Registered Nurse (RN) Utilization Review Jobs

RN Utilization Review Full-time
Southeast Health

Utilization Review Nurse

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

Registered Nurse Utilization Review Flex

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

Preservice Review Nurse - PST time zone - Remote

UnitedHealthcare Las Vegas, NV
$28.94 - $51.63 / hour
At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and optimized. Ready to make a difference? Join us to start Caring. Connecting. Growing together The Preservice Review RN is responsible for reviewing requests received from providers, using approved protocols and criteria. (Milliman Care Guidelines or Healthcare Operations Protocols). The RN is expected to approve those requests that meet medical necessity, along with benefit level, and the contractual status of the provider / facility as appropriate for self-funded lines of business. This position is also a resource to new staff and may precept as well. Candidates must be available to work Monday - Friday from 8:00 am - 5:00 pm PST. *** You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. Primary Responsibilities Evaluate and assess each request verifying eligibility and specific product Determine benefit level based on site of service Utilize written criteria to approve, pend or send the case to the medical director for review Send cases for pending process when appropriate Maintain at least 98% accuracy of clinical review case notes in Facets Maintain productivity standards and maintain compliance with all regulatory agencies including NCQA, DOL, DOI for each state, Medicaid, CMS and OPM Maintain at least 98% accuracy in summarizing cases for the Medical Director to review using appropriate protocols based members clinical and benefit information Maintain compliance with turnaround times based on the member's product, the type of request and the specific regulatory agency Be knowledgeable of and comply with the Nurse Practice Act for each state that licensure is required to perform SHL business Precepts / act as a resource for new staff You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications A current, unrestricted RN license for the state of Nevada 2+ years of recent critical care, ER and/or med-surg nursing experience Proficient with Microsoft Word to create, edit, save and send documents Proven ability to navigate a Windows environment, Microsoft Outlook, and conduct Internet searches Preferred Qualifications 2+ years Utilization Management experience in managed care, acute or rehab setting Knowledge of utilization review process and prior authorization process in a managed health care industry Knowledge of ICD9 / CPT coding and Milliman Care Guidelines Soft Skills Detail oriented, excellent organizational skills Ability to work well under pressure with sound decision making ability Excellent written and oral communication skills All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $28.94 to $51.63 per hour based on full-time employment. We comply with all minimum wage laws as applicable. Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants. At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission. UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations. UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.
RN Utilization Review Full-time
UF Health

RN, Utilization Management | Utilization Management

UF Health St. Augustine, FL
Overview Make an impact by supporting the right care at the right time through utilization management excellence. 💻 Work Style: Onsite 📍 Location: St. Agustine, FL 🕒 FTE: Full-Time (1.0 FTE) ⏰ Schedule: Monday – Friday, 3:00 PM – 11:00 PM Plays a critical role in evaluating patient medical records to ensure the necessity and appropriateness of healthcare services. Involves coordinating with healthcare providers to maintain compliance with utilization management guidelines and optimizing treatment plans for effective patient care and resource utilization. Requires clear communication of authorization decisions and ongoing monitoring to support timely discharge planning. Analyzes utilization data to identify trends and collaborates with interdisciplinary teams to enhance care coordination while ensuring accurate documentation and regulatory compliance. Responsibilities Key Responsibilities Evaluates patient medical records to determine the medical necessity and appropriateness of healthcare services. Coordinates with healthcare providers and care teams to ensure compliance with utilization management guidelines and payer requirements. Supports effective treatment planning, patient care coordination, and appropriate resource utilization. Communicates authorization decisions and utilization determinations while supporting timely discharge planning efforts. Analyzes utilization management data and trends to identify opportunities for improved care coordination and operational efficiency. Collaborates with interdisciplinary teams to ensure accurate documentation, regulatory compliance, and quality patient outcomes. Qualifications Education & Licensure Registered Nurse (RN) with a current Florida nursing license required. Experience & Skills Minimum of three (3) years of experience in utilization review, utilization management, or case management required. Knowledge of healthcare utilization guidelines, payer requirements, and regulatory compliance standards. Experience evaluating medical necessity, treatment plans, and appropriate levels of care. Strong communication and collaboration skills related to authorization determinations and care coordination. Demonstrated ability to analyze utilization data, identify trends, and support patient care and discharge planning initiatives.
RN ER Utilization Review Full-time
Albany Medical Center

Utilization Review Nurse: Emergency Dept

Albany Medical Center Albany, NY
$84,783 - $131,414 / year
Department/Unit: Care Management/Social Work Work Shift: Day (United States of America) Salary Range: $84,783.00 - $131,414.00 Responsible for Utilization Management, Quality Screening and Delay Management for assigned patients. Most qualified candidates will have experience in Emergency/Trauma Care and/or previous Utilization Review roles. Qualifications and Ideal Characteristics Registered nurse with a New York State current license. Bachelor's degree required. Masters degree preferred. Minimum of three years clinical experience in an assigned service. Recent experience in case management, utilization management and/or discharge planning/home care in a high volume, acute care hospital preferred. PRI and Case Management certification preferred. Assertive and creative in problem solving, critical thinking skills, systems planning and patient care management. Self-directed with the ability to adapt in a changing environment. Basic knowledge of computer systems with skills applicable to utilization review process. Excellent written and verbal communication skills. Working knowledge of MCG criteria and ability to implement and utilize. Understanding of Inpatient versus Outpatient surgery and ICD10-Coding (preferred) and Observation status qualifications. Ability to work independently and demonstrate organizational and time management skills. Strong analytic, data management and PC skills. Working knowledge of Medicare regulatory requirements, Managed Care Plans A. Mission, Core Values and Service Excellence Contributes to the creation of a compassionate and caring environment for patients, families, and colleagues through displays of kindness and active listening. Recognizes and appreciates that each employee’s work is valuable and contributes to the success of the Mission. Demonstrates excellence in daily work. Willing to actively participate in performance and quality improvement activities and to work towards enhancing customer/patient satisfaction. Exhibits positive service excellence skills to patients, visitors, and coworkers by greeting others in a friendly manner, keeping customers/patients/colleagues informed about progress, delays, and changes. Demonstrates effective teamwork by interacting in a positive manner with colleagues and creating a collaborative work environment. Initiates open communication, conveys positive intent, offers assistance. Contributes to a safe and secure environment for patients, visitors, colleagues by following established procedures and protocols. Demonstrates stewardship by thoughtful and responsible use of resources including maintaining a clean and hospitable environment, starting work on time, displaying a consciousness regarding costs, supplies and department finances. Demonstrates respect for individual differences of each person by acknowledging the essence of each person, appreciating, and responding to unique, spiritual, personal, and cultural backgrounds of patients, families, and colleagues. B. Utilization Management Completes Utilization Management and Quality Screening for assigned patients. Applies MCG criteria to monitor appropriateness of admissions and continued stays, and documents findings based on Departmental standards. While performing utilization review identifies areas for clinical documentation improvement and contacts appropriate department. Identifies at-risk populations using approved screening tool and follows established reporting procedures. Monitors LOS and ancillary resource use on an ongoing basis. Takes actions to achieve continuous improvement in both areas. Refers cases and issues to Medical Director and Triad Team in compliance with Department procedures and follows up as indicated. Communicates covered day reimbursement certification for assigned patients. Discusses payor criteria and issues and a case-by-case basis with clinical staff and follows up to resolve problems with payors as needed. Uses quality screens to identify potential issues and forwards information to the Quality Department. Demonstrates proper use of MCG and documentation requirements through case review and inter-rater reliability studies. Delay Management Facilitates removal of delays and documents delays when they exist. Reports internal and external delays to the Triad Team. Collaborates with the health care team and appropriate department in the management of care across the continuum of care by assuring communication with Triad Team and health care team. Maintains complete confidentiality of patient information, in addition to hospital and individual physician practice pattern data. Provides information and inservices as necessary to physicians and ancillary staff. Thank you for your interest in Albany Med Health System!​ Albany Med Health System is an equal opportunity employer. This role may require access to information considered sensitive to Albany Med Health System, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that: Access to information is based on a “need to know” and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Med Health System policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification.
RN Manager/Supervisor Utilization Review Full-time
The Christ Hospital Health Network

