Registered Nurse (RN) Utilization Review Jobs

RN Utilization Review Home Health Full-time
UnitedHealthcare

Secondary Review Nurse - Indiana

UnitedHealthcare Indianapolis, IN
$29 - $52 / 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 $29 - $52 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 Telehealth Part-time
UnityPoint Health

Registered Nurse Utilization Management Specialist

UnityPoint Health West Des Moines, IA
Remote: Yes Area of Interest: Nursing FTE/Hours per pay period: 0.4 Department: Utilization Management Shift: Weekends-days, Saturday and Sunday 7am-3:30pm. 32hrs per pay period. 16 hrs per week. Job ID: 185266 Overview We are seeking an RN Utilization Management Specialist to join our team at UnityPoint Health! This position serves a key role in coordinating the organization’s interdisciplinary effort to assess and promote appropriate utilization of health care resources, provision of high-quality health care, optimal clinical outcomes, and patient and provider satisfaction. The RN UM Specialist will work to track and minimize the inappropriate use of such resources, provides the Utilization Management function for patients admitted to UPH, and facilitate effective utilization of resources through ongoing interactions with physicians, third party payers and regulatory agencies. Hours: Weekend-days, Saturday & Sunday, 7am-3:30pm Location: Remote - applicants must reside within the UnityPoint Health footprint of Iowa, Illinois, or Wisconsin Why UnityPoint Health? At UnityPoint Health, you matter. We’re proud to be recognized as a Top 150 Place to Work in Healthcare by Becker's Healthcare several years in a row for our commitment to our team members. Our competitive Total Rewards program offers benefits options that align with your needs and priorities, no matter what life stage you’re in. Here are just a few: Expect paid time off, parental leave, 401K matching and an employee recognition program. Dental and health insurance, paid holidays, short and long-term disability and more. We even offer pet insurance for your four-legged family members. Early access to earned wages with Daily Pay, tuition reimbursement to help further your career and adoption assistance to help you grow your family. With a collective goal to champion a culture of belonging where everyone feels valued and respected, we honor the ways people are unique and embrace what brings us together. And, we believe equipping you with support and development opportunities is a vital part of delivering an exceptional employment experience. Find a fulfilling career and make a difference with UnityPoint Health. Responsibilities Performs utilization management reviews using established criteria to confirm medical necessity, appropriate level of care and efficient use of resources. Maximizes positive financial outcomes for patients and hospital by conducting timely initial and ongoing concurrent chart review for hospitalized patients to monitor appropriateness of treatment, resource utilization, quality of care. Applies utilization criteria using designated software to complete documentation related to utilization review activities in an accurate and timely manner for the purpose of providing information for other members of the healthcare team and to facilitate decision making. Requests secondary reviews with physician advisors as appropriate, if admission or continued stay criteria are not met, assuring appropriate and timely level of care status. Assesses patient status, including reviewing outpatient surgical and observation admissions for the appropriate level of care, and continuously monitors length of stay for appropriate and timely medical management. Applies accepted potentially avoidable day logic to reviews for accurate and timely data collection. Proactively monitors insurance approval status in partnership with the UM Administrative Coordinator. Provides education to staff and physicians regarding medical necessity, levels of care and appropriate utilization of resources as needed. Pursues denials at the affiliate level in a timely manner to secure payment of services. Serves as a resource to internal and external staff, providers, payers, and patients on issues related to utilization management Maintains current knowledge of Utilization Review Methodology, software, criteria, and regulations governing various payment systems. Maintains current knowledge of the UPH Utilization Management Plan. Maintains current knowledge of CMS rules (e.g., Code 44, A – B Rebilling, HINN, etc.) and other regulatory agencies requirements to insure appropriate reimbursement. Coordinates and monitors appeals with internal and external physician advisors for Second Level Review as needed. Provides education to patients and families regarding the role of the Utilization Management Specialist and provides clarification when needed on level of care and their payer source regulatory requirements – as needed. Qualifications Education: Required: Associates Degree or Diploma (RN) in Nursing Preferred: Bachelor’s Degree or higher preferred in nursing, business, or related field Experience: Required: 2 years of nursing experience Preferred: 5+ years of nursing experience Preferred: Experience in Utilization Management, case management, denials, or managed care Preferred: Management experience a plus Licensing/Certifications: Required: Registered Nurse – Licensed and registered in the appropriate state(s) Valid driver’s license when driving any vehicle for work-related reasons
RN Utilization Review Per Diem
Kaiser Permanente

