases entered into the Riverside safety event reporting application "rCare" risk and peer review modules as well as other case finding methods as assigned, such as review of morbidity and mortality cases. Independently performs review of electronic medical records for potential, assigned and referred cases, and develops a summary of the case with focus questions. Maintains knowledge of the rCare risk and peer review modules and all associated policies, procedures, workflows, and business rules. Has knowledge of standard reports and is able to run standard reports and create on demand reports to routinely check for rCare file completeness, identify outstanding items to follow up on, determine the volume of cases by peer review committee, department or unit as requested. Runs reports to verify activity and status of cases referred to each peer review committee, as well as cases closed and adjudicated for outcomes. What you will do Support all aspects of the rCare Peer Review Process and complete assignments in a timely manner. Review cases referred to peer review are entered into the rCare Peer Review module, and require a case summary with timeline when appropriate, with focused questions posed to the assigned peer reviewer. Conducts an initial review and develops a case summary if the case requires further review. The case summary should identify focused questions for review by the Peer Review Coordinator for collaboration with Chief Medical Officer and Quality Director, identifies cases appropriate for referral to peer review. Identify and use multiple methods for case finding using triggers, quality screens, complication reports, and mortality reports as well as rCare risk/safety event reports, patient/family complaints, EPIC reports, service line dashboards, etc. Obtains and seeks continual education related to the peer review process. Follows up with assigned peer reviewer to assure timely responses and referral to the appropriate Peer Review committee for further discussion and adjudication. Maintains an electronic log with the status report of peer review cases by medical specialty that includes cases identified for potential external peer review. Assures all peer reviewed cases have a completed analysis, conclusions, recommendations and actions documented in both the case summary. Qualifications Education Bachelors Degree, Nursing (Preferred) Experience 3-4 years Recent patient care in acute care setting (Required) Computer experience including Microsoft Office Suite (Work, Excel) and data entry skills (Required) 3-4 years Related experience in quality, patient safety or risk management (Preferred) Knowledge of report building and graphs (Preferred) Licenses and Certifications Registered Nurse (RN) - Virginia Department of Health Professions (VDHP) Upon Hire(Required) To learn more about being a team member with Riverside Health System visit us at https://www.riversideonline.com/careers .
RN Utilization Review Full-time
UT Southwestern Medical Center