Manager Utilization Review- RN - Main Case Management - Full Time - Days

The Christ Hospital Health Network Cincinnati, OH
Job Description The Manager, Utilization Review-RN oversees hospital utilization review functions. This role is responsible for the planning, operations, and daily oversight of the department to facilitate the highest quality, cost-effective care and appropriate case status based on evidence-based criteria. This position oversees department alignment with payer policy and revenue cycle processes. The manager should support appropriate use of healthcare resources, regulatory compliance, and safe, efficient patient transitions across the continuum of care. Responsibilities Leadership & Team Management Supervise and support Utilization Review Nurses and administrative support staff. Develop and maintain job descriptions and policies and procedures to be compliant with accrediting and regulatory agencies. Provide coaching, performance evaluations, and staff development. Develop, maintain and oversee orientation plans for new staff, conducting new hire reviews according to Human Resource policies. Develop staffing plans, schedules, and productivity benchmarks to ensure clinical competency and patient coverage. Foster a collaborative, patient-centered team environment Create and implement action plans based upon employee satisfaction surveys and other feedback. Provide interdepartmental training and support on case management and utilization review requirements, tools, and processes. Participate in development, implementation and oversight of budget Represent department by presenting information in committees and workgroups. Utilization Review Oversight Ensure accurate application of evidence-based criteria such as InterQual and Milliman Care Guidelines. Ensure timely clinical reviews and follow-up for payer approvals. Collaborate with Physician Advisor (PA) to ensure criteria are applied appropriately for correct patient status. Monitor admission status, length of stay (LOS), and medical necessity. Oversee payer communications and processes, including authorizations, concurrent reviews, and denial management. Remain current on individual payer policies. Collaborate with Revenue Cycle partners to analyze trends and implement strategies to reduce denials. Regulatory Compliance & Quality Ensure compliance with Medicare Conditions of Participation and other federal/state requirements. Maintain readiness for audits (e.g., CMS, Joint Commission). Develop and enforce policies, procedures, and documentation standards. Lead quality improvement initiatives focused on denial reductions and appropriate case status Support processes to achieve optimal clinical and financial outcomes. Provide input and oversight of platforms/systems for effective documentation and data tracking. Care Coordination & Collaboration Collaborate with physicians, nursing leadership, finance, and ancillary departments to facilitate patient access to the most appropriate level of care across the continuum and to continuously improve quality of care. Participate in interdisciplinary rounds as needed and escalation processes. Serve as a liaison between department and external payers or agencies. Data Analysis & Reporting Collaborate with IT and data analytics partners to coordinate collection, analysis and reporting of outcomes data reflecting the effectiveness of the UR department. Track and report key performance indicators (KPIs), including: Denial rates and peer to peer outcomes Appropriate status and observation to inpatient conversions Discharge delays Use data to drive operational improvements and strategic planning. Performs other duties as assigned to support the work of the department and health system. Qualifications EDUCATION: Graduate of accredited school of nursing or other healthcare professional field. Master’s degree in a health-related field, health care management or business management strongly preferred with a minimum of 3 years case management/utilization review experience or a Bachelor of Science in Nursing (BSN) with a minimum of 5 years case management/utilization review experience required. YEARS OF EXPERIENCE: 3+ years of leadership or supervisory experience preferred, Lean/Six Sigma or process improvement experience preferred. REQUIRED SKILLS AND KNOWLEDGE: Strong knowledge of payer systems, Medicare/Medicaid, and regulatory requirements. Participation in professional organizations and ongoing professional development relating to utilization review. Experience with EHR systems and utilization review software. Leadership and team development Clinical and regulatory expertise Financial and utilization management Critical thinking and problem-solving Communication (oral and written) and conflict resolution Data analysis and performance improvement Technology/systems proficiency Time management and multi-tasking. LICENSES REGISTRATIONS &/or CERTIFICATIONS: Active OH RN License required; Certified Case Manager (CCM)/Accredited Case Manager (ACM) preferred
RN Utilization Review Full-time
UT Southwestern Medical Center

PRN Utilization Review RN - M-F Days

UT Southwestern Medical Center Dallas, TX
Must be available to work daytime hours (between 8am-6:30pm) Monday - Friday WHY UT SOUTHWESTERN? With over 75 years of excellence in Dallas-Fort Worth, Texas, UT Southwestern is committed to excellence, innovation, teamwork, and compassion. As a world-renowned medical and research center, we strive to provide the best possible care, resources, and benefits for our valued employees. Ranked as the number 1 hospital in Dallas-Fort Worth according to U.S. News & World Report, we invest in you with opportunities for career growth and development to align with your future goals. Our highly competitive benefits package offers healthcare, PTO and paid holidays, on-site childcare, wage, merit increases and so much more. We invite you to be a part of the UT Southwestern team where you'll discover a culture of teamwork, professionalism, and a rewarding career! Job Summary Conduct medical certification review for medical necessity for acute care facility and services. Use nationally recognized, evidence-based guidelines approved by medical staff to recommend level of care to the physician and serve as a resource to the medical staff on issues related to admission qualifications, resource utilization, national and local coverage determinations and documentation requirements. Benefits UT Southwestern is proud to offer a competitive and comprehensive benefits package to eligible employees. Our benefits are designed to support your overall wellbeing, and include: PPO medical plan, available day one at no cost for full-time employee-only coverage 100% coverage for preventive healthcare-no copay Paid Time Off, available day one Retirement Programs through the Teacher Retirement System of Texas (TRS) Paid Parental Leave Benefit Wellness programs Tuition Reimbursement Public Service Loan Forgiveness (PSLF) Qualified Employer Learn more about these and other UTSW employee benefits! Required EXPERIENCE AND EDUCATION Education Graduate of accredited nursing program and holds an active unrestricted RN license in the State of Texas Experience 5 years experience to include 2 years of clinical experience and minimum of 3 years of recent utilization review experience. and Prior experience with Epic CCM. Licenses and Certifications (RN) REGISTERED NURSE Holds an active unrestricted license in the State of Texas. and Preferred Experience Job Duties Acute care experience preferred Collaborates with the Central Scheduling Department (CSD) team to provide accurate and complete clinical information in order to obtain authorization. Conducts admission reviews for Medicare and Medicaid beneficiaries as well as private insurance members and self-pay patients utilizing evidence-based guidelines. New admission reviews are done concurrently at the point of entry when the admission order is placed and necessary clinical information is available in the medical record. Communicate with admitting physicians and physician advisors when documentation does not appear to support hospital level of care. Use hospital approved medical necessity tool to determine level of care for inpatient or observation/outpatient services based on physician documentation, H&P, treatment plan, potential risks, and basis for expectation of a two-midnight stay. Keeps current on all Federal, State and local regulatory changes that affect delivery or reimbursement of acute care services within the scope of Utilization Management. Uses knowledge of national and local coverage determinations to appropriately advise physicians. Proactively collaborates with admitting physician to provide accurate level of care determination at the time of review. Escalates identified progression-of-care/patient flow barriers to appropriate departments. Actively participates in daily huddles, departmental meetingsand education offerings. Identifies and records episodes of preventable delays or avoidable days due to failure of progression-of-care processes. Educates members of the patient's care team on the appropriate access to and use of various levels of care. Promotes use of evidence-based protocols and/or order sets to influence high-quality and cost-effective care. Serves as a resource person to physicians, care coordinators, physician offices and billing office for coverage and compliance issues. Completes all reviews within department established policies and best practice standards. Meets department quality standards as established for the department, ie: Inter-rater Reliability audits, completing all initial reviews within established time frames, completes concurrent and discharge reviews to meet department and industry standards. Performs other duties as assigned. SECURITY AND EEO STATEMENT Security This position is security-sensitive and subject to Texas Education Code 51.215, which authorizes UT Southwestern to obtain criminal history record information. EEO UT Southwestern Medical Center is committed to an educational and working environment that provides equal opportunity to all members of the University community. As an equal opportunity employer, UT Southwestern prohibits unlawful discrimination, including discrimination on the basis of race, color, religion, national origin, sex, sexual orientation, gender identity, gender expression, age, disability, genetic information, citizenship status, or veteran status. Primary Location Texas-Dallas-5323 Harry Hines Blvd Work Locations 5323 Harry Hines Blvd Job Nursing Organization 844107 - Utilization Management Schedule Per Diem - PRN Shift Day Job Employee Status Regular Job Type Standard Job Posting Jan 21, 2026, 12:49:13 AM
RN Utilization Review Home Health Full-time
UnitedHealthcare