Case Manager Utilization RN-Per Diem Day

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

Preservice Review Nurse RN - Remote

UnitedHealthcare El Segundo, CA
$29 - $52 / hour
Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together. Let's face it, no industry is moving faster than health care. And no organization is better positioned to lead health care forward than UnitedHealthcare, part of the UnitedHealth Group family of businesses. In this role, you'll discuss cases with treating physicians and other health care professionals to ensure our members receive the proper health services. You'll also stay in touch with acute long-term care, acute rehabilitation or skilled nursing facilities to help patients through their care plan. It's an exciting opportunity to bring your skills to a truly inspired organization. You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. Primary Responsibilities: Perform clinical coverage review services, which require interpretation of state and federal mandates, applicable benefit language and consideration of relevant clinical information Communicate all types of benefit determinations, including decisions regarding coverage guidelines, contractual limitations and reimbursement determinations Speak to health care providers and/or members to explain benefit coverage determinations and to obtain additional clinical information Act as a resource for others with less experience It feels great to have autonomy and there's also a lot of responsibility that comes with it. In this role, you'll be accountable for making decisions that directly impact our members. And at the same time, you'll be challenged by leveraging technologies and resources in a rapidly-changing, production-driven environment You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications: Current unrestricted RN license in the state of residency 3+ RN years of experience, including experience in an inpatient/acute setting Designated homework space and access to install secure high-speed internet via cable/DSL Preferred Qualifications: Bachelor's Degree Background involving utilization review for an insurance company or experience in case management Ability to use your diverse knowledge and experience to make health care work better for our patients Familiarity with Milliman Care Guidelines *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 $29.00 - $52.00 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
Kaiser Permanente

Case Management Utilization RN, 40/hr Day

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

Utilization Management Case Manager Lead

Cottage Health Santa Barbara, CA
$63 - $97 / hour
Job Description Santa Barbara Cottage Hospital seeks a Utilization Management Case Manager Lead for their Care Management department responsible for providing education on current and updated regulatory compliance, orients and trains all new hires. Assists Manager of Case Management with meetings, audits, and other tasks assigned by the Manager of Case Management. QUALIFICATIONS: All job qualifications listed indicate the minimum level necessary to perform this job proficiently. Education: Required: Associate's Degree in Nursing (ADN). Preferred: Bachelor's Degree in Nursing (BSN). Certifications, Licenses, Registrations: Required: Current California Nursing license in good standing. Preferred: Certification in Case Management. Years of Related Work Experience: Required: 3 years as a case manager in an acute care setting. Other patient care experience may be considered. Preferred: 5 years of experience as a case manager in an acute care setting. About Us Cottage Health is a leading acute care hospital system, located on the central coast of California, widely known for our superior patient care, innovation, medical research and education. Our health system operates primarily in Santa Barbara, CA, since 1888, and consists of three acute care hospitals, a Rehabilitation Hospital, multiple clinics and a multi-site Urgent Care system. Our mission is to serve the central coast communities with excellence, integrity, and compassion. Every day we touch thousands of lives in many different ways, resolute in our mission to put patients first. We take pride in helping our patients get back to living their lives - in the places they love. Pay for non-physician positions is determined based on related years of experience and internal equity. Eligible employees may also receive additional forms of compensation, including shift differentials, on-call pay, incentive pay, and bonus opportunities, where applicable. Manager and above positions may participate in Cottage Health’s annual management incentive program. Physician compensation is determined based upon specialty and may include bonus potential. For more information on our comprehensive Total Rewards offerings, please visit https://cottagehealth.org/careers/total-rewards . If you're already a Cottage Health employee, please apply on this link only.
RN Utilization Review Full-time
Tuba City Regional Healthcare

