Registered Nurse (RN) Utilization Review Jobs

RN Utilization Review Full-time
DCH Health System

Utilization Review Care Manager, RN

DCH Health System Tuscaloosa, AL
Overview Evaluates patients for appropriateness of admission type and setting, utilizing a combination of clinical information, medical necessity standards, and/or and InterQual guidelines. The Utilization Review Nurse utilizes clinical knowledge to support the coordination and documentation and communication of medical services and/or benefits. The Utilization Nurse also serves on the liaison between the physicians, patients, payers and care managers regarding termination of benefits, denial notification, and expedited appeals. Has access to highly sensitive, confidential information. Responsibilities Evaluates medical records for appropriateness of admission status utilizing a combination of clinical information, screening criteria, and third party information. Collaborates with business office, care managers, attending physicians, and physician advisors as needed. Works with Patient Registration\Financial Counselor (s) to identify correct insurance source and proper billing. Verifies patient admission information for each assigned patient within 24 hours of patient’s admission (next business day) or per payer guidelines. Collaborates with the Case Manager to identify referrals to Financial Counselors. Negotiates resolution of disagreements over the need for acute hospital level of care with the insurer. Educates staff and physicians about managed care principles, observation status, and reimbursement rules. Maintains records in a complete, detailed, and orderly manner. Identifies Potential Avoidable Days per department policy. Conducts self-auditing of medical records for status accuracy and provides peer consultation regarding cases in which patients are failing to progress and/or experiencing significant deviation from the plan of care. Collaborates with case managers and social workers for patients with complex, clinical, financial and psycho-social needs. Reviews physician orders and patient progression and intervenes with care coordination as needed. Collaborates with other departments to eliminate barriers, as necessary. Builds trusting relationships with attending physician, patient and/or family and other members of the healthcare team. Establishes a caring relationship with patients and their caregivers, promotes patient engagement and guides patients/families through the transition phase Gathers information for statistical monitors, plus special projects within the Care Management Department. Updates and documents in Expanse and Cortex, pertinent clinical information by utilizing screening criteria and assigns next review date. Responsible to support and participate in department strategies and efforts focused on improving length of stay (LOS) and reduction of avoidable readmissions. Responsible to support and participate in department strategies and efforts focused on improving clinical documentation by physicians. Identifies and reports Quality and Risk Management concerns and enters risk events in Midas. Is knowledgeable of hospital mission, vision, and values and performs in a manner to support them. Reviews an average of 25 patients per day. Delivers denial letters from all payers to the beneficiary or proper representative; explain appeal rights. Must be able to successfully complete the Interrater Reliability Tool for InterQual Level of Care Acute Criteria. (Adult and Pediatric) after successful orientation. DCH Standards Maintains performance, patient and employee satisfaction and financial standards as outlined in the performance evaluation. Performs compliance requirements as outlined in the Employee Handbook Must adhere to the DCH Behavioral Standards including creating positive relationships with patients/families, coworkers, colleagues and with self. Requires use of electronic mail, time and attendance software, learning management software, and intranet. Must adhere to all DCH Health System policies and procedures. All other duties as assigned. Qualifications Anyone hired after July, 2011 must meet the following: Minimum of Registered Nurse with current Alabama license. Minimum 2 years experience as an RN preferred. Minimum of at least 2 years as care management and/or utilization management experience preferred. Minimum of 2 years of Med Surgical experience preferred; Utilization Review experience preferred. Expected to work under minimal management supervision Efficient use of basic computer skills Ability to multi task, prioritize and effectively adapt to a fast paced changing environment Sedentary work involving periods of sitting, talking, and listening. Work requires sitting for extended periods, talking on the phone, and typing on the computer. Work requires the ability to perform close inspection of computer generated documents as well as a PC monitor. Typical office working environment with productivity and quality expectations. Ability to establish priorities, meet deadlines, and maintain proper productivity. Ability to form positive, collaborative relationships with hospital staff, patients, families, and payers. Ability to problem solve in a proactive, creative manner, using sound judgment based on factual information and clinical knowledge. Ability to effectively negotiate with internal and external providers of patient care services. Ability to develop leadership skills and to serve as a role model for clinical staff. Ability to actively participate in multidisciplinary teams. Ability to work independently or within a team structure. Excellent interpersonal skills, communication style, and organization. Must be able to read, write legibly, speak, and comprehend English. WORK CONTEXT Ability to form positive, collaborative relationships with physicians, colleagues, hospital staff, patients, families, and external contacts. Ability to provide guidance and direction to subordinates, including performance standards and monitoring performance. Ability to encourage and build mutual trust, respect, and cooperation among team members. Ability to communicate with people outside the organization and represent the organization to the public, government, and other external sources. Ability to work independently or within a team structure. May be exposed to environmental cleaning chemicals PHYSICAL FACTORS Requires Light work. Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly to move objects. If the use of arm and/or leg controls requires exertion of forces greater than that for sedentary work and the worker sits most of the time, the job is rated for light work. Ability to tolerate prolonged periods of sitting or standing and/or walking. Ability to reach reasonable distances to handle equipment. Good manual and finger dexterity. Must be able to perform the duties with or without reasonable accommodation. Hearing and vision must be normal or corrected to within normal range. Physical presence onsite is essential.
RN Utilization Review Full-time
Molina Healthcare

Care Review Clinician (RN)

Molina Healthcare Long Beach, CA
$27.73 - $54.06 / hour
JOB DESCRIPTION Job SummaryProvides 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: $27.73 - $54.06 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
RN Utilization Review Full-time
Conviva Senior Primary Care