Secondary Review Nurse - Indiana

UnitedHealthcare Indianapolis, IN
$28.94 - $51.83 / hour
At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us to start Caring. Connecting. Growing together. The Secondary Review Nurse plays a critical role in evaluating clinical requests for Home and Community-Based Services (HCBS). This position ensures that care provided is medically necessary, cost-effective, and tailored to the individual needs of each member, while remaining compliant with state regulations. If you reside within the state of Indiana , you will enjoy the flexibility to work remotely * as you take on some tough challenges. Primary Responsibilities Participate in secondary reviews for HCBS services and Medicaid services Review and process prior authorization requests for LTSS and HCBS services Apply clinical judgment and decision support tools to determine medical necessity and appropriateness of services Collaborate with care managers, physicians, and other stakeholders to ensure continuity of care and alignment with the members' service plan Monitor utilization patterns and identify opportunities for improved care coordination and cost containment Document all clinical decisions and communications in accordance with regulatory and organizational standards Support quality improvement initiatives and participate in developing education and training for staff Identify potential quality of care concerns, including instances of over/or underutilization of services and escalate these issues as needed Stay current with established guidelines and regulatory requirements You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear directions on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications Current, unrestricted RN license for Indiana 3+ years of clinical experience in a hospital, acute care, home health / hospice, direct care or case management and the ability to quickly identify needs and issues 2+ years of experience with completing functional assessments for LTSS services 2+ years of Medicaid, Medicare, or Managed Care experience and with Long-Term Services and Supports Intermediate level of knowledge of LTSS experience determining eligibility and appropriate allocation of services Intermediate level of computer/typing proficiency to enter/retrieve data in electronic clinical records; experience with email, internet research, use of online calendars and other software applications Preferred Qualifications Pre-authorization experience Utilization Management experience Case Management experience Knowledge of state and federal guidelines Home health or hospice Proven problem-solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action All Telecommuters will be required to adhere to UnitedHealth Group's Telecommuter Policy. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $28.94 to $51.83 per hour based on full-time employment. We comply with all minimum wage laws as applicable. At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location, and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups, and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission. UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations. UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. #RPO #GREEN
RN Utilization Review Home Health Full-time
UnitedHealthcare

Secondary Review Nurse - Indiana

UnitedHealthcare Indianapolis, IN
$28.94 - $51.83 / hour
At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us to start Caring. Connecting. Growing together. The Secondary Review Nurse plays a critical role in evaluating clinical requests for Home and Community-Based Services (HCBS). This position ensures that care provided is medically necessary, cost-effective, and tailored to the individual needs of each member, while remaining compliant with state regulations. If you reside within the state of Indiana , you will enjoy the flexibility to work remotely * as you take on some tough challenges. Primary Responsibilities Participate in secondary reviews for HCBS services and Medicaid services Review and process prior authorization requests for LTSS and HCBS services Apply clinical judgment and decision support tools to determine medical necessity and appropriateness of services Collaborate with care managers, physicians, and other stakeholders to ensure continuity of care and alignment with the members' service plan Monitor utilization patterns and identify opportunities for improved care coordination and cost containment Document all clinical decisions and communications in accordance with regulatory and organizational standards Support quality improvement initiatives and participate in developing education and training for staff Identify potential quality of care concerns, including instances of over/or underutilization of services and escalate these issues as needed Stay current with established guidelines and regulatory requirements You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear directions on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications Current, unrestricted RN license in the state of Indiana 3+ years of clinical experience in a hospital, acute care, home health / hospice, direct care or case management, able to quickly identify needs and issues 2+ years of experience with completing functional assessments for LTSS services 2+ years of experience with Medicaid, Medicare, or Managed Care and Long Term Services and Supports Intermediate level of knowledge of LTSS experience determining eligibility and appropriate allocation of services Intermediate level of computer/typing proficiency to enter/retrieve data in electronic clinical records; experience with email, internet research, use of online calendars and other software applications Preferred Qualifications Pre-authorization experience Utilization Management experience Case Management experience Knowledge of state and federal guidelines Home health or hospice Proven problem-solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action All Telecommuters will be required to adhere to UnitedHealth Group's Telecommuter Policy. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $28.94 to $51.83 per hour based on full-time employment. We comply with all minimum wage laws as applicable. At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location, and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups, and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission. UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations. UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment. #RPO #GREEN
RN Manager/Supervisor Utilization Review Full-time
State of Ohio

Clinical Review Nurse Supervisor (Medicaid Health Systems Administrator 1)