Utilization Review RN - Sign on eligible

Tuba City Regional Healthcare Tuba City, AZ
Navajo Preference Employment Act In accordance with Navajo Nation and federal law, TCRHCC has implemented an Affirmative Action Plan pursuant to the Navajo Preference in Employment Act. Pursuant to this Plan and corresponding TCRHCC Policy, applicants who meet the necessary qualifications for this position and (1) are enrolled members of the Navajo Nation, Hopi Tribe, or San Juan Southern Paiute Tribe will be given preference in hiring and employment for this position, (2) are legally married to enrolled members of the Navajo Nation, Hopi Tribe, or San Juan Southern Paiute Tribe and meet residency requirements will be given secondary preference, and (3) are enrolled members of other federally-recognized American Indian Tribes will be given tertiary preference. Overview POSITION SUMMARY The Utilization Review (UR) Nurse ensures that patients receive appropriate care by verifying medical necessity, confirming the correct patient status, and monitoring the ongoing need for services while working to reduce unnecessary length of stay and prevent delays; they support accurate clinical documentation for proper reimbursement, coordinate with providers and the care team on discharge planning and transitions, manage resource use to control costs, communicate with payers to prevent denials, and ensure compliance with CMS and Joint Commission requirements while contributing to reporting and quality improvement efforts. They also serve as a key liaison between clinical care, finance, and regulatory requirements, helping align patient care with both quality standards and reimbursement rules. Ultimately, their role has a direct impact on patient outcomes, hospital efficiency, and the organization’s financial performance. Qualifications NECESSARY QUALIFICATIONS Education: Bachelor’s Degree in Nursing License/Certification: A valid, current, full and unrestricted Professional Nursing License to practice as a Registered Nurse (RN) in any state of the United States of America, The Commonwealth of Puerto Rico, or a territory of the United States Must have and maintain current Basic Life Support (BLS) certification by the American Heart Association (AHA) throughout employment Experience: Three (3) years of clinical nursing experience performing direct patient care with at least 2 years in an Inpatient setting on a medical-surgical unit, PACU, or higher acuity Inpatient unit (ICU, Step-Down, Telemetry, etc.) or home health (direct care) {clinical experience qualification may be determined by hiring manager/director.} Demonstrate knowledge of case management, purchased referred care and utilization review Demonstrate knowledge of electronic health record systems. Other Skills and Abilities: A record of satisfactory performance in all prior and current employment as evidenced by positive employment references from previous and current employers. All employment references must address and indicate success in each one of the following areas: Positive working relationships with others Possession of high ethical standards and no history of complaints Reliable and dependable; reports to work as scheduled without excessive absences Effective verbal & written communication skills Team management focus promoting a positive and pro-active approach to problem resolution Experience in hospital-based utilization review Proficient or experienced with clinical criteria sets for Miliman Care Guidelines(MCG) Completion of and receiving above-satisfactory scores on all job interviews, demonstrating to the satisfaction of the interviewers and TCRHCC that the applicant can perform the essential functions of the job Successful completion of and positive results from all background and reference checks, including positive employment references from authorized representatives of past and current employers demonstrating to the satisfaction of TCRHCC a record of satisfactory performance and that the applicant can perform the essential functions of the job Successful completion of fingerprint clearance requirements, physical examinations, and other screenings indicating that the applicant is qualified to be employed by TCRHCC and demonstrating to the satisfaction of TCRHCC that the applicant can perform the essential functions of the job Submission of all required employment-related documents, applications, resumes, references, and other required information free of false, misleading or incomplete information, as determined by TCRHCC. MENTAL AND PHYSICAL EFFORT The physical and mental demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. Physical: This position requires an individual of high energy who can maintain a long and flexible schedule to meet the management requirements. The physical requirements include; sitting at a desk for long periods of time, long periods of sitting in meetings; frequent sitting for intense work on a personal computer, frequent walking to interact with staff within the facility, frequent bending, kneeling, crouching, twisting, maintaining balance and reaching. Must be able to hear, speak and comprehend over the telephone and in person with others. Must have ability to lift, push and pull up to 50lbs frequently. Sensory requirements for position include prolonged ability for far, near, and color vision, depth perception, seeing fine details, hearing normal speech, telephone use and ability to frequently hear overhead pages. Must have ability of both hand manipulation in simple and firm grasping, fine manipulation, and use of keyboard. Mental: Uses independent judgment and analytical skills to make decisions that impact operations, finances, and customer service within the organization. The incumbent must have the ability to perform in structured and unstructured environments and possess a keen attention to detail and propose practices/mechanisms to enhance customer satisfaction. Must have ability to continually concentrate, handle a high degree of flexibility, handle multiple priorities in stressful situation, demonstrate high degree of patience, adapt to shift work, work in areas that are close in crowded, frequently cope with high levels of stress, make decisions under high pressure, work alone, and occasionally cope with anger/fear/hostility of others in a calm way and manage altercations. Environmental: May frequently be exposed to chemical agents, extremes in temperature of humidity, occasional exposure to infectious diseases, dust, fumes, gases, hazardous or moving equipment, and loud noises. Responsibilities ESSENTIAL FUNCTIONS Adheres to most current ACMA Case Management Standards of Practice and Scope of Services Adheres to ANA Nursing Scope and Standards of Practice Adheres to most current ANA The Code of Ethics for Nurses Coordination of service specific assessments, service planning and enrollment. Works with all facets of the Case Management continuum, i.e., social support, alternate resources, community referrals, discharge planning, Nursing Home/Skilled Nursing Placement and resource utilization. Comprehensive and client centered service planning and coordination Works proactively with the established RN Case Managers/ Social Workers of TCRHCC as a team member for care coordination of the patient populations served by TCRHCC. Consistent and on-going case consultation with all direct service providers. Developing and maintaining internal and external resource relationships. Promote patient advocacy Promote quality of care Promote cost effective medical outcomes Promote appropriate admission status Provide continuity of care between utilization management and care coordinators Commits to professional development towards becoming an expert in utilization management including but not limited to: Knowing Medicare rules and regulations related to utilization Knowing payor policies related to utilization management Knowing TCRHCC 638 policies related to utilization management. Keeping abreast of current changes affecting utilization management as applicable. Collaborates with attending physician if ambiguous documentation pertaining to patient status placement requires clarification. Utilizes electronic utilization management database for documentation of interventions and communications (MCG Guidelines, Careport and Allscripts) Reviews precertification requests for medical necessity for all payors as applicable, referring to the second level physician reviewer those that require additional expertise Collaborates with payor utilization management liaisons and medical directors as applicable. Uses clinical and analytical skills to review and interpret diagnostic test results to determine appropriateness of patient's level of care. Assists with the development of department reports, policy/procedures manuals, and program objectives Conduct system and procedural efficiency evaluation to determine progress, performance, and conformity with program requirements. Will provide a consistent and on-going collaboration through communication with service providers. Facilitates appropriate clinical documentation to ensure that the level of services and acuity of care are accurately reflected in the medical record. Improves the overall quality and completeness of clinical documentation by performing admission/continued stay clinical reviews using clinical enhancement guidelines for selected patient populations. Reviews clinical issues as needed with the coding staff to assign a working DRG to reflect any changes in patient status and procedures/treatments and confers with the physician to finalize diagnoses. Conducts timely follow-up reviews of clinical documentation to ensure that issues discussed and clarified with the physician have been recorded in the patient’s chart. Participates in review and analysis of monthly data relating to clinical quality documentation and insurance medical necessity criteria. Ensure proper PPE is worn at all times while on duty including but not limited to, face mask, gloves, gown, isolation gown, NIOSH-approved N95 filtering facepiece respirator or higher, if available), and eye or face shield. Completes all donning and doffing tasks in a safe acceptable method and discard of used PPE accordingly. (see CDC website for most current updated) Complete task training for all routine cleaning and decontamination processes for all surfaces contaminated by a communicable disease to ensure a high level of patient, visitor, employee and external customer satisfaction. Performs other duties as assigned.
RN Utilization Review Per Diem
Northern Nevada Health System