Utilization Management Nurse

Conviva Senior Primary Care Louisville, KY
$71,100 - $97,800 / year
Become a part of our caring community Conviva Care Solutions is seeking a RN who will collaborate with other health care givers in reviewing actual and proposed medical care and services against established CMS Coverage Guidelines/NCQA review criteria and who is interested in being part of a team that focuses on excellent service to others. Preferred Locations: Daytona, FL, Louisville, KY, San Antonio, TX Use your skills to make an impact Required Qualifications Active Unrestricted RN license Possession of or ability to obtain Compact Nursing License 3+ years of clinical RN experience; Prior clinical experience, managed care experience, DME, Florida Medicaid OR utilization management experience Ability to work independently and within a team setting Valid driver's license and/or dependable transportation necessary Travel for offsite Orientation 2 to 8 weeks Travel to offsite meetings up to 6 times a year Willing to work in multiple time zones Strong written and verbal communication skills Attention to detail, strong computer skills including Microsoft office products Ability to work in fast paced environment Ability to form positive working relationships with all internal and external customers Available for On Call weekend/holiday rotation if needed Preferred Qualifications Education: BSN or bachelor's degree in a related field Experience with Florida Medicaid Experience with Physical Therapy, DME, Cardiac or Orthopedic procedures Compact RN License Previous experience in utilization management within Insurance industry Previous Medicare Advantage/Medicare/Medicaid Experience Current nursing experience in Hospital, SNF, LTAC, DME or Home Health. Bilingual Additional Information We offer tangible and intangible benefits such as medical, dental and vision benefits, 401k with company matching, tuition reimbursement, 3 weeks paid vacation time, paid holidays, work-life balance, growth, a positive and fun culture and much more. To ensure Home or Hybrid Home/Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. Satellite, cellular and microwave connection can be used only if approved by leadership. Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense. Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information. Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. Scheduled Weekly Hours 40 Pay Range The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc. $71,100 - $97,800 per year This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance. Description of Benefits Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities. Application Deadline: 05-05-2026 About us About Conviva Senior Primary Care: Conviva Senior Primary Care provides proactive, preventive care to seniors, including wellness visits, physical exams, chronic condition management, screenings, minor injury treatment and more. As part of Humana’s Primary Care Organization, which includes CenterWell Senior Primary Care, Conviva’s innovative, value-based approach means each patient gets the best care, when needed most, and for the lowest cost. We go beyond physical health – addressing the social, emotional, behavioral and financial needs that can impact our patients' well-being. About CenterWell, a Humana company: CenterWell is a leading healthcare services business focused on creating integrated and differentiated experiences that put our patients at the center of everything we do. The result is high-quality healthcare that is accessible, comprehensive and, most of all, personalized. As the largest provider of senior-focused primary care, a leading provider of home healthcare and a leading integrated home delivery, specialty, hospice and retail pharmacy, CenterWell is focused on whole health and addressing the physical, emotional and social wellness of our patients. CenterWell is part of Humana Inc. (NYSE: HUM). Learn more about what we offer at CenterWell.com. ​ Equal Opportunity Employer It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.
RN Utilization Review Full-time
Elevance Health

Utilization Management / Medical Management Nurse - CA HMO

Elevance Health CA
$38.34 - $69.02 / hour
Anticipated End Date: 2026-04-30 Position Title: Utilization Management / Medical Management Nurse - CA HMO Job Description: Utilization Management / Medical Management Nurse – California HMO (JR179164) Virtual: 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. Alternate locations may be considered if candidates reside within a commuting distance to an office. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting locations will not be considered for employment, unless an accommodation is granted as required by law. Note : Associates in this job working from a California location are eligible for overtime pay based on California employment law. Work Hours – Pacific Time : 8 hour shift within 8am – 6pm PST. Rotating Weekends and holidays. The Medical Management Nurse is responsible for review of the most complex or challenging cases that require nursing judgment, critical thinking, and holistic assessment of member’s clinical presentation to determine whether to approve requested service(s) as medically necessary. Works with healthcare providers to understand and assess a member’s clinical picture. Utilizes nursing judgment to determine whether treatment is medically necessary and provides consultation to Medical Director on cases that are unclear or do not satisfy relevant clinical criteria. Acts as a resource for Clinicians. May work on special projects and helps to craft, implement, and improve organizational policies. Primary duties may include but are not limited to: Utilizes nursing judgment and reasoning to analyze members’ clinical information, interface with healthcare providers, make assessments based on clinical presentation, and apply clinical guidelines and/or policies to evaluate medical necessity. Works with healthcare providers to promote quality member outcomes, optimize member benefits, and promote effective use of resources. Determines and assesses abnormalities by understanding complex clinical concepts/terms and assessing members’ aggregate symptoms and information. Assesses member clinical information and recognizes when a member may not be receiving appropriate type, level, or quality of care, e.g., if services are not in line with diagnosis. Provide consultation to Medical Director on particularly peculiar or complex cases as the nurse deems appropriate. May make recommendations on alternate types, places, or levels of appropriate care by leveraging critical thinking skills and nursing judgment and experience. Collaborates with case management nurses on discharge planning, ensuring patient has appropriate equipment, environment, and education needed to be safely discharged. Collaborates with and provides nursing consultation to Medical Director and/or Provider on select cases, such as cases the nurse deems particularly complex, concerning, or unclear. Serves as a resource to lower-level nurses. May participate in intradepartmental teams, cross-functional teams, projects, initiatives and process improvement activities. Educates members about plan benefits and physicians and may assist with case management. Collaborates with leadership in enhancing training and orientation materials. May complete quality audits and assist management with developing associated corrective action plans. May assist leadership and other stakeholders on process improvement initiatives. May help to train lower-level clinician staff. Minimum Requirements: Requires a minimum of associate’s degree in nursing. Requires a minimum of 4 years care management or case management experience and requires a minimum of 2 years clinical, utilization review, or managed care experience; or any combination of education and experience, which would provide an equivalent background. Current active, valid and unrestricted RN license to practice as a health professional within the scope of licensure in the state of California required. Preferred Skills, Capabilities, and Experiences: Strong acute, inpatient clinical experience is areas such as Med/Surg, Critical Care, ER, Telemetry, etc. strongly preferred. Utilization management/review within managed care or hospital setting strongly preferred. Hospital Case Management preferred. HMO experience preferred. Managed care UM/ Utilization Review in hospital preferred. For candidates working in person or virtually in the below locations, the salary* range for this specific position is $38.34 to $69.02. Locations : California; Colorado; Columbus, OH; Illinois; Minnesota; Nevada; Washington State In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws . * The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law. Job Level: Non-Management Non-Exempt Workshift: 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 may contact elevancehealthjobssupport@elevancehealth.com for assistance. 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 .
RN Utilization Review Full-time
BAYADA Home Health Care