State of Ohio Uptown District, OH
$39.22 / hour
What You Will Do At ODM Office: Legal Counsel Bureau: Program Integrity Classification: Medicaid Health Systems Administrator 1 RN (PN: 20092018) Job Overview The Ohio Department of Medicaid (ODM) is seeking a Registered Nurse (RN) to be a part of our Surveillance/Utilization Review Section (SURS). SURS is charged with helping the agency review utilization of Medicaid services, detect fraud, waste and abuse and recover inappropriate payments to providers. As a Clinical Review Nurse Supervisor your responsibilities will include: Helping to manage an over $ 7million/ year hospital utilization contract Reviewing necessary medical record reviews and making a determination on hospital appeals. Supervising and training RNs, Auditors, and Analysts in identifying fraud, waste, and abuse in the Medicaid program. Participating/leading meetings with external stakeholders including law enforcement Developing and implementing changes to processes and procedures as needed in a team environment Evaluating provider clinical compliance with state and federal Program Integrity rules Evaluating provider medical documentation and billing practices for fraud, waste and abuse Recovering overpayments for medically unnecessary services via administrative procedures and/or referrals to health oversight agencies Responding to provider clinical reconsideration (appeal) requests Consulting on clinical matters with ODM policy units and other state agencies Coordinating clinical Program Integrity efforts with ODM contractors and managed care plans Presenting findings from clinical reviews of provider non-compliance Responding to inquiries from the public, consumers, providers, and other agencies Completion of graduate core program in business, management or public administration, public health, health administration, social or behavioral science or public finance; 12 mos. exp. in the delivery of a health services program or health services project management (e.g., health care data analysis, health services contract management, health care market & financial expertise; health services program communication; health services budget development, HMO & hospital rate development, health services eligibility, health services data base analysis); Current & valid license as registered nurse as issued by Ohio Board of Nursing, pursuant to Sections 4723.03-4723.09 of Ohio Revised Code; Or 12 months experience as Medicaid Health Systems Specialist, 65293, may be substituted for the experience required, but not for the mandated licensure. Note: education & experience is to be commensurate with approved position description on file. Or equivalent of Minimum Class Qualifications for Employment noted above may be substituted for the experience required, but not for the mandated licensure. Technical Skills: Nursing Professional Skills: Collaboration, Confidentiality, Continuous Improvement, Innovation, Verbal Communication, Written Communication Agency Contact Name and Information HumanResources@medicaid.ohio.gov Unposting Date May 31, 2026, 10:59:00 PM Work Location Lazarus 5 Primary Location United States of America-OHIO-Franklin County-Columbus Compensation $39.22/hour Schedule Full-time Work Hours 8:00 am - 5:00 pm Classified Indicator Classified Union Exempt from Union Professional Skills Collaboration, Innovation, Verbal Communication, Written Communication, Confidentiality, Continuous Improvement Agency Overview About Us: Investing in opportunities for Ohioans that work for every person and every family in every corner of our state is at the hallmark of Governor DeWine’s agenda for Ohio’s future. To ensure Ohio is “the best place to live, work, raise and family and start a business,” we must have strong schools, a great quality of life, and compassion for those who need our help. Responsibilities Ohio Department of Medicaid plays a unique and necessary role in supporting the governor’s vision. As the single state Medicaid agency responsible for administering high-quality, person-centric healthcare, the department is committed to supporting the health and wellbeing of nearly one in every four Ohioans served. We do so by: Delivering a personalized care experience to more than three million people served. Improving care for children and adults with complex behavioral health needs. Working collectively with our partners and providers to measurably strengthen wellness and health outcomes. Streamlining administrative burdens so doctors and healthcare providers have more time for patient care. Ensuring financial transparency and operational accountability across all Medicaid programs and services.
RN Utilization Review Per Diem
Yale New Haven Health

RN-Utilization Coordinator-Geriatric Psychiatry-Per Diem

Yale New Haven Health Bridgeport, CT
Overview To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day. At Bridgeport Hospital, we are committed to providing quality medical care and treatment that is coordinated and centered on the patient's specific needs. We strive to achieve benchmarks as a Patient Centered Medical Home and provide health care in a setting where patients are at the center of their care team. All employees of Bridgeport Hospital are part of the patients care team and contribute to the team approach of promoting access, continuous, comprehensive care and work to provide quality improvement in the care provided to their patients. SUMMARY In collaboration with physician(s), actively participates in the quality review process and assures continual improvement of nursing practice and quality patient care. Essential duties and responsibilities include the following . Other duties may be assigned. EEO/AA/Disability/Veteran. RESPONSIBILITIES Provides indirect care to select patients and families. Demonstrates knowledge of developmental stages and applies development theories/concepts when planning and implementing care for the adult patient as observed by supervisor and as indicated by feedback from staff. In conjunction with Care Coordinator monitors patient records to assess the effective utilization of hospital resources. Conducts admission reviews utilizing hospital approved criteria within 24 hours of admission to determine length of stay and compliance with third party payer regulations as evidenced by lack of denials. Acts as an advisor to physicians concerning documentation requirements of third party payers and contractual obligations. Reviews patients records to identify areas of under or over utilization or delays in the scheduling of hospital services. Monitors lab tests, consultations, and diagnostic tests daily to prevent duplication of services and insure completion in a timely manner as observed by supervisor and feedback from staff . Facilitates patients progress through hospital system by monitoring effective utilization of hospital services as evidenced by random review of lengths of stay. Provides appropriate information to third party payers in accordance with departmental policy and procedures as evidenced by third party coverage of hospital staff . Obtains authorization from insurance companies for Extended Care Facilities and relays information to Care Coordinator and/or Social Worker. Participates in data collection aspects of quality review. Assists staff in the collection of quality review data. JOB DESCRIPTION RESPONSIBILITIES Provides input into the design and the implementation of monitoring and evaluation strategies and tools as indicated by feedback from the Quality Management Department. Works closely with assigned Care Coordinator, Clinical Reimbursement Coordinator, and Medical Director of Care Coordination, and alerts them of all EHR issues, including observation, denials, Code 44's, etc. Utilizes relevant research findings to support and advance nursing practice and improve patient outcomes. Integrates relevant research findings into practice as evidenced by observation and feedback. Develops nursing guidelines, policies, and procedures based on pertinent research findings as evidenced by documentation. Assists health care team members in the development of research proposals as evidenced by feedback. Assists staff in the collection of research data as appropriate as evidenced by feedback from staff. Reviews pertinent research findings with health care team members as evidenced by observation and feedback from staff. Collaborates with Care Coordinator, Clinical Reimbursement Coordinator, and Medical Director of Care Coordination, in evaluating new procedures and nursing care practices with staff as evidenced by feedback. Professional Development Attends educational seminars to maintain and meet expectations set forth by hospital and departmental standards. Attends and participates in in-service meetings and other designated training events that will enhance skills on a regular basis as documented by attendance at training seminars. Maintains knowledge of trends and developments in the field of discharge planning and utilization. EDUCATION (number of years and type required to perform the position duties): BSN degree as of January 2020 EXPERIENCE (number of years and type required to meet an acceptable level of performance): 3-5 years clinical experience in the area of specialty. SPECIAL SKILLS: Strong interpersonal and leadership skills. ACCOUNTABILITY (how this position is held accountable for such as goals achievement, budget adherence, or other areas of accountability): Effective 01/01/2016, an essential function of this position is the requirement to work mandatory rotating Holidays and Weekends in addition to working regularly scheduled hours . COMPLEXITY (describe planning, problem solving, decision making, creative activity, or other special factors inherent in the responsibilities of this position): In personal and job-related decisions and actions, consistently demonstrates the values of integrity (doing the right thing), patient-centered (putting patients and families first), respect (valuing all people and embracing all differences), accountability (being responsible and taking action), and compassion (being empathetic). LICENSURE/CERTIFICATION: Current RN licensure in the State of Connecticut. EEO/AA/Disability/Veteran Additional Information 16 hours per week RN with psychiatric experience required. experience with reimbursement and insurance authorizations preferred YNHHS Requisition ID 162254
RN Utilization Review Full-time
Cottage Health