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

Northern Nevada Health System Sparks, NV
Responsibilities When it comes to choosing a hospital, one thing is clear: quality and convenience count. Northern Nevada Medical Center's tradition of providing quality healthcare in a comfortable, accessible environment means peace of mind for the thousands of patients served by the hospital each year. Northern Nevada Medical Center is a 124-bed acute care hospital located on 23 hillside acres at 2375 E. Prater Way in Sparks, Nevada. Website: https://www.nnmc.com Job Summary: This Utilization Review Nurse (RN) is Per Diem on our Case Management Unit and offers a convenient schedule. The Northern Nevada Health System is seeking a Utilization Review Nurse (RN) who will be responsible for carrying out utilization management functions by planning, coordinating, and managing patient needs during hospitalization and throughout the continuum of care. Must be available to work weekends and holidays. Job Duties/Responsibilities: Conducts admission and continued stay reviews per guidelines to ensure medical necessity of level of care and hospitalization for multiple entities. Reviews medical record for presence of accurate placement orders reconciles variances with patient providers. Works collaboratively with attending providers, specialty providers, and physician advisors to ensure application of evidence-based guidelines for determining appropriate status. Collaborate with Patient Access team to ensure correct payer source for hospitalization and communication. About Universal Health Services One of the nation’s largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (UHS) has built an impressive record of achievement and performance. Growing steadily since its inception into an esteemed Fortune 500® corporation, annual revenues during 2025 were $17.4 billion. In 2026, UHS was again recognized as one of Fortune World’s Most Admired Companies™ and in 2025, was listed in Forbes ranking of America’s Largest Public Companies. Headquartered in King of Prussia, PA, UHS has approximately 101,500 employees and continues to grow through its subsidiaries. Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory care access points, an insurance offering, a physician network and various related services located in 40 U.S. states, Washington, D.C., Puerto Rico and the United Kingdom. For additional information visit www.uhs.com . Qualifications Requirements: Graduate of an accredited or NLN approved RN program. Current license as a RN in the State of Nevada required. Two (2) years of clinical experience in an acute care hospital setting with (1) year in an inpatient or outpatient case management setting required. Demonstrates compliance with hospital policies and procedures at all times. Demonstrates strong leadership, organization, communication and interpersonal skills. EEO Statement All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws. Avoid and Report Recruitment Scams We are aware of a scam whereby imposters are posing as Recruiters from UHS, and our subsidiary hospitals and facilities. Beware of anyone requesting financial or personal information. At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skill set and experience with the best possible career path at UHS and our subsidiaries. During the recruitment process, no recruiter or employee will request financial or personal information (e.g., Social Security Number, credit card or bank information, etc.) from you via email. Our recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc. If you suspect a fraudulent job posting or job-related email mentioning UHS or its subsidiaries, we encourage you to report such concerns to appropriate law enforcement. We encourage you to refer to legitimate UHS and UHS subsidiary career websites to verify job opportunities and not rely on unsolicited calls from recruiters.
RN Utilization Review Correctional Other
US Department of Justice