Clinical Coding and OASIS Review Specialist, RN, PT, OT, SLP

BAYADA Home Health Care Dallas, TX
$77,000 - $81,000 / year
Please note- Candidates must have COS-C, HCS-O or COQS and HCS-D or BCHH-C in order to be considered, there is no flexibility around this requirement. BAYADA Home Health Care has an immediate opening for a Full Time, OASIS and Coding Review Manager with OASIS and Coding certification to work remotely. RN, PT, OT, and SLP's with certifications will be considered for this role. BAYADA believes that our clients and their families deserve home health care delivered with compassion, excellence, and reliability. Apply your skills and knowledge of OASIS and ICD-10 coding to help clients receive the home health care services they need. BAYADA Perks: This is a fully remote position. Base Salary: $77,000 - $81,000 / year BAYADA offers a comprehensive benefits plan that includes the following: Paid holidays, vacation and sick leave, vision, dental and medical health plans, employer paid life insurance, 401k with company match, direct deposit, and employee assistance program Responsibilities: Review clinical information for appropriateness, congruency, and accuracy as it relates to the OASIS and ICD 10 coding while using the Medicare PDGM billing model and CMS guidelines. Review and communicate OASIS edit recommendations to each clinician to promote OASIS accuracy. Perform final review and lock OASIS. Timely review and coding of OASIS documents with productivity maintained at the quarterly target set by the Director of MCM. Prevent or decrease the occasion of Medicare denials by assuring proper coding on the plan of care and accurate OASIS documentation. Provide support and communication to all disciplines within the service. Provide customer service/education and act as a resource to Medicare Certified Offices with regards to CMS guidelines, Home Care Coding, PDGM guidelines and billing related issues. Provide ongoing communication with service offices via e-mail, zoom, or telephone (specific to the service office needs). Communication with service offices monthly and as appropriate with a focus on documentation trends, star ratings and potential revenue impact. Perform related duties, or as required or requested by Manager/Director. Qualifications: Competency in PC skills required to perform job function Active State RN Nursing License, Physical (PT), Occupational (OT) or Speech (SLP) Therapists with required certifications with a minimum of 2 years clinical experience. Please note, while this is a clinical opening, BAYADA does have non-clinical openings available COS-C or HCS-O or COQS OASIS Certification and experience required BCHH-C or HCS-D Home Health Care Coding Certification and experience required HCHB, SHP, and Coding Center experience, a plus! Be part of a caring, professional team that is instrumental in providing the highest quality care while developing your career with an industry leader. Apply now for immediate consideration. OASIS Review, Utilization Review, Quality Assurance, Remote, Home Health Coding, Coder, Medicare As an accredited, regulated, certified, and licensed home health care provider, BAYADA complies with all state/local mandates. BAYADA is celebrating 50 years of compassion, excellence, and reliability. Learn more about our 50th anniversary celebration and how you can join in here. BAYADA Home Health Care, Inc., and its associated entities and joint venture partners, are Equal Opportunity Employers. All employment decisions are made on a non-discriminatory basis without regard to sex, race, color, age, disability, pregnancy or maternity, sexual orientation, gender identity, citizenship status, military status, or any other similarly protected status in accordance with federal, state and local laws. Hence, we strongly encourage applications from people with these identities or who are members of other marginalized communities.
RN Utilization Review Full-time
Molina Healthcare

Care Review Clinician (RN) CA License

Molina Healthcare Long Beach, CA
$30.37 - $59.21 / hour
JOB DESCRIPTION Job SummaryProvides 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. Must be licensed in CA. 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: $30.37 - $59.21 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
RN Utilization Review Full-time
Mass General Brigham

Utilization Management Nurse

Mass General Brigham Somerville, MA
$58,656 - $142,448.80 / year
Site: Mass General Brigham Health Plan Holding Company, Inc. Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham. Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham, we are at the forefront of transformation with one of the world’s leading integrated healthcare systems. Together, we are providing our members with innovative solutions centered on their health needs to expand access to seamless and affordable care and coverage. Our work centers on creating an exceptional member experience – a commitment that starts with our employees. Working with some of the most accomplished professionals in healthcare today, our employees have opportunities to learn and contribute expertise within a welcoming and supportive environment that embraces their unique and varied backgrounds, experiences, and skills. We are pleased to offer competitive salaries and a benefits package with flexible work options, career growth opportunities, and much more. Given equity, this position will pay somewhere between $90,000 to $107,000 annually. At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience, if applicable, education, certifications, and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums, and bonuses as applicable, and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package. Job Summary The UMCM will utilize clinical knowledge to analyze, assess, and render approval decisions, to determine the need for physician review as well as complete determinations following physician review. The ideal candidate will have prior authorization (outpatient review) experience in a managed care setting with commercial health plan knowledge. Principal Duties and Responsibilities: • Expertise in clinical review for prospective, concurrent, retrospective utilization management reviews utilizing Interqual ®, company policies and procedures, and other resources as determined by review, including physician reviews as needed for all lines of business as per departmental needs • Review authorization requests for medical services, including making initial eligibility and coverage determinations, screening for medical necessity appropriateness, determining if additional information is required, and referral to correct programs within Mass General Brigham Health Plan as needed. • Manage incoming requests for procedures and services including patient medical records and related clinical information. • Strong working knowledge of commercial, self-insured, fully insured and limited network plans. • Adherence to program, departmental and organizational performance metrics including productivity. • Excellent verbal and written communication skills. • Excellent problem solving and customer service skills. • Would need to be available for “on call” for a minimum of once per month with the possibility of that increasing depending on staff availability; Approximately 6 months after hire. • Must be self-directed and highly motivated with an ability to multi-task. • Develop and maintain effective working relationships with internal and external customers • Hold self and others accountable to meet commitments. • Sound decision-making and time management skills. • Proactive in areas of professional development, personally and for the department. • Persist in accomplishing objectives to consistently achieve results despite any obstacles and setbacks that arise. • Build strong relationships and infrastructures that designate Mass General Brigham Health Plan as a people-first organization. • Proficient with Microsoft Word, Excel, Outlook, McKesson InterQual ®, Outlook, SharePoint, PC based operating system, and web-based phone system. Qualifications Education Associate's Degree Nursing required or Bachelor's Degree Nursing preferred Licenses and Credentials Massachusetts Registered Nurse (RN) license required ​ Experience At least 2-3 years of utilization review experience is highly preferred Experience using Interqual or Milliman is highly preferred At least 1-2 years of experience in a payer setting is highly preferred At least 1-2 years of experience in an acute care setting is highly preferred Knowledge, Skills, and Abilities Demonstrate Mass General Brigham Health Plan’s core brand principles of always listening, challenging conventions, and providing value Strong aptitude for technology-based solutions. Embrace opportunities to take the complexity out of how we work and what we deliver. Listen to our constituents, learn, and act quickly in our ongoing pursuit of meaningful innovation Current in healthcare trends. Ability to inject energy, when and where it’s needed. Exercise self-awareness; monitor impact on others; be receptive to and seek out feedback; use self-discipline to adjust to feedback. Be accountable for delivering high-quality work. Act with a clear sense of ownership. Bring fresh ideas forward by actively listening to and working with employees and the people we serve. Communicate respectfully and professionally with colleagues Strong EQ; exercises self-awareness; monitors impact on others; is receptive to and seeks out feedback; uses self-discipline to adjust to feedback. Education Associate's Degree Nursing required or Bachelor's Degree Nursing preferred Licenses and Credentials Massachusetts Registered Nurse (RN) license required ​ Experience At least 2-3 years of utilization review experience is highly preferred Experience using Interqual or Milliman is highly preferred At least 1-2 years of experience in a payer setting is highly preferred At least 1-2 years of experience in an acute care setting is highly preferred Knowledge, Skills, and Abilities Demonstrate Mass General Brigham Health Plan’s core brand principles of always listening, challenging conventions, and providing value Strong aptitude for technology-based solutions. Embrace opportunities to take the complexity out of how we work and what we deliver. Listen to our constituents, learn, and act quickly in our ongoing pursuit of meaningful innovation Current in healthcare trends. Ability to inject energy, when and where it’s needed. Exercise self-awareness; monitor impact on others; be receptive to and seek out feedback; use self-discipline to adjust to feedback. Be accountable for delivering high-quality work. Act with a clear sense of ownership. Bring fresh ideas forward by actively listening to and working with employees and the people we serve. Communicate respectfully and professionally with colleagues Strong EQ; exercises self-awareness; monitors impact on others; is receptive to and seeks out feedback; uses self-discipline to adjust to feedback. Additional Job Details (if applicable) Working Conditions Would need to be available for “on call” for a minimum of once per month with the possibility of that increasing depending on staff availability; Approximately 6 months after hire. This is a remote role with occasional onsite team meetings in Somerville, MA. Remote Type Remote Work Location 399 Revolution Drive Scheduled Weekly Hours 40 Employee Type Regular Work Shift Day (United States of America) Pay Range $58,656.00 - $142,448.80/Annual Grade 98TEMP At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package. EEO Statement: 8925 Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran’s Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642. Mass General Brigham Competency Framework At Mass General Brigham, our competency framework defines what effective leadership “looks like” by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.
RN Utilization Review Full-time
University of Maryland Medical System