Utilization Management Case Manager

Cottage Health Santa Barbara, CA
$60 - $92 / hour
Job Description Santa Barbara Cottage Hospital seeks a Utilization Management Case Manager for their Care Management department responsible for the utilization management, quality assurance, and discharge planning activities for assigned services/areas/patients within Cottage Health. Case management activities will result in quality outcomes, optimal care/cost management of services and/or procedures, a high level of customer satisfaction and contribution to an overall value-oriented experience of stakeholders and persons served. QUALIFICATIONS: All job qualifications listed indicate the minimum level necessary to perform this job proficiently. Education: Minimum: Associate's Degree in Nursing (ADN). Preferred: Bachelor's Degree in Nursing (BSN). Certifications, Licenses, Registrations: Minimum: Current California Nursing license in good standing. Preferred: Certification in Case Management. Years of Related Work Experience: Minimum: 2 years direct patient care experience in an acute care setting. Other patient care experience may be considered. Preferred: Previous experience as a case manager in an acute care setting. About Us Cottage Health is a leading acute care hospital system, located on the central coast of California, widely known for our superior patient care, innovation, medical research and education. Our health system operates primarily in Santa Barbara, CA, since 1888, and consists of three acute care hospitals, a Rehabilitation Hospital, multiple clinics and a multi-site Urgent Care system. Our mission is to serve the central coast communities with excellence, integrity, and compassion. Every day we touch thousands of lives in many different ways, resolute in our mission to put patients first. We take pride in helping our patients get back to living their lives - in the places they love. Cottage Health is an Equal Opportunity Employer. Cottage Health applicants are considered solely based on their qualifications, without regard to race, color, ethnicity, religion, age, gender, transgender, gender expression and identity, national origin, ancestry, disability, sexual orientation, marital status, military status or any other classification protected by law. This policy applies to all aspects of the relationship between Cottage Health and an applicant or employee. Cottage Health is committed to upholding discrimination-free hiring practices. We strive to cultivate an environment where exceptional people bring diverse perspectives and find belonging, support and connection to their work. Any Cottage Health applicants who require assistance or reasonable accommodations during the application process may request the need for accommodation with the Recruiter. Pay for non-physician positions is determined based on related years of experience and internal equity. Eligible employees may also receive additional forms of compensation, including shift differentials, on-call pay, incentive pay, and bonus opportunities, where applicable. Manager and above positions may participate in Cottage Health’s annual management incentive program. Physician compensation is determined based upon specialty and may include bonus potential. For more information on our comprehensive Total Rewards offerings, please visit https://cottagehealth.org/careers/total-rewards . If you're already a Cottage Health employee, please apply on this link only.
RN Manager/Supervisor Utilization Review Telehealth Full-time
Molina Healthcare

Supervisor, Healthcare Services (RN- CA License)

Molina Healthcare Long Beach, CA
$76,425 - $149,028 / year
JOB DESCRIPTION Job Summary Leads and supervises multidisciplinary team of healthcare services professionals in some or all of the following functions: care management, utilization management, behavioral health, care transitions, long-term services and supports (LTSS), and/or other special programs. Ensures members reach desired outcomes through integrated delivery and coordination of care across the continuum, and contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Assists in implementing health management, care management, utilization management, behavioral health and other program activities in accordance with regulatory, contract standards and accreditation compliance. • Functions as a “hands-on” supervisor, assisting with assessing and evaluation of systems, day-to-day operations and efficiency of operations/services. • Assists in the coordination of orienting and training staff to ensure maximum efficiency and productivity, program implementation, and service excellence. • Trains and supports team members to ensure high-risk, complex members are adequately supported. • Assists with staff performance appraisals, ongoing monitoring of performance, and application of protocols and guidelines. • Collaborates with and keeps healthcare services leadership apprised of operational issues, staffing, resources, system and program needs. • Assists with coordination and reporting of department statistics and ongoing client reports, as assigned. • Local travel may be required (based upon state/contractual requirements). Required Qualifications • At least 5 years health care experience, and at least 2 years of managed care experienced in one or more of the following areas: utilization management, care management, care transitions, behavioral health, long-term services and supports (LTSS), or equivalent combination of relevant education and experience. r equivalent combination of relevant education and experience. • Registered Nurse (RN), Licensed Vocational Nurse (LVN), Licensed Practical Nurse (LPN), Licensed Clinical Social Worker (LCSW), Licensed Marriage and Family Therapist (LMFT), Licensed Professional Clinical Counselor (LPCC), or Licensed Master of Social Work (LMSW). Clinical licensure and/or certification required ONLY if required by state contract, regulation, business operating model, or state board licensing mandates. If licensed, license must be active and unrestricted in state of practice. • Ability to manage conflict and lead through change. • Operational and process improvement experience. • Strong written and verbal communication skills. • Working knowledge of Microsoft Office suite. • Ability to prioritize and manage multiple deadlines. • Excellent organizational, problem-solving and critical-thinking skills. Preferred Qualifications • CA Registered Nurse (RN). License must be active and unrestricted in state of practice. • Certified Case Manager (CCM), Certified Professional in Health Care Management certification (CPHM), Certified Professional in Health Care Quality (CPHQ) or other health care or management certification. • Medicaid/Medicare population experience. • Clinical experience. • Supervisory/leadership experience. MCG experience. 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: $76,425 - $149,028 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
RN Manager/Supervisor Utilization Review Telehealth Full-time
Molina Healthcare

(RN)Healthcare Services Supervisor- Inpatient UM/UR (CA License Required)- REMOTE

Molina Healthcare Long Beach, CA
$76,425 - $149,028 / year
JOB DESCRIPTION Job Summary Leads and supervises multidisciplinary team of healthcare services professionals in some or all of the following functions: care management, utilization management, behavioral health, care transitions, long-term services and supports (LTSS), and/or other special programs. Ensures members reach desired outcomes through integrated delivery and coordination of care across the continuum, and contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Assists in implementing health management, care management, utilization management, behavioral health and other program activities in accordance with regulatory, contract standards and accreditation compliance. • Functions as a “hands-on” supervisor, assisting with assessing and evaluation of systems, day-to-day operations and efficiency of operations/services. • Assists in the coordination of orienting and training staff to ensure maximum efficiency and productivity, program implementation, and service excellence. • Trains and supports team members to ensure high-risk, complex members are adequately supported. • Assists with staff performance appraisals, ongoing monitoring of performance, and application of protocols and guidelines. • Collaborates with and keeps healthcare services leadership apprised of operational issues, staffing, resources, system and program needs. • Assists with coordination and reporting of department statistics and ongoing client reports, as assigned. • Local travel may be required (based upon state/contractual requirements). Required Qualifications • At least 5 years health care experience, and at least 2 years of managed care experienced in one or more of the following areas: utilization management, care management, care transitions, behavioral health, long-term services and supports (LTSS), or equivalent combination of relevant education and experience. r equivalent combination of relevant education and experience. • Registered Nurse (RN), Licensed Vocational Nurse (LVN), Licensed Practical Nurse (LPN), Licensed Clinical Social Worker (LCSW), Licensed Marriage and Family Therapist (LMFT), Licensed Professional Clinical Counselor (LPCC), or Licensed Master of Social Work (LMSW). Clinical licensure and/or certification required ONLY if required by state contract, regulation, business operating model, or state board licensing mandates. If licensed, license must be active and unrestricted in state of practice. • Ability to manage conflict and lead through change. • Operational and process improvement experience. • Strong written and verbal communication skills. • Working knowledge of Microsoft Office suite. • Ability to prioritize and manage multiple deadlines. • Excellent organizational, problem-solving and critical-thinking skills. Preferred Qualifications • CA Registered Nurse (RN). License must be active and unrestricted in state of practice. • Certified Case Manager (CCM), Certified Professional in Health Care Management certification (CPHM), Certified Professional in Health Care Quality (CPHQ) or other health care or management certification. • Medicaid/Medicare population experience. • Clinical experience. • Supervisory/leadership experience. MCG experience. 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: $76,425 - $149,028 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
RN Utilization Review Full-time
St. Joseph's Health