Nurse (Utilization Review Nurse)

US Department of Justice Fort Worth, TX
Corrections professionals who foster a humane and secure environment and ensure public safety by preparing individuals for successful reentry into our communities.
RN Utilization Review
Community First Medical Center

Case Manager - Utilization Review RN

Community First Medical Center Chicago, IL
$43.47 - $53 / hour
Description Under the general direction of the Director of Behavioral Health, the Case Manager – Utilization Review RN provides clinically based case management and utilization review services to support the delivery of high-quality, cost-effective patient care. The RN is responsible for concurrent utilization review, medical necessity determination, denial prevention, discharge planning, care coordination, and resource management across the continuum of care. The Case Manager – Utilization Review RN collaborates with physicians, interdisciplinary team members, physician advisors, social workers, revenue cycle staff, and third-party payers to ensure appropriate utilization of hospital resources, regulatory compliance, optimal reimbursement, and safe patient transitions. Community First Medical Center offers benefits to all its full-time and part-time employees : United Healthcare Medical PPO/HMO/HSA Plans, premiums as low as $50.00/full time, $85.00/Part Time Met Life Dental and Vision Paid Time Off (PTO) with annual accruals up to 168 hrs./year Six paid holidays Company Paid Life insurance and Short-term Disability 401(k) after 90 days Continuing Education reimbursement and 2 days paid off separate from PTO Free Parking Garage Internal Growth Opportunities Requirements To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. QUALIFICATIONS Education Associate Degree in Nursing required. Bachelor of Science in Nursing (BSN) preferred. Experience Minimum three (3) years of acute care nursing experience required. Minimum two (2) years of Case Management and/or Utilization Review experience preferred. Experience with discharge planning, utilization review, denial management, and payer authorization preferred. Licensure Current Illinois Registered Nurse license required. ACM, CCM, or CMAC certification preferred. KNOWLEDGE, SKILLS & ABILITIES Knowledge of Medicare, Medicaid, and commercial insurance regulations. Working knowledge of InterQual and/or MCG criteria. Behavioral Health background knowledge Access to Behavioral Health Networks Understanding of utilization management and care coordination principles. Knowledge of discharge planning and post-acute care resources. Strong analytical and critical thinking skills. Excellent verbal and written communication skills. Ability to prioritize multiple complex patient cases. Ability to build collaborative relationships with physicians and interdisciplinary teams. Computer proficiency and electronic medical record experience. PERFORMANCE EXPECTATIONS Success in this role is measured by: Appropriate admission status determination Denial prevention and appeal success Timely discharge planning Reduction in avoidable days Average Length of Stay management Readmission reduction Documentation compliance Regulatory compliance Patient throughput Patient and physician satisfaction
RN Utilization Review Full-time
Bryan Health