Utilization Review Nurse

University of Maryland Medical System Bel Air, MD
$38.67 - $58.05 / hour
Job Requirements This role is full-time. Monday - Friday 8:00 am - 4:30 pm EST Responsible for performing utilization management. Proactively review, identify and document potentially avoidable utilization and patient quality/efficiency concerns. Work collaboratively with internal team as well as external entities to reduce potentially avoidable utilization and denials. Evaluates utilization documentation and recommends processes related to optimal reimbursement and compliance. Perform compliance tasks related to utilization. Orient new team members to acute care criteria. Work Experience Education & Training: Current Maryland RN license required. Bachelors of Science degree in Nursing preferred. Work Orientation & Experience: Minimum of 3 years’ acute care experience required. Experience in utilization management, case management and discharge planning preferred. Basic computer skills required. Skills & Abilities: Demonstrate skill in a) performing complete clinical assessments; b) effective critical thinking skills both written and oral; and c) age appropriate interpersonal interactions (patients may range from newborn to geriatric adult.) Ability to a) communicate and collaborate effectively with both internal and external customers (colleagues, Medical Staff, liaisons, and patient/family); b) assess, adapt, and calmly respond to changing and/or crisis environment; c) make independent decisions consistent with current policies, procedures, and ethical standards; d) prioritize work assignments and manage time effectively to complete duties; and e) assist in data analysis. REPORTING RELATIONSHIPS: Supervised by: Director of Utilization Management Supervision provided to: None. Additional Information All your information will be kept confidential according to EEO guidelines. Compensation: Pay Range: $38.67 - $58.05 Other Compensation (if applicable): Review the 2025-2026 UMMS Benefits Guide Benefits Additional Information All your information will be kept confidential according to EEO guidelines. Compensation: Pay Range: $38.67 - $58.05 Other Compensation (if applicable): Review the 2025-2026 UMMS Benefits Guide
RN Utilization Review Full-time
St. Joseph's Health

Utilization Management Resource Nurse

St. Joseph's Health Paterson, NJ
The Utilization Management Registered Nurse (UM RN) is responsible for evaluating the medical necessity, appropriateness, and efficiecny of healthcare services in accordance with established criteria, regulatory requirements, and organizational role. The UM RN ensures optimal patient care delivery while supporting compliance, quality outcomes, and effective resource utilization. The role is responsible for the assessment of medcial necessity, both for admission to the hospital as well as continued stay. This function ensurses that services are not only appropriate but ensures that an authorization is obtained from the payer, if required, and that the documentation supports the care delivered in such a way that minimzes risks of denials.
RN Utilization Review Full-time
CVS Health

Utilization Management Nurse Consultant

CVS Health IL
$32.01 - $68.55 / hour
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours. Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function. Typical office working environment with productivity and quality expectations. Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor. Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment. Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding. Effective communication skills, both verbal and written Required Qualifications - 2+ years of experience as a Registered Nurse in adult acute care/critical care setting - Must have active current and unrestricted RN licensure in state of residence - Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours Preferred Qualifications - 2+ years of clinical experience required in med surg or specialty area - Managed Care experience preferred, especially Utilization Management - Preference for those residing in CT zones Education Associates Degree required BSN preferred Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $32.01 - $68.55 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan . No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 04/30/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
RN Utilization Review Full-time
CVS Health

Utilization Management Nurse Consultant

CVS Health OH
$29.10 - $62.32 / hour
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours. Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function. Typical office working environment with productivity and quality expectations. Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor. Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment. Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding. Effective communication skills, both verbal and written Required Qualifications - 2+ years of experience as a Registered Nurse in adult acute care/critical care setting - Must have active current and unrestricted RN licensure in state of residence - Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours Preferred Qualifications - 2+ years of clinical experience required in med surg or specialty area - Managed Care experience preferred, especially Utilization Management - Prefe rence for those residing in Eastern Standard Time (EST) zone. Education Associates Degree required BSN preferred Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $29.10 - $62.32 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan . No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 04/18/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
RN Utilization Review Full-time
John Muir Health

RN - Case Manager - AS Utilization Management - Walnut Creek - Full Time - 8 Hour - Days