Utilization Management Registered Nurse

St. Joseph's Health Paterson, NJ
The Utilization Management Registered Nurse (UM RN) is responsible for evaluating the medical necessity, appropriateness, and efficiency 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 medical necessity, both for admission to the hospital as well as continued stay. This function ensures 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 minimizes risks of denials.
RN Utilization Review Full-time
Meadville Medical Center

REGISTERED NURSE-Utilization Management- Full Time- On Site

Meadville Medical Center Meadville, PA
$5,000 SIGN ON BONUS (for external candidates only) Utilization management (UM ) is the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of the applicable health benefits plan. Prior authorization that allow payers, particularly health insurance companies to manage the cost of health care benefits by assessing its appropriateness before it is provided using evidence-based criteria or guidelines. Strong utilization management process can reduce payment denials. Clinical documentation specialists is designed to improve the physician’s documentation in the patient’s medical record, supporting the appropriate severity of illness, expected risk of mortality and complexity of care of the patient. Clinical documentation is responsible for extensive collaboration with physician is, nursing staff, support staff, other patient caregiver and medical records coding staff. Employee insurance liaison Meadville Medical Center has self-funded insurance. One staff member is assigned to work with Human resources, Highmark Liaison, Medical director and employees. Set process is to call medical procedures out of network and employee needs to request a waiver from our current liaison. The liaison will review the requested procedure with our current medical director. If the request is approved the liaison of UM will notify the employee and out Highmark Liaison. Medical necessity rules will be reviewed, urgency and medical history. The decision will be called to the employee. If it is not favorable, this can be appealed to human resources If this process is not followed, and the employee gets a bill. The liaison will review what was performed. They will review with the medical director and make a decision to override the out of network rules. The liaison support HR represented as needed. Applicate: Curious and Detailed Oriented. Actively seek out new ideas, possibilities, and answers to the tough questions. Pays meticulous attention to detail. Committed to life-long learning UM Process Payors may use different criteria and may require their data set be applied for their population. Utilization management is a strategy for managing cost and quality under the latest CMS reimbursement Reviews precertification requests for medical necessity, referring to the Medical Director those that require additional expertise. Reviews Clinical information for concurrent reviews, extending the length of stay for inpatients as appropriate. Establishes effective rapport with other employees, professional support service staff, customers, clients, patient’s families and physicians. Use effective relationship management, coordination of services, resource management, education, patient advocacy and related interventions. CDS-Inpatients Advanced clinical expertise and extensive knowledge of complex disease processes with a broad clinical experience in an inpatient setting required Pursues a subsequent review of records every 3 days to support and assign a working DRG assignment upon discharge. Formulates queries when it is determined there is missing documentation, conflicting documentation or unclear documentation. Provides on-going education to physicians and essential healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the patient's record. Use of coding nomenclature demonstrated knowledge of ICD-10 classifications, and thorough understanding of the effect coded data has prospective payment, outcome models, utilization, and reimbursement. Participates in the analysis and trending of statistical data for specified patient population; identifies opportunity for improvement. Promotes a partnership with the inpatient-coding professionals to ensure the accuracy of principal diagnosis, procedures and completeness of supporting documentation to determine the working and final DRG, severity of illness and risk of mortality. Acts as a resource person for the interdisciplinary team in order to promote collaboration and coordination of patient care considering age specific, developmental, cultural, and spiritual needs of the patient. Overall department goals Promotes improved quality of care and/or life. Promotes cost effective medical outcomes. Prevents hospitalization when possible and appropriate. Promotes decreased lengths of observation stays or inpatient stays when appropriate. Provides for continuity of care. Assures appropriate levels of care are received by our patients. Participates in rounding on the nursing floors. Works with HIM on coding issues. Provides advice and counsel to precertification staff in physician offices or in house. Identifies appropriate alternative resources and demonstrate creativity in managing each case to fully utilize all available resources. Maintains accurate records of all communications and interventions. Other duties as assigned. MINIMUM EDUCATION, KNOWLEDGE, SKILLS, AND ABILITIES REQUIRED Proof of successful completion of education requirements for board certified registered nurse as defined by the state in which the employee is to practice as well as proof of such licensure in good standing. 5 years’ experience as a Registered Nurse is preferred. Ability to read analyze and interpret documents, reports, technical procedures, governmental regulations and correspondence BLS required. Certification for UM nurse and CDI specialists is encouraged.
RN Manager/Supervisor Utilization Review Telehealth Full-time
Samaritan Health Services

Utilization Management Program Manager-RN

Samaritan Health Services Corvallis, OR
Summary Samaritan Health Plans (SHP) provides health insurance options to Samaritan employees, community employers, and Medicare and Medicaid members. SHP operates a portfolio of health plan products under several different legal structures: InterCommunityHealth Plans, Inc. (IHN) is designated as a regional Coordinated Care Organization (CCO) for Medicaid beneficiaries; Samaritan Health Plans, Inc. offers Medicare Advantage, Commercial Large Group, and Commercial Large Group PPO and EPO plans. As part of an Integrated Delivery System, Samaritan Health Plans is strategically and operationally aligned with Samaritan Health Services’ mission of Building Healthier Communities Together. This is a remote position in which we are able to employ in the following states: Arizona, Arkansas, Connecticut, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Mexico, North Carolina, Oklahoma, Oregon, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, or Wisconsin Our Ideal Candidate Will Have The Following Experience Health plan utilization management Medicare and Medicaid rules and regulations and health plan benefit structure and policy. Data analysis to include reporting results and developing improvement plans Quality Management experience in a healthcare setting Occasionally JOB SUMMARY/PURPOSE Executes program(s) that meet the needs of the organization, employees and/or customers. Plans, initiates, oversees execution of all elements for assigned program(s). Leads the development, implementation and management of assigned program(s) and associated projects. Oversees process from planning to completion. Works with multiple internal teams, vendors, clients. Responsible for explaining, training, and mentoring the entire organization on the program. Collaborates with SHS system experts to ensure focus, alignment, and best practices for the program. EXPERIENCE/EDUCATION/QUALIFICATIONS Current unencumbered Oregon RN License required within 90 days of hire. BSN preferred. Master's degree in a related field preferred. One (1) year clinical nursing experience plus four (4) years health plan utilization management experience required. Experience or training in the following required: Health care delivery systems and/or managed care patients. Computer applications including electronic documentation (e.g., MS Office, EPIC, Clinical Care Advanced). Experience in the following preferred: Team leadership. Case management. Medicare and Medicaid rules and regulations and health plan benefit structure and policy. KNOWLEDGE/SKILLS/ABILITIES Leadership - Inspires, motivates, and guides others toward accomplishing goals. Achieves desired results through effective people management. Conflict resolution - Influences others to build consensus and gain cooperation. Proactively resolves conflicts in a positive and constructive manner. Critical thinking - Identifies complex problems. Involves key parties, gathers pertinent data and considers various options in decision making process. Develops, evaluates and implements effective solutions. Communication and team building - Lead effectively with excellent verbal and written communication. Delegates and initiates/manage cross-functional teams and multi-disciplinary projects. PHYSICAL DEMANDS Rarely (1 - 10% of the time) (11 - 33% of the time) Frequently (34 - 66% of the time) Continually (67 - 100% of the time) CLIMB - STAIRS LIFT (Floor to Waist: 0"-36") 0 - 20 Lbs LIFT (Knee to chest: 24"-54") 0 - 20 Lbs LIFT (Waist to Eye: up to 54") 0 - 20 Lbs CARRY 1-handed, 0 - 20 pounds BEND FORWARD at waist KNEEL (on knees) STAND WALK - LEVEL SURFACE ROTATE TRUNK Standing REACH - Upward PUSH (0 - 20 pounds force) PULL (0 - 20 pounds force) SIT CARRY 2-handed, 0 - 20 pounds ROTATE TRUNK Sitting REACH - Forward MANUAL DEXTERITY Hands/wrists FINGER DEXTERITY PINCH Fingers GRASP Hand/Fist
RN Utilization Review Full-time
Emanate Health