Utilization Management RN- Weekender

Bryan Health Lincoln, NE
Summary GENERAL SUMMARY: Conducts day-to-day activities for the clinical, financial and utilization coordination of the patient’s hospital experience. Proactively consults with the interdisciplinary team which includes, but is not limited to, hospital patient care staff, physicians, patient support and family to ensure the patient’s hospital stay meets medical necessity and insurance authorizations are obtained in order to facilitate the patient’s and hospitals financial well-being. PRINCIPAL JOB FUNCTIONS: 1. *Commits to the mission, vision, beliefs and consistently demonstrates our core values. 2. *Performs utilization review activities, including concurrent and retrospective reviews as required. 3. *Determines the medical necessity of request by performing first level reviews, using approved evidence based guidelines/criteria. 4. *Collaborates with the patient’s provider and other healthcare team members in managing the patient’s length of stay and determining the continuing medical necessity of continued stays. 5. *Refers cases to reviewing physician when the treatment request does not meet criteria per appropriate algorithm. 6. *Participates in concurrent and retrospective denials and appeals process by researching issues surrounding the denial, participating in all levels of the appeal and process follow-up. 7. *Serves as an internal and external resource regarding appropriate level of care; admission status/classification; Medicare/Medicaid rules, regulations, and policies; 3rd party and managed care contracts; discharge planning; and length of stay. 8. Ensures appropriate resource utilization relevant to the financial, regulatory and clinical aspects of care; proposes alternative treatment to ensure a cost effective and efficient plan of care. 9. *Maintains awareness of financial reimbursement methodology, utilization management, payer/reimbursement practices and regulations and participates in resource stewardship. 10. *Promotes quality improvement initiatives and health care outcomes based on currently accepted clinical practice guidelines and total quality improvement initiatives. 11. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise. 12. Participates in meetings, committees and department projects as assigned. 13. Performs other related projects and duties as assigned. (Essential Job functions are marked with an asterisk “*”. Refer to the Job Description Guide for the definition of essential and non-essential job functions.) Attach Addendum for positions with slightly different roles or work-specific differences as needed. REQUIRED KNOWLEDGE, SKILLS AND ABILITIES: 1. Maintains clinical competency as required for the unit including but not limited to age-specific competencies relative to patient’s growth and developmental needs, annual skill competency verification and mandatory education and competencies. 2. Knowledge of governmental and third party payer regulations and requirements related to patient hospitalization and acute rehabilitation admission, stay and discharge activities, i.e., CMS, CARF, FIM (TM). 3. Knowledge of computer hardware equipment and software applications relevant to work functions. 4. Skill in conflict diffusion and resolution. 5. Ability to communicate effectively both verbally and in writing. 6. Ability to perform crucial conversations with desired outcomes. 7. Ability to establish and maintain effective working relationships with all levels of personnel and medical staff. 8. Ability to problem solve and engage independent critical thinking skills. 9. Ability to maintain confidentiality relevant to sensitive information. 10. Ability to prioritize work demands and work with minimal supervision. 11. Ability to perform crucial conversations with desired outcomes. 12. Ability to maintain regular and punctual attendance. EDUCATION AND EXPERIENCE: Current Registered Nurse licensure from the State of Nebraska or approved compact state of residence as defined by the Nebraska Nurse Practice Act. Minimum of two (2) years recent clinical experience required. Prior care coordination and/or utilization management experience preferred. OTHER CREDENTIALS / CERTIFICATIONS: Basic Life Support (CPR) certification required. Bryan Health recognizes American Heart Association (for healthcare professionals), American Red Cross (for healthcare professionals) and the Military Training Network. PHYSICAL REQUIREMENTS: (Physical Requirements are based on federal criteria and assigned by Human Resources upon review of the Principal Job Functions.) (DOT) – Characterized as sedentary work requiring exertion up to 10 pounds of force occasionally and/or a negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects, including the human body.
RN Utilization Review Full-time
MercyOne