John Muir Health Walnut Creek, CA
$89.23 - $121.58 / hour
Job Description: The role of the inpatient case manager is one of patient advocate of appropriate utilization of resources. The inpatient case manager applies the process of assessment, planning, implementation, monitoring, evaluation and coordination of care to meet the patient’s health care needs through hospitalization and transition back to the community and does this in coordination with the interdisciplinary health team. The RN Case Manager is expected to function within the full scope of the nursing practice with specialized focus on care coordination, compliance, transition management, education, and utilization management. Education: Bachelor's Degree Accredited School of Nursing Required Experience: 3 years Nursing - Medical/Surgical Preferred or 3 years Nursing - Critical Care Preferred 2 years Care Coordination - Case Management Preferred or Equivalent Work Experience Certifications/Licensures: RN Registered Nursing - California Board of Nursing Required BLS Basic Life Support - American Heart Association Required ACM Accredited Case Manager - ACMA American Case Management Association or CCM Certified Case Manager - CCMC Commission for Case Manager Certification Strongly Preferred Skills: Strong written and verbal communication skills. Effectively motivates teams. Strong knowledge of Medicare and Medi-Cal guidelines and benefit resources as applicable to hospitalization and transition planning. Working know ledge of common diagnoses and procedures and the impact this w ill have to patients/families and their ability to manage their care outside of the hospital. Specialized know ledge may be required for certain areas of practice. Knowledge of individual and family development over the life span, and the influences of cultural and spiritual values in health care. General knowledge of commercial coverage plans and usually covered benefits. Strong understanding of various reimbursement models and impact to care delivery, patient management and reimbursements such as ACOs, DRGs, Full Risk, etc. Strong understanding of the criteria, rules and regulations around Inpatient, Observation and Outpatient levels of patient management. Strong know ledge of geriatrics and the impact to health and function in the aged as w ell as a working know ledge of chronic/progressive disease states such as CHF, COPD, Diabetes and End Stage Renal Disease, etc. Clear understanding of the role of the inpatient Social Worker and Palliative Care Resources. Ability to plan, organize, manage time and prioritize work in collaboration with others. Ability to work independently and as a part of a multidisciplinary team. Effective problem solving and conflict resolution skills. Ability to work respectfully and creatively with clients of diverse functional abilities, social, economic, and cultural backgrounds to support both client autonomy and client safety. Leadership skills to delegate and provide direction/guidance to staff and hold others accountable. Able to learn and work in a variety of computer programs, including EPIC, Allscripts, InterQual, and Microsoft Outlook. Work shift: 0800-1630 Days worked per week: 5 Hours worked per day: 8 work schedule: Tuesday-Saturday (week 1) Wednesday-Saturday (week 2) Work Shift: 08.0 - 08:00 - 16:30 No Waive (United States of America) Pay Range: $89.23 - $121.58 Hourly Offer amounts are based on demonstrated/relevant experience and/or licensure. Pay will be adjusted to the local market if hired outside of the Bay Area. Note: Positions at JMH which are exempt (not eligible for overtime) under the level of Manager are listed as hourly for compensation purposes on this posting. The work shift will contain the word ‘exempt’ on it. Scheduled Weekly Hours: 36
RN Utilization Review Full-time
John Muir Health

RN - Case Manager - AS Utilization Management - Walnut Creek - Full Time - 8 Hour - Days

John Muir Health Walnut Creek, CA
$89.23 - $121.58 / hour
Job Description: The role of the inpatient case manager is one of patient advocate of appropriate utilization of resources. The inpatient case manager applies the process of assessment, planning, implementation, monitoring, evaluation and coordination of care to meet the patient’s health care needs through hospitalization and transition back to the community and does this in coordination with the interdisciplinary health team. The RN Case Manager is expected to function within the full scope of the nursing practice with specialized focus on care coordination, compliance, transition management, education, and utilization management. Education: Bachelor's Degree Accredited School of Nursing Required Experience: 3 years Nursing - Medical/Surgical Preferred or 3 years Nursing - Critical Care Preferred 2 years Care Coordination - Case Management Preferred or Equivalent Work Experience Certifications/Licensures: RN Registered Nursing - California Board of Nursing Required BLS Basic Life Support - American Heart Association Required ACM Accredited Case Manager - ACMA American Case Management Association or CCM Certified Case Manager - CCMC Commission for Case Manager Certification Strongly Preferred Skills: Strong written and verbal communication skills. Effectively motivates teams. Strong knowledge of Medicare and Medi-Cal guidelines and benefit resources as applicable to hospitalization and transition planning. Working know ledge of common diagnoses and procedures and the impact this w ill have to patients/families and their ability to manage their care outside of the hospital. Specialized know ledge may be required for certain areas of practice. Knowledge of individual and family development over the life span, and the influences of cultural and spiritual values in health care. General knowledge of commercial coverage plans and usually covered benefits. Strong understanding of various reimbursement models and impact to care delivery, patient management and reimbursements such as ACOs, DRGs, Full Risk, etc. Strong understanding of the criteria, rules and regulations around Inpatient, Observation and Outpatient levels of patient management. Strong know ledge of geriatrics and the impact to health and function in the aged as w ell as a working know ledge of chronic/progressive disease states such as CHF, COPD, Diabetes and End Stage Renal Disease, etc. Clear understanding of the role of the inpatient Social Worker and Palliative Care Resources. Ability to plan, organize, manage time and prioritize work in collaboration with others. Ability to work independently and as a part of a multidisciplinary team. Effective problem solving and conflict resolution skills. Ability to work respectfully and creatively with clients of diverse functional abilities, social, economic, and cultural backgrounds to support both client autonomy and client safety. Leadership skills to delegate and provide direction/guidance to staff and hold others accountable. Able to learn and work in a variety of computer programs, including EPIC, Allscripts, InterQual, and Microsoft Outlook. Work shift: 0800-1630 Days worked per week: 5 Hours worked per day: 8 work schedule: Sunday to Wednesday (week 1) Sunday-Thursday (week2) Work Shift: 08.0 - 08:00 - 16:30 No Waive (United States of America) Pay Range: $89.23 - $121.58 Hourly Offer amounts are based on demonstrated/relevant experience and/or licensure. Pay will be adjusted to the local market if hired outside of the Bay Area. Note: Positions at JMH which are exempt (not eligible for overtime) under the level of Manager are listed as hourly for compensation purposes on this posting. The work shift will contain the word ‘exempt’ on it. Scheduled Weekly Hours: 36
RN Utilization Review Full-time
Temple Health

RN Case Manager - Utilization Review (Temple Hospital Jeanes Campus)

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 2 years experience in clinical nursing preferably in acute care Preferred General Experience in utilization review, case management, PreCertification, or discharge planning Preferred General Experience and knowledge of Medicare, Medicaid, and commercial insurance guidelines Preferred General Experience and knowledge of MCG and InterQual criteria tools Preferred Licenses PA Registered Nurse License Required or Multi State Compact RN License Required Schedule: M-F 8:00am-4:30pm with every third weekend requirement
RN Utilization Review Full-time
CVS Health

Utilization Management Nurse Consultant

CVS Health OH
$29.10 - $62.32 / hour
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours. Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function. Typical office working environment with productivity and quality expectations. Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor. Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment. Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding. Effective communication skills, both verbal and written Required Qualifications - 2+ years of experience as a Registered Nurse in adult acute care/critical care setting - Must have active current and unrestricted RN licensure in state of residence - Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours Preferred Qualifications - 2+ years of clinical experience required in med surg or specialty area - Managed Care experience preferred, especially Utilization Management - Preference for those residing in EST zones Education Associates Degree required BSN preferred Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $29.10 - $62.32 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan . No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 04/30/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
RN Utilization Review Full-time
CVS Health