CDI Quality Review RN

UT Southwestern Medical Center Dallas, TX
WHY UT SOUTHWESTERN? With over 75 years of excellence in Dallas-Fort Worth, Texas, UT Southwestern is committed to excellence, innovation, teamwork, and compassion. As a world-renowned medical and research center, we strive to provide the best possible care, resources, and benefits for our valued employees. Ranked as the number 1 hospital in Dallas-Fort Worth according to U.S. News & World Report, we invest in you with opportunities for career growth and development to align with your future goals. Our highly competitive benefits package offers healthcare, PTO and paid holidays, on-site childcare, wage, merit increases and so much more. We invite you to be a part of the UT Southwestern team where you'll discover a culture of teamwork, professionalism, and a rewarding career! Job Summary The CDI Quality Review Nurse (QRN) will work under the direction of the Clinical Documentation Integrity ("CDI") Manager and conduct second-level reviews of targeted cases to identify and capture opportunities to improve the integrity of the medical record. The focus of the Quality Review Nurse will be on identifying and capturing methodology-specific risk variables (Vizient, HCC's, Elixhauser) on a post-discharge, pre-coding/billing basis, as well as identifying potential process improvements to capture the opportunities concurrently. The Quality Review Nurse will also validate that the record reflects the most appropriate principal diagnosis and diagnosis related group (DRG). The Quality Review Nurse will support the objective for accurate reflection of patient acuity, severity of illness, risk of mortality, and DRG assignment in compliance with industry rules and regulations. Benefits UT Southwestern is proud to offer a competitive and comprehensive benefits package to eligible employees. Our benefits are designed to support your overall wellbeing, and include: PPO medical plan, available day one at no cost for full-time employee-only coverage 100% coverage for preventive healthcare-no copay Paid Time Off, available day one Retirement Programs through the Teacher Retirement System of Texas (TRS) Paid Parental Leave Benefit Wellness programs Tuition Reimbursement Public Service Loan Forgiveness (PSLF) Qualified Employer Learn more about these and other UTSW employee benefits! Experience And Education Required Education Bachelor's Degree in Nursing Experience 5 years patient care nursing experience in an acute care setting and 3 years Clinical Document Integrity experience Licenses and Certifications (RN) REGISTERED NURSE Upon Hire and (CCDS) Cert Clinical Documentation Upon Hire or (CDIP) CERT DOCUMNTATN IMPROVMNT PRAC Upon Hire Preferred Education Master's Degree in Nursing Experience 7 years patient care nursing experience in an acute care setting 5 years Clinical Document Integrity experience Experience working in a remote environment Job Duties Conduct post-discharge, pre-coding/billing reviews on targeted records identified for second-level review for opportunity to accurately capture methodology-specific risk variables (Vizient, HCC‿s, Elixhauser); present on admission (POA) status, patient admission source, avoidable patient safety indicators (PSI‿s), and DRG assignment in compliance with industry rules and regulations If a documentation opportunity is identified, place physician query and follow up for response If coding opportunity is identified, coordinate with Coding Team to review and address opportunity, as applicable Utilize methodology-specific risk calculators and guidance documents to understand if additional diagnoses and/or risk variables will impact the reported quality impact of a specific patient encounter Maintain a summary of opportunities identified through second-level review for feedback and education with the CDS Team, Providers, and Coding Team Identify and communicate any process improvement opportunities for front-end correction and education Periodically review the criteria established for cases triggering a second-level review and recommend updates or modifications to the criteria to maximize impact on quality scores Maintains an expert level of knowledge of CDI and Coding related guidelines and practices Other duties as assigned SECURITY AND EEO STATEMENT Security This position is security-sensitive and subject to Texas Education Code 51.215, which authorizes UT Southwestern to obtain criminal history record information. EEO UT Southwestern Medical Center is committed to an educational and working environment that provides equal opportunity to all members of the University community. As an equal opportunity employer, UT Southwestern prohibits unlawful discrimination, including discrimination on the basis of race, color, religion, national origin, sex, sexual orientation, gender identity, gender expression, age, disability, genetic information, citizenship status, or veteran status. Primary Location Texas-Dallas-5323 Harry Hines Blvd Work Locations 5323 Harry Hines Blvd Organization 844004 - Clin Documentation Integrity Schedule Full-time Shift Day Job Employee Status Regular Job Type Standard Job Posting Jun 4, 2026, 8:44:48 PM
RN Utilization Review Full-time
South Texas Health System McAllen

Case Manager RN Utilization Review FT McAllen

South Texas Health System McAllen McAllen, TX
Responsibilities POSITION SUMMARY: RN Case Manager responsible to manage resource utilization and clinical outcomes for patients as well discharge needs of the patients. RN will also be responsible to help with the denial management process. There may be occasions when it will be necessary to work weekends, holidays, evenings, nights, and/or on-call/call-back status. Demonstrates Service Excellence standards at all times. Qualifications QUALIFICATIONS: 1. 1 years previous acute care RN experience required. (Previous defined as: ‘within the last three years’) 2. Bilingual preferred (Spanish). 3. Experience in Health Care Coordination preferred. 4. Must demonstrate commitment and adherence to STHS’s Compliance Program and Code of Conduct through compliance with all policies and procedures, the Code of Conduct, attendance at required training and immediately reporting suspected compliance issue(s) to the Compliance Officer. EDUCATION / LICENSURE: 1. Licensed in the State of Texas 2. Registered Nurse currently licensed in the State of Texas, or part of a compact state license, or has a valid temporary RN license for the State of Texas while waiting to receive the permanent license. BSN preferred. 3. Effective January 6, 2016, must possess an Associate Degree, Baccalaureate Degree or Diploma from a School of Nursing or University. EEO Statement All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws. We believe that diversity and inclusion among our teammates is critical to our success. Notice At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skillset and experience with the best possible career path at UHS and our subsidiaries. We take pride in creating a highly efficient and best in class candidate experience. During the recruitment process, no recruiter or employee will request financial or personal information (Social Security Number, credit card or bank information, etc.) from you via email. The recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc. If you are suspicious of a job posting or job-related email mentioning UHS or its subsidiaries, let us know by contacting us at: https://uhs.alertline.com or 1-800-852-3449. Authorized by Corporate Human Resources
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: 40 Position Overview *Please note - this is not a remote position* 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 Supplemental Group Term Life & Accidental Death & Dismemberment Insurance Disability Benefits – Long Term Disability (LTD) 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 Telehealth Full-time
Centene

Clinical Review Nurse - Concurrent Review (RN)