Utilization Review RN

MercyOne Des Moines, IA
Employment Type: Full time Shift: Day Shift Description: At MercyOne, health care is more than just a doctor’s visit or a place to go when you need medical attention. Our Mission is based on improving the health of our communities – that means not only when you are sick but keeping you well. MercyOne Central Iowa sets the standard for personalized and radically convenient care in the Des Moines metro area and surrounding counties. MercyOne Des Moines Medical Center, founded by the Sisters of Mercy in 1893, is the longest continually operating hospital in Des Moines and Iowa’s largest medical center, with 802 beds available. The hospital is one of the Midwest’s largest referral centers. With more than 7,000 colleagues and a medical staff of almost 1,500 physicians and allied health professionals, MercyOne Central Iowa is one of Iowa’s largest employers. General Requirements: Responsible for the review of inpatient and outpatient admission records for appropriate admission status at Mercy Medical Center and Mercy West Lakes. Works in collaboration with the attending physician and the Case Management staff utilizing admission criteria guidelines-and second level physician review process when appropriate. Interacts with insurance providers to obtain authorization and continued stay approval for admission. Collaborates with the Verification department, Revenue cycle and Medical Eligibility to facilitate the establishment of the correct payer source for patient stay and the documentation of the interactions in the STAR admitting system. Shift: Full-Time Days | Flexible Day Shift (7:00 AM – 3:30 PM) Rotation on weekends. ESSENTIAL FUNCTIONS: Conducts admission review per the Utilization Management Plan to ensure that the hospitalization is approved based on established criteria. Reviewing may be both concurrent or post discharge. Carries out hospital programs and principles of utilization review in compliance with hospital policies and external regulatory agencies Peer Review Organization (PRO), Joint Commission, and multiple payer defined criteria for eligibility. Applies Milliman Careguidelines Criteria for appropriate status determination. Engages in discussion with the attending physician for clarification and/or status correction. Engages second level physician review as indicated to support the appropriate status. Ensures timely communication with Case Management staff for all concurrent status changes. Administers Notice of Status Change to the patient/family when indicated. Provides education and information for the patient/family for clarification of the change. Documents in the Medical Record Utilization Management forms accurately to reflect the appropriate admission criteria and appropriate status along with any communications. Collaborates with MercyOne Post Denials team to determine potential appeals or downgrades and documents in STAR. Ensures timely notification to Admitting of status of change or status discrepancies identified. Reviews the records on admission for status orders present addressing Center for Medicare Services rules and guidelines around admission status. Monitors insurance coverage for patients in the STAR admitting/financial system and communicates any updates to the Verification Department. Provides clinical information as request from the insurance payer via the query, fax or portal in a timely manner to prevent technical denials. Enters authorization, approvals and denials into the STAR systems and communicates pertinent changes to Case Management. Engages the attending physician to advocate and communicate via Peer to Peer Review for discussion with insurance for admission, continued stay or status when required. Reviews denial letters/faxes received in Care Coordination Department and direct to Conifer Appeal Department for appeal. Documents in the STAR system. Collaborates in monitoring and addressing observation outliers and status discrepancies with Medical Records Department and Admitting Department. Collaborates with the Recovery Audit Contractor (RAC) Coordinator and Conifer for Medicare/Medicaid RAC Denials management. MARGINAL FUNCTIONS: General office duties of filing, data retrieval and computer use. MINIMUM KNOWLEDGE, SKILLS AND ABILITIES REQUIRED: Current licensure as a registered nurse in the State of Iowa. Five (5) years clinical nursing experience. Bachelor of Science - Nursing or degree in healthcare-related field preferred. Proof of completion of Mandatory Reporter abuse training specific to population served within three (3) months of hire. Knowledge of eligibility requirements for insurance coverage with respect to health care services: ambulatory, observation stays, surgical, acute care, subacute and continuum of care services. Demonstrated ability to manage complex management and clinical situations. Ability to work within a function independently exercising judgement to reach resolutions to issues. Specialty certification in Utilization Review within 12 months of hire preferred. Colleagues of MercyOne Health System enjoy competitive compensation with a full benefits package and opportunity for growth throughout the system! Visit MercyOne Careers to learn more about the benefits, culture, and career development opportunities available to you at MercyOne Health System ’s circle of care . Want to learn more about MercyOne Des Moines? Click here: Find a Location Des Moines, Iowa (IA), MercyOne Des Moines Iowa’s capital city offers a balanced urban-suburban experience with a cost of living below the national average. It’s ranked among the top safest large metros and boasts strong education options, including highly rated public schools, private academies and nearby universities like Drake University and Grand View University. Cultural highlights include theaters, museums, music festivals and a thriving food scene, while outdoor enthusiasts enjoy extensive parks and bike trails. Located just minutes from the airport, Des Moines offers easy access to regional attractions and a welcoming, community-focused atmosphere. MercyOne Des Moines Medical Center is a leading 656-bed acute ‑ care , not ‑ for ‑ profit Catholic hospital and one of Iowa’s largest employers. Founded in 1893, it’s the longest continuously operating hospital in Des Moines. Accredited as a Top Regional Hospital by U.S. News & World Report, named one of Becker’s 100 Great Hospitals, and ranked among the top 50 cardiovascular hospitals by IBM Watson Health. With Joint Commission Gold Seal accreditation, stroke and heart care awards, CAP-accredited lab and ACS-certified Cancer Center, this flagship facility offers comprehensive services including robotic surgery, cancer care, neurosciences, rehab, emergency/trauma, maternity, behavioral health and a robust nursing excellence program. Our Commitment Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.
RN Utilization Review Part-time
Capital Health

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

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

ED Case Management Utilization RN, 32/hr Night

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

Coordinator-RN Utilization-3p-11p

North Mississippi Health Services Tupelo, MS
Posting Description We believe a career is more than just a career — it's a calling. Our teammates' "True North" is what calls them to health care; it’s their passion. At North Mississippi Health Services, we believe in helping you leverage and connect that passion with a much greater purpose that impacts people you know and love. Essential Functions List major areas of responsibility and briefly what the person does in each area. Coordinates: Consults with physician services Utilizes clinical diagnostics, physician documentation and non-physician clinical guidelines to facilitate status determination of inpatient, outpatient or outpatient observation. Coordinates final status with admitting and attending physicians Performs initial and concurrent clinical reviews as indicated by payer and patient clinical needs Inpatient and/or outpatient notification and precertification of services to payers Facilitates peer to peer, written reconsiderations or appeals throughout all denial cycle as appropriate Facilitates appropriate observation utilization Consults with patient financial services Educations: Provides education and literature to physician services regarding IPPS and OPPS Educates physicians and other care team member on level of care criteria and other third party payer requirements Reporting/Recordkeeping: Updates patient’s medical records as required Shares medical necessity documentation with payers to facilitate reimbursement Regulation : Adheres to NMHS/NMMC Policies/Procedures/Guidelines Complies with applicable Local/State/Federal policies/procedures/guideline/regulations/laws/statues Know How Job Knowledge Specify required education, licensure/certification, prior experience, skill behavior, equipment operation, type and duration of on-the-job training, patient population to be served, etc. Associates Degree in Nursing, required; Bachelor’s Degree preferred Licensed as a Registered Nurse by the Mississippi Board of Nursing; required Minimum of 5 years clinical and/or healthcare experience; required Excellent organizational and communication (written and verbal) skills; required Knowledge of various payer sources, federal/state laws/regulations, and cost containment; required Certified as an Accredited Case Manager (ACM); desirable Excellent interpersonal skills; required Demonstrates ability to care for a patient population from pediatric to geriatric; required
RN Utilization Review Part-time
Kaweah Health