Utilization Management Nurse Consultant

CVS Health IA
$26.01 - $56.14 / hour
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours. Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function. Typical office working environment with productivity and quality expectations. Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor. Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment. Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding. Effective communication skills, both verbal and written Required Qualifications - 2+ years of experience as a Registered Nurse in adult acute care/critical care setting - Must have active current and unrestricted RN licensure in state of residence - Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours Preferred Qualifications - 2+ years of clinical experience required in med surg or specialty area - Managed Care experience preferred, especially Utilization Management - Preference for those residing in CST zones Education Associates Degree required BSN preferred Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $26.01 - $56.14 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan . No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 04/30/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
RN Utilization Review Full-time
CVS Health

Utilization Management Nurse Consultant

CVS Health PA
$29.10 - $62.32 / hour
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary This is a fulltime remote Utilization Management Nurse Consultant opportunity. Utilization management is a 24/7 operation. Work schedules may include weekends and holidays and evening rotations. Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function. Typical office working environment with productivity and quality expectations. Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor. Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment. Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding. Effective communication skills, both verbal and written Required Qualifications Must have active current and unrestricted RN licensure in state of residence 3+ years of experience as a Registered Nurse 1+ years of clinical experience in acute or post-acute setting Candidates must be able to work Monday - Friday 8:00am-5:00pm EST with late night rotation 10:30 - 7pm EST. Work schedules include weekends, holidays and evening rotations Preferred Qualifications Experience working in ER, Med/Surg, and/or Critical care setting Managed Care experience Utilization review experience Experience working with MS office applications such as Teams, Outlook, Excel, and Word Education Minimum of an Associate's Degree in Nursing BSN preferred Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $29.10 - $62.32 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan . No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 04/18/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
RN Utilization Review Full-time
Gentiva

RN Clinical Review Specialist - Remote

Gentiva Michigan Center, MI
Overview Audit Documentation. Ensure Compliance. Improve Quality Standards. As a Clinical Review Specialist, you will be responsible for completing chart audits and other functions that monitor, improve, and enforce compliance and Quality Assurance standards. You’ll collaborate with local and corporate teams to identify training needs, guide process improvements, and ensure adherence to federal and state regulations—all while supporting exceptional hospice care delivery. As a Clinical Review Specialist, You Will: Conduct proactive, recurring audits to support company infrastructure. Review and analyze documentation in HomeCareHomeBase (HCHB), making recommendations to improve accuracy and compliance. Quantify documentation quality and guide local management in targeted improvement strategies. Adhere to quality assurance, compliance, and departmental plans. Identify skill gaps among hospice agency staff and work with management to arrange appropriate training. Prepare reports and data analysis to support quality improvement initiatives. Assist in HCHB adjustments to prevent recurring deficiencies. Stay current on hospice best practices and recommend beneficial training resources. Support orientation and ongoing education of staff and committees on quality assurance and care standards. Participate in defining factors that influence care quality for hospice patients. Coordinate management calls to review patient chart findings and improvement recommendations. Compile local documentation outcome data and use company-wide insights to enhance QA. Meet or exceed department chart audit productivity expectations. This is a work from home position. To support operational needs and business hours, candidates should reside in one of these states: Alabama, Arkansas, Florida, Georgia, Indiana, Kansas, Michigan, Missouri, North Carolina, Pennsylvania, South Carolina, Tennessee, Texas or Virginia. About You Qualifications – What You’ll Bring: Registered Nurse (RN) currently licensed in the state of residence. Minimum of three years’ Hospice and Home Care experience, including at least one year in clinical record review and QAPI. Experience participating in state surveys. Valid driver’s license and insurance coverage. Strong understanding of documentation requirements to support medical necessity for hospice care. Knowledge of hospice federal and state regulations. Ability to manage confidential information with discretion. Initiative in researching and resolving documentation issues. Skilled at gathering and processing time-sensitive data from multiple sources. Flexible, responsive, and able to adapt to changing priorities in a fast-paced environment. Preferred Experience (Not Required) BSN or equivalent degree Previous experience with HomeCare HomeBase (HCHB) documentation systems. Prior quality assurance leadership experience in a hospice setting. We Offer Benefits for All Hospice Associates (Full-Time & Per Diem): Competitive Pay 401(k) with Company Match Career Advancement Opportunities National & Local Recognition Programs Teammate Assistance Fund Additional Full-Time Benefits: Medical, Dental, Vision Insurance Mileage Reimbursement or Fleet Vehicle Program Generous Paid Time Off + 7 Paid Holidays Wellness Programs (Telemedicine, Diabetes Management, Joint & Spine Concierge Care) Education Support & Tuition Assistance Free Continuing Education Units (CEUs) Company-paid Life & Long-Term Disability Insurance Voluntary Benefits (Pet, Critical Illness, Accident, LTC) Apply today and help support compassionate care that makes every moment count. Legalese This is a safety-sensitive position Employee must meet minimum requirements to be eligible for benefits Where applicable, employee must meet state specific requirements We are proud to be an EEO employer We maintain a drug-free workplace ReqID: 2026-134461 Category: Branch Admin and Clerical Position Type: Full-Time Company: Gentiva
RN Utilization Review Full-time
Gentiva

RN Clinical Review Specialist - Remote

Gentiva Orlando, FL
Overview Audit Documentation. Ensure Compliance. Improve Quality Standards. As a Clinical Review Specialist, you will be responsible for completing chart audits and other functions that monitor, improve, and enforce compliance and Quality Assurance standards. You’ll collaborate with local and corporate teams to identify training needs, guide process improvements, and ensure adherence to federal and state regulations—all while supporting exceptional hospice care delivery. As a Clinical Review Specialist, You Will: Conduct proactive, recurring audits to support company infrastructure. Review and analyze documentation in HomeCareHomeBase (HCHB), making recommendations to improve accuracy and compliance. Quantify documentation quality and guide local management in targeted improvement strategies. Adhere to quality assurance, compliance, and departmental plans. Identify skill gaps among hospice agency staff and work with management to arrange appropriate training. Prepare reports and data analysis to support quality improvement initiatives. Assist in HCHB adjustments to prevent recurring deficiencies. Stay current on hospice best practices and recommend beneficial training resources. Support orientation and ongoing education of staff and committees on quality assurance and care standards. Participate in defining factors that influence care quality for hospice patients. Coordinate management calls to review patient chart findings and improvement recommendations. Compile local documentation outcome data and use company-wide insights to enhance QA. Meet or exceed department chart audit productivity expectations. This is a work from home position. To support operational needs and business hours, candidates should reside in one of these states: Alabama, Arkansas, Florida, Georgia, Indiana, Kansas, Michigan, Missouri, North Carolina, Pennsylvania, South Carolina, Tennessee, Texas or Virginia. About You Qualifications – What You’ll Bring: Registered Nurse (RN) currently licensed in the state of residence. Minimum of three years’ Hospice and Home Care experience, including at least one year in clinical record review and QAPI. Experience participating in state surveys. Valid driver’s license and insurance coverage. Strong understanding of documentation requirements to support medical necessity for hospice care. Knowledge of hospice federal and state regulations. Ability to manage confidential information with discretion. Initiative in researching and resolving documentation issues. Skilled at gathering and processing time-sensitive data from multiple sources. Flexible, responsive, and able to adapt to changing priorities in a fast-paced environment. Preferred Experience (Not Required) BSN or equivalent degree Previous experience with HomeCare HomeBase (HCHB) documentation systems. Prior quality assurance leadership experience in a hospice setting. We Offer Benefits for All Hospice Associates (Full-Time & Per Diem): Competitive Pay 401(k) with Company Match Career Advancement Opportunities National & Local Recognition Programs Teammate Assistance Fund Additional Full-Time Benefits: Medical, Dental, Vision Insurance Mileage Reimbursement or Fleet Vehicle Program Generous Paid Time Off + 7 Paid Holidays Wellness Programs (Telemedicine, Diabetes Management, Joint & Spine Concierge Care) Education Support & Tuition Assistance Free Continuing Education Units (CEUs) Company-paid Life & Long-Term Disability Insurance Voluntary Benefits (Pet, Critical Illness, Accident, LTC) Apply today and help support compassionate care that makes every moment count. Legalese This is a safety-sensitive position Employee must meet minimum requirements to be eligible for benefits Where applicable, employee must meet state specific requirements We are proud to be an EEO employer We maintain a drug-free workplace ReqID: 2026-134461 Category: Branch Admin and Clerical Position Type: Full-Time Company: Gentiva
RN Utilization Review Full-time
Gentiva