Centene Woodland Hills, CA
$27.02 - $48.55 / hour
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. Location: Remote. Must work PST hours. *Must hold RN license in California. Position Purpose: Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member. Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines Reviews member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities Collaborates with care management on referral of members as appropriate Performs other duties as assigned. Complies with all policies and standards. Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience. 2+ years of acute care experience required. Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. License/Certification: For Health Net of California: RN license required. Must be licensed in CA. Pay Range: $27.02 - $48.55 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
RN Utilization Review Outpatient Full-time
Baptist Health South Florida

Utilization Review Registered Nurse, Case Management, FT, 07A-7:30P Local Remote

Baptist Health South Florida Boca Raton, FL
$73,860.80 - $96,019.04 / year
Baptist Health is the region's largest not-for-profit healthcare organization, with 12 hospitals, over 29,000 employees, 4,500 physicians and 200 outpatient centers, urgent care facilities and physician practices across Miami-Dade, Monroe, Broward and Palm Beach counties. With internationally renowned centers of excellence in cancer, cardiovascular care, orthopedics and sports medicine, and neurosciences, Baptist Health is supported by philanthropy and driven by its faith-based mission of medical excellence. For 26 years, we've been named one of Fortune's 100 Best Companies to Work For, and in the 2025-2026 U.S. News & World Report Best Hospital Rankings, Baptist Health was the most awarded healthcare system in South Florida, earning 63 high-performing honors. What truly sets us apart is our people. At Baptist Health, we create personal connections with our colleagues that go beyond the workplace, and we form meaningful relationships with patients and their families that extend beyond delivering care. Many of us have walked in our patients' shoes ourselves and that shared experience fuels out commitment to compassion and quality. Our culture is rooted in purpose, and every team member plays a part in making a positive impact – because when it comes to caring for people, we're all in. At Baptist Health, we’re committed to supporting our employees at every stage of their journey, both personally and professionally. Our approach is rooted in a “grow our own” philosophy, designed to help our team members build meaningful, long-term careers with us, supported by benefits that make a real difference, including: Career growth and development opportunities , with clear pathways and ongoing support Comprehensive health and wellness resources that go beyond traditional benefits A wellness program that can help employees eliminate their medical plan deductible, reducing out-of-pocket healthcare costs Tuition reimbursement to support continued learning and advancement And so much more Together, these benefits and others reflect our commitment to caring for our people, so they can build fulfilling careers with us while making a meaningful impact every day. Description: The purpose of this position is to conduct initial, concurrent, retrospective chart review for clinical financial resource utilization. Coordinates with healthcare team for optimal/efficient patient outcomes, while decreasing length of stay (LOS) and avoid delays and denied days. They are accountable for a designated patient caseload and provides intervention, coordination to decrease avoidable delays, denial of reimbursement. Specific functions within this role include: Screens pre-admission, admission process using established criteria for all points of entry. Facilitates communication between payers, review agencies, healthcare team. Identify delays in treatment or inappropriate utilization and serves as a resource. Coordinates communication with physicians. Identify opportunities for expedited appeals and collaborates to resolve payer issues. Ensures/Maintains effective communication with Revenue Cycle Departments. Estimated salary range for this position is $73860.80 - $96019.04 / year depending on experience. Qualifications: Degrees: Associates. Licenses & Certifications: MCG Care Guidelines Specialist. Registered Nurse. Additional Qualifications: RNs hired prior to 2-2012 (10/1/2017 at Bethesda or 7/1/2019 at BRRH) with an Associates Degree in Nursing are not required to have a BSN to continue their non-leadership role as an RN. however, they are required to complete the BSN within 3 years of job entry date. MCG Specialist Certification ISC/HRC required within 12 months of job entry date. 3 years of Nursing experience preferred. Excellent written, interpersonal communication and negotiation skills. Strong critical thinking skills and the ability to perform clinical/chart review abstract information efficiently. Strong analytical, data management and computer skills. Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components. Current working knowledge of payer and managed care reimbursement preferred. Ability to work independently and exercise sound judgment in interactions with the health care team and patients/families. Knowledgeable in local, state, and federal legislation and regulations. Ability to tolerate high volume production standards. Minimum Required Experience: 3 Years of Nursing experience with 1 year of previous Utilization Review experience required. EOE, including disability/vets
RN Utilization Review Full-time
St. Bernards Healthcare