Quality Review Nurse - DOU & NSU - Full Time - Days - 10hr QVH

Emanate Health Walnut Valley, CA
$54.63 - $84.67 / hour
Current Emanate Health Employees - Please log into your Workday account to apply Everyone at Emanate Health plays a vital role in the care we deliver. No matter what department you belong to, the work you do at Emanate Health affects lives. When you join Emanate Health, you become part of a team that works together to strengthen our communities and grow as individuals. On Glassdoor's list of "Best Places to Work" in 2021, Emanate Health was named the #1 ranked health care system in the United States, and the #19 ranked company in the country. J ob S u mma r y Provides expertise to the organization in the form of quality management review and performance improvement knowledge. Supports the hospital units and staff in preparation for surveys, clinical documentation review, regulatory needs and rounding on patients with discharge calls. Assists in the review process and peer education/correction. J ob Re q u i reme nts M ini m um E du ca ti o n Re qui reme nt : BSN preferred. M i n i m um E x p er i e n c e Re qui reme nt : Minimum of three years of acute care experience. Excellent customer service skills required. Experience in Telemetry, DOU, or Neuroscience preferred M ini m um Li ce n s e Re qui reme nt : California RN license and BLS required. ACLS required within 90 days of hire or transfer. NIHSS Stroke Certification required within 90 days of hire or transfer. Delivering world-class health care one patient at a time. Pay Range: $54.63 - $84.67
RN Utilization Review Full-time
Capital Health

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

Capital Health Hopewell, VA
$39.40 - $51.47 / hour
Capital Health is the region's leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advanced technology. Capital Health is a dynamic health care resource accredited by the DNV that includes two hospitals, an outpatient center, satellite ED, and an expansive network of primary and specialty care. Capital Health Medical Group is made up of more than 600 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region. Capital Health recognizes that attracting the best talent is key to our strategy and success as an organization. As a result, we aim for flexibility in structuring competitive compensation offers to ensure we can attract the best candidates. The listed pay range or pay rate reflects compensation for a full-time equivalent (1.0 FTE) position. Actual compensation may differ depending on assigned hours and position status (e.g., part-time). Pay Range: $39.40 - $51.47 Scheduled Weekly Hours: 40 Position Overview Performs chart review of identified patients to identify quality, timeliness and appropriateness of patient care. Conducts admission reviews for Medicare, Medicaid beneficiaries, as well as private insurers and self pay patients, based on appropriate guidelines. Uses these criteria guidelines to screen for appropriateness for inpatient level of care or observation services based on physician certification (physicians H&P, treatment plan, potential risks and basis for expectation of a 2 midnight stay). Refers cases as appropriate, to the UR physician advisor for review and determination. Gathers clinical information to conduct continued stay utilization review activities with payers on a daily basis. Performs concurrent and retrospective clinical reviews with various payers, utilizing the appropriate guidelines as demonstrated by compliance with all applicable regulations, policies and timelines. Adheres to CMS guidelines for utilization reviews as evidenced by utilization of the relevant guidelines and appropriate referrals to the physician advisor and the UR Committee. Identifies, develops and implements strategies to reduce length of stay and resource consumption. . Confers proactively with admitting physician to provide coaching on accurate level of care determinations at point of hospital entry. Keeps current on all regulatory changes that affect delivery or reimbursement of acute care services. Uses knowledge of national and local coverage determinations to appropriately advise physicians. Understands and applies federal law regarding the use of Hospital Initiated Notice of Non-Coverage (HINN) and Lifetime Reserve Days letters. Identifies and records consistently any information on any progression of care or patient flow barriers using the Avoidable Days tool in the Utilization software program. Consults with medical staff, care team and case managers as necessary to resolve immediate progression of care barriers through appropriate administrative and medical channels. Engages care team colleagues in collaborative problem solving regarding appropriate utilization of resources. Recognizes and responds appropriately to patient safety and risk factors. Represents Utilization Management at various committees, professional organizations an physician groups as needed. Promotes the use of evidence based protocols and or order sets to influence high quality and cost effective care. Identifies, develops and implements strategies to reduce lengths of stay and resource consumption in the patient population. Participates in performance improvement activities. Promotes medical documentation that accurately reflects findings and interventions, presence of complication or comorbidities, and patient's need for continued stay. Identifies and records episodes of preventable delays or avoidable days due to failure of progression of care processes. Maintains appropriate documentation in the Utilization software system on each patient to include specific information of all resource utilization activities. Participates actively in daily huddles, patient care conferences, and hospitalist or nurse handoff reports to maintain knowledge about intensity of services and the progression of care. Identifies potentially wasteful or misused resources and recommends alternatives if appropriate by analyzing clinical protocols. Maintains related continuing education credits = 15 per calendar year. MINIMUM REQUIREMENTS Education: Minimum of Associate's degree in Nursing. Graduate of an accredited school of nursing. CPHQ, CCM or CPUR preferred. Experience: Three years of clinical nursing or two years quality management, utilization review or discharge planning experience. Other Credentials: Registered Nurse - NJ Knowledge and Skills: Three years of clinical nursing or two years quality management, utilization review or discharge planning experience. CPHQ, CCM or CPUR preferred. Special Training: Basic computer skills including the working knowledge of Microsoft Office, UR software and EMR. Possesses familiarity with MCG guidelines. Mental, Behavioral and Emotional Abilities: Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form. Usual Work Day: 8 Hours PHYSICAL DEMANDS AND WORK ENVIRONMENT Frequent physical demands include: Sitting , Standing , Walking Occasional physical demands include: Climbing (e.g., stairs or ladders) , Carry objects , Push/Pull , Twisting , Bending , Reaching forward , Reaching overhead , Keyboard use/repetitive motion , Talk or Hear Continuous physical demands include: Lifting Floor to Waist 10 lbs. Lifting Waist Level and Above 5 lbs. Sensory Requirements include: Accurate Near Vision, Accurate Far Vision, Accurate Color Discrimination, Accurate Depth Perception, Accurate Hearing Anticipated Occupational Exposure Risks Include the following: N/A This position is eligible for the following benefits: Medical Plan Prescription drug coverage & In-House Employee Pharmacy Dental Plan Vision Plan Flexible Spending Account (FSA) - Healthcare FSA - Dependent Care FSA Retirement Savings and Investment Plan Basic Group Term Life and Accidental Death & Dismemberment (AD&D) Insurance Supplemental Group Term Life & Accidental Death & Dismemberment Insurance Disability Benefits – Long Term Disability (LTD) Disability Benefits – Short Term Disability (STD) Employee Assistance Program Commuter Transit Commuter Parking Supplemental Life Insurance - Voluntary Life Spouse - Voluntary Life Employee - Voluntary Life Child Voluntary Legal Services Voluntary Accident, Critical Illness and Hospital Indemnity Insurance Voluntary Identity Theft Insurance Voluntary Pet Insurance Paid Time-Off Program The pay range listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future. When determining base salary and/or rate, several factors may be considered including, but not limited to location, years of relevant experience, education, credentials, negotiated contracts, budget, market data, and internal equity. Bonus and/or incentive eligibility are determined by role and level. The salary applies specifically to the position being advertised and does not include potential bonuses, incentive compensation, differential pay or other forms of compensation, compensation allowance, or benefits health or welfare. Actual total compensation may vary based on factors such as experience, skills, qualifications, and other relevant criteria.
RN Manager/Supervisor Utilization Review Telehealth Full-time
TurningPoint Healthcare Solutions