RN Clinical Review Specialist - Remote

Gentiva Little Rock, AR
Overview Audit Documentation. Ensure Compliance. Improve Quality Standards. As a Clinical Review Specialist, you will be responsible for completing chart audits and other functions that monitor, improve, and enforce compliance and Quality Assurance standards. You’ll collaborate with local and corporate teams to identify training needs, guide process improvements, and ensure adherence to federal and state regulations—all while supporting exceptional hospice care delivery. As a Clinical Review Specialist, You Will: Conduct proactive, recurring audits to support company infrastructure. Review and analyze documentation in HomeCareHomeBase (HCHB), making recommendations to improve accuracy and compliance. Quantify documentation quality and guide local management in targeted improvement strategies. Adhere to quality assurance, compliance, and departmental plans. Identify skill gaps among hospice agency staff and work with management to arrange appropriate training. Prepare reports and data analysis to support quality improvement initiatives. Assist in HCHB adjustments to prevent recurring deficiencies. Stay current on hospice best practices and recommend beneficial training resources. Support orientation and ongoing education of staff and committees on quality assurance and care standards. Participate in defining factors that influence care quality for hospice patients. Coordinate management calls to review patient chart findings and improvement recommendations. Compile local documentation outcome data and use company-wide insights to enhance QA. Meet or exceed department chart audit productivity expectations. This is a work from home position. To support operational needs and business hours, candidates should reside in one of these states: Alabama, Arkansas, Florida, Georgia, Indiana, Kansas, Michigan, Missouri, North Carolina, Pennsylvania, South Carolina, Tennessee, Texas or Virginia. About You Qualifications – What You’ll Bring: Registered Nurse (RN) currently licensed in the state of residence. Minimum of three years’ Hospice and Home Care experience, including at least one year in clinical record review and QAPI. Experience participating in state surveys. Valid driver’s license and insurance coverage. Strong understanding of documentation requirements to support medical necessity for hospice care. Knowledge of hospice federal and state regulations. Ability to manage confidential information with discretion. Initiative in researching and resolving documentation issues. Skilled at gathering and processing time-sensitive data from multiple sources. Flexible, responsive, and able to adapt to changing priorities in a fast-paced environment. Preferred Experience (Not Required) BSN or equivalent degree Previous experience with HomeCare HomeBase (HCHB) documentation systems. Prior quality assurance leadership experience in a hospice setting. We Offer Benefits for All Hospice Associates (Full-Time & Per Diem): Competitive Pay 401(k) with Company Match Career Advancement Opportunities National & Local Recognition Programs Teammate Assistance Fund Additional Full-Time Benefits: Medical, Dental, Vision Insurance Mileage Reimbursement or Fleet Vehicle Program Generous Paid Time Off + 7 Paid Holidays Wellness Programs (Telemedicine, Diabetes Management, Joint & Spine Concierge Care) Education Support & Tuition Assistance Free Continuing Education Units (CEUs) Company-paid Life & Long-Term Disability Insurance Voluntary Benefits (Pet, Critical Illness, Accident, LTC) Apply today and help support compassionate care that makes every moment count. Legalese This is a safety-sensitive position Employee must meet minimum requirements to be eligible for benefits Where applicable, employee must meet state specific requirements We are proud to be an EEO employer We maintain a drug-free workplace ReqID: 2026-134461 Category: Branch Admin and Clerical Position Type: Full-Time Company: Gentiva
RN Utilization Review Other
Spectrum Healthcare Resources

Utilization Management Registered Nurse

Spectrum Healthcare Resources Cheyenne, WY
$39 - $48 / hour
Job Description Spectrum Healthcare Resources has an excellent opportunity for a civilian Utilization Management Registered Nurse at FE Warren Air Force Base in Cheyenne, WY. Full-time opportunity Monday - Friday (0700-1700) No weekends, on-call or holidays required Provide care and resources to military community Full complement of benefits to include health, dental and vision insurance, PTO, 11 Paid Holidays, 401(k) and more Pay range is $39-48/hour Job Requirements: BSN Degree 6 years of clinical nursing experience and 1 year of utilization management experience required Knowledge, skills and computer literacy to interpret and apply medical care criteria, such as InterQual or Milliman Ambulatory Care Guidelines. Experience in performing prospective, concurrent, and retrospective reviews to justify medical necessity for medical care to aid in collection and recovery from multiple insurance carriers. Current RN license in Wyoming Job duties: Monitor specialty care referrals for appropriateness, covered benefit, and authorized surgery/medical procedures, laboratory, radiology, pharmacy, and general hospital procedures and regulations to analyze medical referrals/appointments. Receives and makes patient telephone calls and computer/written correspondence regarding specialty clinic appointments and referrals. Develops and implements a comprehensive Utilization Management plan/program for beneficiaries within MTF’s goals and objectives. Company Overview: At Spectrum, we utilize over thirty-five years of experience providing optimal solutions for federal agencies that are both innovative and cost-effective. We hold ourselves to the highest standard to ensure successful outcomes for the facilities and health care professionals we serve. As a Joint Commission Certified Healthcare Resource, dependability and service are the driving forces of our mission. EOE/Disabled/Veterans Location : Location US-WY-Cheyenne Recruiter : Full Name: First Last Lauren Larkin Direct phone number 571-410-2088 Recruiter : Email Lauren_Larkin@spectrumhealth.com
RN Utilization Review Other
Spectrum Healthcare Resources