UTILIZATION EXPERT - RN - WEEKENDS

St. Bernards Healthcare Jonesboro, AR
JOB REQUIREMENTS Education Licensed to practice in the State of Arkansas. Graduate of an approved school of Nursing. Current RN licensure or permit as a registered nurse in the State of Arkansas, BSN preferred. Experience Minimum of three years clinical nursing experience. Case Management or Utilization Review Experience preferred. Works efficiently with others and demonstrates tact, discretion and diplomacy. Ability to operate technical equipment as acquired through orientation. Physical Normal hospital environment. Exposure to biological hazards. Frequent exposure to unpleasant odors. Close eye work. Hearing of normal and soft tones. Distinguish temperatures by touch and proximity. Carrying up to 40 lbs. Push/pulling up to 350 lbs. Frequent sitting, standing, walking, bending, stooping, climbing and reaching. Operates computer terminals This is a safety sensitive position. Please see the St. Bernards Substance Abuse Policy for further information. JOB SUMMARY The Utilization Review Nurse follows the medical center Utilization Review plan and operates under the policies of the Support Services Dept. The position requires knowledge of field and utilization of discretion and judgment in role of utilization review and clinical documentation duties. The nurse must possess the ability to positively interact with other medical center departments, insurance companies, review agencies, and physician offices. The nurse must provide essential and appropriate medical information to those requiring it and do so in a timely manner and with concern for maintaining patient confidentiality. To achieve optimal clinical and financial outcomes, through utilization, service, quality indicators, and patient flow. Work closely with case management staff to ensure level of care change is communicated and flows smoothly. Works closely with the physicians, allied health nurses, and coding department to facilitate clinical documentation program. This position is required to utilize independent judgment.
RN Utilization Review Full-time
Atlanticare

Registered Nurse - Utilization Management - Full Time

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

Registered Nurse - Utilization Management - Full Time

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

RN-Utilization Review- 40/hrs, Day Shifts (Temple Hospital)

Temple Health Philadelphia, PA
Utilizing InterQual and other appropriate criteria, responsible for reviewing all admissions and continued stay of patients in conformance with the established criteria set forth in the hospital's utilization management and quality assurance plan. Will determine the medical necessity for admission and continued stays for patients within department's scope of service and to meet the hospital's objectives for assuring a high quality of patient care as well as assuring the effective and efficient utilization of available health services. Identifies appropriate level of care for inpatients and outpatients requiring overnight care. Education Other Graduate Of An Accredited School Of Nursing Required Bachelor's Degree BSN Required Experience 1 year experience of recent Utilization Review in acute care or in insurance company setting. Required 1 Year Experience In Medical-surgical Setting. Required 1 year experience in working with competency utilizing InterQual criteria. Required General Experience In Working With Utilization Review Standards Required Licenses PA Registered Nurse License Required Certified Case Manager Preferred Multi State Compact RN License Required Or
RN Utilization Review Full-time
Wooster Community Hospital Health System