Supervisor, Clinical Review Nurse

TurningPoint Healthcare Solutions Lake Mary, FL
Position: Supervisor, Clinical Review Nurse Location: Any Job Id: 694-TBD # of Openings: 1 Job Description TurningPoint is an innovative healthcare services and technology organization that is committed to working with Health Plans and Providers to develop advanced technical and clinical solutions that improve the quality and affordability of surgical care patients receive. We are seeking a highly motivated and results orientated Nurse Supervisor to join our fast-paced and rapidly growing company. Primary Responsibilities This position is responsible for Utilization Management (UM) activities, including but not limited to the supervision of UM and Prior Authorization clinical team processes. This individual develops, implements, supports and promotes managed care strategies, policies and programs that drive the delivery of quality healthcare. Providing leadership and demonstrating responsibility and accountability for the delivery of quality services to a team of clinical staff Reviewing pre-authorization requests for appropriateness of care within established evidence-based criteria sets Interacting with other TurningPoint personnel to assure quality customer service is provided. Acting as an internal resource by answering questions requiring clinical interpretation Identifying high cost utilization and making appropriate referral Assisting the Director of Utilization Management in developing guidelines and procedures for the department Skills, Education & Experience Requirements An active and unrestricted Registered Nurse (RN) Associate’s Degree is required. Bachelor of Science in Nursing (BSN) Degree is preferred Five (5) years of clinical experience; or any combination of education and experience, which would provide an equivalent background Experience in surgical utilization review, pain management, case management, or health insurance pre-authorization and/or utilization management Minimum of 3 years experience Supervising and Managing a team of clinical and non-clinical staff members Ability to function effectively in an interdisciplinary team that includes physicians, nurses, other healthcare personnel and administrative staff Ability to work independently with minimal supervision Ability to organize, prioritize and complete work in a timely manner despite many deadlines and competing priorities Benefits TurningPoint offers a number of benefits to full-time employees including, but not limited to: medical, dental, vision, disability, life, PTO. All employees, age 21 and over, are eligible to participate in the 401(k)-retirement savings plan. Job Type: Full-time Apply for this Position
RN Utilization Review Full-time
Cottage Health

Utilization Management Case Manager

Cottage Health Santa Barbara, CA
$60 - $92 / hour
Qualifications Santa Barbara Cottage Hospital seeks a Utilization Management Case Manager for their Care Management department responsible for the utilization management, quality assurance, and discharge planning activities for assigned services/areas/patients within Cottage Health. Case management activities will result in quality outcomes, optimal care/cost management of services and/or procedures, a high level of customer satisfaction and contribution to an overall value-oriented experience of stakeholders and persons served. QUALIFICATIONS: All job qualifications listed indicate the minimum level necessary to perform this job proficiently. Education: Minimum: Associate's Degree in Nursing (ADN). Preferred: Bachelor's Degree in Nursing (BSN). Certifications, Licenses, Registrations: Minimum: Current California Nursing license in good standing. Preferred: Certification in Case Management. Years of Related Work Experience: Minimum: 2 years direct patient care experience in an acute care setting. Other patient care experience may be considered. Preferred: Previous experience as a case manager in an acute care setting. About Us Cottage Health is a leading acute care hospital system, located on the central coast of California, widely known for our superior patient care, innovation, medical research and education. Our health system operates primarily in Santa Barbara, CA, since 1888, and consists of three acute care hospitals, a Rehabilitation Hospital, multiple clinics and a multi-site Urgent Care system. Our mission is to serve the central coast communities with excellence, integrity, and compassion. Every day we touch thousands of lives in many different ways, resolute in our mission to put patients first. We take pride in helping our patients get back to living their lives - in the places they love. Cottage Health is an Equal Opportunity Employer. Cottage Health applicants are considered solely based on their qualifications, without regard to race, color, ethnicity, religion, age, gender, transgender, gender expression and identity, national origin, ancestry, disability, sexual orientation, marital status, military status or any other classification protected by law. This policy applies to all aspects of the relationship between Cottage Health and an applicant or employee. Cottage Health is committed to upholding discrimination-free hiring practices. We strive to cultivate an environment where exceptional people bring diverse perspectives and find belonging, support and connection to their work. Any Cottage Health applicants who require assistance or reasonable accommodations during the application process may request the need for accommodation with the Recruiter. Pay for non-physician positions is determined based on related years of experience and internal equity. Eligible employees may also receive additional forms of compensation, including shift differentials, on-call pay, incentive pay, and bonus opportunities, where applicable. Manager and above positions may participate in Cottage Health’s annual management incentive program. Physician compensation is determined based upon specialty and may include bonus potential. For more information on our comprehensive Total Rewards offerings, please visit https://cottagehealth.org/careers/total-rewards . If you're already a Cottage Health employee, please apply on this link only.
RN Utilization Review Telehealth Full-time
L.A. Care Health Plan

Utilization Management Nurse Specialist RN II

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

RN, Utilization Management | Utilization Management

UF Health Gainesville, FL
Overview Join an onsite clinical team focused on ensuring the right care at the right time for every patient. 💻 Work Style: Onsite 📍 Location: Gainesville, FL 🕒 FTE: Part-Time (.6) 🗓️ Schedule: Weekend Only (12-hour shifts) Evaluates patient medical records to determine the medical necessity and appropriateness of healthcare services in alignment with utilization management guidelines. Collaborates with healthcare providers to support compliance, optimize treatment plans, and promote efficient resource utilization. Communicates authorization decisions clearly and monitors patient progress to support timely discharge planning. Analyzes utilization data to identify trends and opportunities for improvement. Partners with interdisciplinary teams to enhance care coordination, ensure accurate documentation, and maintain compliance with regulatory and organizational standards. Responsibilities Key Responsibilities Evaluates patient medical records to ensure the necessity and appropriateness of healthcare services. Coordinates with healthcare providers to ensure compliance with utilization management guidelines. Supports the optimization of treatment plans to promote effective patient care and appropriate resource utilization. Communicates authorization decisions clearly and supports timely discharge planning. Analyzes utilization data to identify trends and opportunities to improve care coordination. Collaborates with interdisciplinary teams to ensure accurate documentation and regulatory compliance. Qualifications Education & Experience: Registered Nurse (RN) with a current Florida license required. Three (3) years of critical care nursing experience, or Five (5) years of medical-surgical nursing experience, or Three (3) years of utilization review, case management, or third-party payer experience. Qualifications Active Registered Nurse (RN) license with 3+ years of experience in utilization review or case management. Strong knowledge of healthcare utilization management guidelines and regulatory compliance. Experience evaluating medical necessity and optimizing treatment plans. Excellent communication skills with the ability to clearly convey authorization decisions. Ability to analyze utilization data and support effective care coordination. Strong organizational skills with the ability to manage multiple priorities simultaneously. Ability to work independently and collaboratively with multidisciplinary teams. Strong attention to detail and innovative problem-solving skills. Flexibility to adjust work hours and days based on departmental needs. Motor Vehicle Operator Designation: Employees in this position will not operate vehicles for an assigned business purpose. Note: Please indicate the appropriate operator designation on the Request for Personnel (RFP) form at the time of submission. Licensure/Certification/Registration: Registered Nurse (RN) with a current Florida license required.
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 Telehealth 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.