Utilization Management Registered Nurse

Spectrum Healthcare Resources Cheyenne, WY
Job Description Spectrum Healthcare Resources has a potential opportunity for a civilian Utilization Management Registered Nurse at FE Warren Air Force Base in Cheyenne, WY. Full-time opportunity Monday through Friday, 40 hours per week Outpatient setting, providing care to our Active Duty Air Men and Women No on-call responsibilities Full complement of benefits to include health, dental and vision insurance, paid time off, 11 Paid Holidays, 401k and more Job Requirements: The Position will have the following requirements: Degree: Baccalaureate of Science in Nursing Program from an approved National League of Nursing. Education: Graduate from a college or university accredited by Accreditation Commission for Education in Nursing (ACEN), the Commission on Collegiate Nursing Education (CCNE). Experience: Six years of clinical nursing experience is required. One year of previous experience in Utilization Management is required. Full time employment in a nursing field within the last 36 months is mandatory. Knowledge, skills and computer literacy to interpret and apply medical care criteria, such as InterQual or Milliman Ambulatory Care Guidelines. Must possess experience in performing prospective, concurrent, and retrospective reviews to justify medical necessity for medical care to aid in collection and recovery from multiple insurance carriers. Review process includes Direct Care and Purchase Care System referrals, ward rounds for clinical data collection, contacting providers to inform them of dollars lost for missing documentation, and providing documentation for appeals resolution. Must possess experience in performing prospective, concurrent, and retrospective reviews to justify medical necessity for medical care to aid in collection and recovery from multiple insurance carriers. Review process includes Direct Care and Purchase Care System referrals, ward rounds for clinical data collection, contacting providers to inform them of dollars lost for missing documentation, and providing documentation for appeals resolution. The Contractor must have a working knowledge of Ambulatory Procedure Grouping (APGs), Diagnostic Related Grouping (DRGs), International Classification of Diseases-Version 9 (ICD), and Current Procedural Terminology-Version 4 (CPT-4) coding. Licensure: Current, full, active, unrestricted license to practice as a Registered Nurse in Wyoming Job duties include but not limited to: Coordinate patient care in collaboration with a wide array of healthcare professionals. Facilitate the achievement of optimal outcomes in relation to clinical care, quality and cost effectiveness. Monitors specialty care referrals for appropriateness, covered benefit, and authorized surgery/medical procedures, laboratory, radiology, pharmacy, and general hospital procedures and regulations to analyze medical referrals/appointments. If unsure coordinates with TRICARE Regional Office Clinical Liaison Nurse and MTF Liaison to remedy errors or uncertainty. Assist with orientation and training of other Medical Management staff and assist in providing, assessing, and improving a wide variety of customer service relations. Assists Flight Commander to ensure Health Service Inspection standards are met at the operational level. Receives and makes patient telephone calls and computer/written correspondence regarding specialty clinic appointments and referrals. Routinely monitors referral management Composite Health Care System (CHCS) queue to ensure patients are being called that do not utilize the Referral Management Center walk-in service. Company Overview: Spectrum Healthcare Resources (SHR) was established in 1988 to deliver systems and processes designed to meet the unique needs of Military and VA Health Systems. SHR is a leading organization that provides physician and clinical staffing and management services to United States Military Treatment Facilities, VA clinics and other Federal Agencies through various contracting vehicles. A Joint Commission Health Care Staffing Services firm, SHR is the military staffing division of TeamHealth, a Nationwide organization that serves 850 civilian and military hospitals with a team of 9,600 affiliated health care professionals. Spectrum Healthcare Resources is an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status, or any other characteristic protected by law. Location : Location US-WY-Cheyenne Recruiter : Full Name: First Last Betty Fisk Direct phone number 314-744-4130 Recruiter : Email betty_fisk@spectrumhealth.com
RN ER Utilization Review Per Diem
Kaiser Permanente

ED Case Management Utilization RN, Per Diem Day

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

Utilization Management Nurse Consultant - Open to residents in Pacific Standard Time Zone

CVS Health NV
$29.10 - $62.32 / hour
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Must Reside in PST Time Zone Position Summary Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours. This is a full-time, remote role. Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care. Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs. Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization. Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function. Typical office working environment with productivity and quality expectations. Work requires the ability to perform close inspection of handwritten and computer generated documents as well as a PC monitor. Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer. Ability to multitask, prioritize and effectively adapt to a fast-paced changing environment. Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding. Effective communication skills, both verbal and written. Required Qualifications Must reside in Pacific Standard Time Zone 2+ years of experience as a Registered Nurse in adult acute care/critical care setting. Must have active current and unrestricted RN licensure in state of residence. Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours. Preferred Qualifications 2+ years of clinical experience required in med surg or specialty area. Managed Care experience preferred, especially Utilization Management. Preference for those residing in PST zones. Education Associates Degree required BSN preferred Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $29.10 - $62.32 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan . No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 04/30/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
RN Utilization Review Full-time
CVS Health

Utilization Management Nurse Consultant - Fully Remote

CVS Health
$26.01 - $74.78 / hour
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary CVS Health Aetna has an opportunity for a full-time Utilization Management (UM) Nurse Consultant. As a Utilization Management Nurse Consultant, you will utilize clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. You would be responsible for ensuring the member is receiving the appropriate care at the appropriate time and at the appropriate location, while adhering to federal and state regulated turn-around times. This includes reviewing written clinical records. Key Responsibilities of the UM Nurse Consultant (Includes but is not limited to) Reviews services to assure medical necessity, applies clinical expertise to assure appropriate benefit utilization, facilitates safe and efficient discharge planning and works closely with facilities and providers to meet the complex needs of the member. Facilitate the delivery of appropriate benefits and/or healthcare information which determines eligibility for benefits while promoting wellness activities. Develops, implements and supports Health Strategies, tactics, policies and programs that ensure the delivery of benefits and to establish overall member wellness and successful and timely return to work. Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure, and clinical judgment to render coverage determination/recommendation along the continuum of care. Communicates with providers and other parties to facilitate care/treatment. Identifies members for referral opportunities to integrate with other products, services and/or programs. Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization. Required Qualifications Registered Nurse (RN) with current unrestricted US licensure in their state of residence is required. 2+ years clinical practice experience as an RN required. 2+ Years Utilization Management experience. Must be willing to travel to the local office as needed if living within approximately 45 minutes/miles. Preferred Qualifications Bilingual proficiency preferred. 1+ year(s) experience utilizing multiple computer systems and applications including Microsoft Word, Excel, Outlook, and web-based applications. Education Associate’s degree in Nursing required. BSN preferred. Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $26.01 - $74.78 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan . No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 04/03/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.