2217 Utilization Review Nurse PT

Wooster Community Hospital Health System Wooster, OH
2217 Utilization Review Nurse PT MAIN FUNCTION: The Utilization Management Nurse Reviewer (RN) serves as the Subject Matter Expert for the organization for patient admission status (inpatient and observation) and works with Providers, Case Management, and the Revenue Cycle team in a consultative manner to ensure appropriate admission status. The UM RN protects the financial interests of the organization by ensuring that the UM review cycle is successfully completed from the point of admission through and including appeal of any denials received. The UM RN is an integral part of the Revenue Cycle team by tracking and trending payer issues and reporting the same to team leaders in order to address identified concerns with payer representatives. REPORTS TO: Manager of Utilization and Denials and System Director of Revenue Cycle MUST HAVE REQUIREMENTS: LPN or RN possessing an active Ohio license 3-5 years clinical nursing experience in varied settings 1-3 year UM experience in an acute care setting Experience using InterQual and/or Milliman criteria. Solid working knowledge of reimbursement methodology. Strong organization, prioritizing and delegation skills. Demonstrated emotional intelligence – self-control, self-awareness, social awareness and relationship management. Excellent oral and written communication Ability to work independently in a fast-paced environment, meeting all deadlines. Ability to problem solve complex, multifaceted situations. Ability to use computers and analytical software. PREFERRED ATTRIBUTES: Bachelor’s degree. UM certification. Strong background in Medicare/Medicaid regulations related to UM and billing compliance. Experience using MCG Indicia tools. POSITION EXPECTATIONS: All expectations detailed below are considered Americans with Disabilities Act (ADA) essential. Follows Appropriate Service Standards Clinical review of 100% of acute bedded patients admitted to inpatient or observation against medical necessity criteria (InterQual or MCG) utilizing provided tools (Meditech, MCG Indicia, payer portals) and prescribed process for appropriateness of status. Clinical review includes the life cycle of the admission, starting with initial case review (ICR) through and including resolution of any claims denied for status or medical necessity. Ensures continued stay reviews are submitted timely per the payer’s requirements, and that responses from the payer include coverage for all days of the stay. Monitors submitted cases for a response from the payer in a timely manner to respond appropriately to any threatened or actual denials immediately to avoid the appeal process whenever possible. Submits reconsiderations immediately (when available) according to the prescribed process. Confers with the Physician Risk Advisor (PRA) on any concerns with current patient status, then communicates needed changes to the attending provider via provided communication tools. Fully documents all case reviews in MCG Indicia/Meditech, including all pertinent information, such as method and proof of submission of all case reviews, results of case reviews and any denials received, communication with PRA and attending providers. Facilitates Peer-to-peer opportunities between the attending provider and the payer. Attends the daily huddle with Case Management and PRA to keep apprised of any changes, and to contribute to the huddle as the Subject Matter Expert on status. Strong collaboration with Case Management, serving as the SME for utilization and status. Ensures that denials are identified in the prescribed manner and ensures all appeals are submitted timely to the payer. Adheres to department productivity standards (35-40 reviews per shift) Assigns submitted appeals to the UM Clerical support team member for follow-up on appeal response. Collaborates with the UM Lead Nurse Reviewer to identify opportunities for improvement through daily work processes and communicates to leadership. Collaborates with the PRA, Director and UM Lead Nurse Reviewer for issues/concerns to submit to the quarterly UM Committee. Performs other duties as assigned, including but not limited to: Demonstrates professional responsibility required of a Utilization Review Nurse. Complies with all department and organization policies at all times. Maintains compliance with all state/federal guidelines and standards, as well as CMS Conditions of Participation. Demonstrates a positive attitude, openness to change and responsiveness to constructive feedback.
RN Utilization Review Internship
Children's Hospital Colorado

Registered Nurse Utilization Review Flex

Children's Hospital Colorado Aurora, CO
$50.68 / hour
Job Overview The Utilization Review RN participates as a member of a multidisciplinary team to support medical necessity reviews, ensure compliance, and actively participate in denial mitigation. It is a collaborative approach that uses pre-established guidelines and criteria to perform review activities to ensure the proper utilization of hospital services and payment of those services by Medicare, Medicaid, and other third-party payors. Department Name: Utilization Management Job Status: flex, not eligible for benefits Shift: variable - must have availability to work at least 24 hours per 2-week pay period. Shifts may include dayshift, evening shift, and weekend shifts, depending on unit staffing needs. Duties & Responsibilities Assesses all new inpatient admissions for identification of status and medical necessity for admission; communicates clinical review process with appropriate Payors. Assesses the continuity of care in conjunction with the Case Managers regarding the continued medical necessity of hospitalization and the status of the discharge plan; communicates this to the appropriate payors. Coordinates with other members of the healthcare team to help identify and control inappropriate resource utilization. Conducts concurrent admission and continued stay reviews based on appropriate utilization review criteria. Utilizes information provided by Patient Access regarding authorized length of stay and follows up with third-party payors on an ongoing basis, documents communications regarding continued authorizations. Follows up on denials communicated to the department and works with the revenue cycle staff to assist with appeals. Maintains and demonstrates appropriate clinical knowledge to assist physicians in providing documentation of severity of illness and intensity of service to assure that criteria for acute hospitalization are met. Employees are expected to comply with all regulatory requirements, including CMS and Joint Commission Standards. Minimum Qualifications EDUCATION – Bachelor of Science in Nursing (BSN) EXPERIENCE – Three years of nursing experience in a pediatric setting or three years of Case Management experience. Needs to include recent UR experience in a hospital or with a Third-Party Payor CERTIFICATION(S) – BLS/CPR from the American Heart Association with at least six (6) months left before expiration is required upon hire LICENSURE – Current Colorado Registered Nurse (RN) license or RN license multistate compact Salary Information Hourly Rate of Pay: $50.68 Benefits Information As a Children’s Hospital Colorado team member, you will receive a competitive pay and benefits package designed to take care of your needs that includes base pay, incentives, paid sick leave and a robust wellness program. As part of our Total Rewards package, Children's Colorado offers an annual employee bonus program that rewards eligible team members based on organizational performance. If organizational goals are met for the year, the bonus is paid out the following April. Children’s Colorado delivers annual base pay increases to eligible team members based on their performance over the previous year. EEO Statement It is our intention that all qualified applicants be given equal opportunity and that selection decisions be based on job-related factors. We do not discriminate on the basis of race, color, religion, national origin, sex, age, disability, or any other status protected by law or regulation. Be aware that none of the questions are intended to imply illegal preferences or discrimination based on non-job-related information. The position is expected to stay open until the posted close date. Please submit your application as soon as possible as the posting is subject to close at any time once a sufficient pool of qualified applicants is obtained. Colorado Residents: In any materials you submit, you may redact or remove age-identifying information such as age, date of birth, or dates of attendance at or graduation from an educational institution. You will not be penalized for redacting or removing this information.
RN Utilization Review Contract
Atlanticare

Registered Nurse - Utilization Management - Per Diem

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

Utilization Review Nurse

Southeast Health Dothan, AL
Southeast. Always the right career direction. Job Description Summary The Utilization Review Nurse screens medical records in accordance with contractual agreement and regulatory requirements for medical necessity on admission and continued stay in the acute care setting. The Utilization Review case manager collaborates with all components of the healthcare system, managing appropriate use of acute care to aid in the achievement of quality outcomes, fiscal responsibility, and patient satisfaction. Job Description Essential Functions Performs admissions and continued stay reviews of all inpatients and outpatient/observation patients in a bed; at times, this may be retrospective. Performs precertification on procedures ordered while patients are hospitalized. Issues required Medicare/Medicaid notifications of medical necessity changes to patients while hospitalized. Issues notifications of non-coverage letters to patients if received during hospital stay. Documents clear billing notes into the Electronic Medical Record (EMR) payer communications navigator to avoid billing denials. Performs medical necessity denial appeals. Maintains a close, collaborative relationship with the medical staff to promote continuity of care and avoid delays in service. Performs other duties as requested by primary manager that do not compromise moral code of conduct or protocols set in place for patient or employee safety Supervised Positions None Qualifications Minimum Education Required Associates degree in Nursing Current Registered Nurse license in the State of Alabama Minimum Education Preferred Bachelor’s degree or higher in Nursing Minimum Experience Required Two (2) years acute care experience Must pass Blue Cross Blue Shield Iterator Reliability Test with 90% within six (6) months of hire Minimum Experience Preferred Three (3) years acute care experience One (1) year utilization review experience Required Knowledge/ Skills/ Abilities Maintain current licensure in the State of Alabama Demonstrates appropriate utilization of the skills of the Registered Nurse as approved by the Alabama Board of Nursing Ability to quickly adapt to changing circumstances in fast-paced environment Actively accepts, understands, and practices appropriate standards of nursing practice. Must demonstrate basic knowledge of discharge planning needs Demonstrates advanced computer skills (ability to generate reports, graph trends). Clinical knowledge and experience in the care of patients with multiple and complex diagnoses, disease process, and care needs. Ability to prioritize work and meet deadlines. Ability to problem solve in a proactive, creative manner, using sound judgment based on factual information and clinical knowledge. Ability to develop leadership skills and to serve as a role model for clinical staff. Ability to lead and actively participate in multidisciplinary teams. Ability to work independently within a team structure. Demonstrates responsibility for educational requirements as evidenced by reading all assigned related references, and attending all required educational meetings, or webinars, and completing annual Symplr requirements. Demonstrates commitment to organizations five (5) priorities and Six Ground Rules Person in this position is required to understand, agree upon and follow our Six Ground Rules: No excuses. We are a team. Bring up your ideas. Poor performance will be addressed. ‘That’s not my job’ is not acceptable Manage Up. Shift Day Shift Details 8:00 am - 4:30 pm FTE 1 Type Regular Join one of Forbes 500 best mid-sized employers in America. Equal Employment Employer Southeast Health is committed to provide equal employment opportunity (EEO) to all persons regardless of age, color, national origin, citizenship status, physical or mental disability, race, religion, creed, gender, sex, sexual orientation, gender identity and/or expression, genetic information, marital status, status with regard to public assistance, veteran status, or any other characteristic protected by federal, state or local law. In addition, Southeast Health will provide reasonable accommodations for qualified individuals with disabilities.