RN-Peer Review Coordinator

Kaweah Health Visalia, CA
$46.44 - $69.66 / hour
Kaweah Health is a publicly owned, community healthcare organization that provides comprehensive health services to the greater Visalia area in central California. With more than 5,000 employees, Kaweah Health provides state-of-the-art medicine and high-quality preventive services in our acute care hospital, specialized health centers and clinics. Our eight-campus healthcare district has 613 beds and offers comprehensive health services across a broad continuum of care. It takes a special person to work for Kaweah Health. We serve a region where the needs are great, which makes the rewards even greater. Every day, we care for people facing unique challenges and in need of healing. Throughout it all, our focus is to make a difference, and we do — in the health of our patients, our loved ones, and our community. Benefits Eligible Part-Time Benefit Eligible Work Shift Day - 8 Hour or less Shift (United States of America) Department 8710 Medical Staff Services A team-oriented and quality focused professional who is responsible for overseeing the Medical Staff Peer Review process. QUALIFICATIONS License /Certification Required: Current Registered Nurse License Education Preferred: Bachelor's degree Experience Required: Three years clinical experience in an acute care setting. Experience with Cerner EMR. Preferred: Quality management experience. Knowledge/Skills/Abilities Strong computer skills to include Microsoft Office, Word, and Excel. Exceptionally strong interdisciplinary collaboration skills. Knowledge of peer review concepts and process and risk management principles preferred. Knowledge of guidelines, healthcare standards, and regulations, (i.e.: evidence-based, CMS, TJC, AHRQ Patient Safety Indicators, Hospital Acquired Conditions) preferred. Knowledge of quality improvement methodologies and analytic tools and methods preferred. Strong communication skills, both written and verbal preferred. JOB RESPONSIBILITIES Essential Supports and coordinates the Medical Staff Peer Review committees and activities as outlined in the Peer Review and Code of Conduct policy including but not limited to: Maintains the confidentiality of patients, practitioners, and the organization. Identifies cases which meet the criteria for preliminary clinical or behavioral case review. Assists peer reviewers in obtaining or provide a complete medical record, imaging studies and other documentation reasonably required to perform Peer Review. Coordinates and communicates with physicians and/or their offices in regard to screening, scoring and assist with their presentation of select cases for peer review or unprofessional behavior review. Attends the medical staff peer review behavior meetings and other related ad hoc meetings. Provides full administrative support which includes preparation of agendas, material gathering, speaker scheduling, chair preparation, recording minutes, and coordinating follow up processes and activities. Provides data identifying the relevant practice patterns and trends of the Practitioner related to defined departmental outcomes. Maintains positive working relationships with medical staff, nursing, and ancillary services as it relates to peer review processes. Performs preliminary (RN level) case review and highlight the potentially relevant issues. Provides relevant benchmark comparisons of the Practitioner under review. Identifies instances of clinical performance and/or unprofessional conduct regarding non-Practitioner staff. Facilitates timely and accurate triage of Medical Staff related Risk Events. Additional Demonstrates the knowledge and skills necessary to provide care and services appropriate to the population served on the assigned unit or work area. Performs other duties as assigned. Pay Range $46.44 -$69.66 If you want to use your talents alongside people who face each day with courage and purpose, in an environment that empowers you to do your absolute best, this is where you belong.
RN Utilization Review Full-time
Connecticut Children's

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

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

UTILIZATION EXPERT - RN - WEEKENDS

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

Utilization Review Nurse

Virginia Mason Franciscan Health Seattle, WA
$52.03 - $101.24 / hour
Job Summary and Responsibilities As our Utilization Review Nurse, you will ensure the medical necessity and appropriateness of care for all hospitalized patients, promoting fiscal responsibility and optimal patient outcomes. You will leverage specialized utilization review criteria, technologies, and tools to verify the correct level of care throughout their acute stay. Every day you will perform meticulous clinical assessments, identify and coordinate cost-effective alternatives, and proactively support provider decision-making. You will collaborate with the healthcare team, patients, families, and both internal/external customers to achieve optimal outcomes efficiently and ethically, ensuring compliance with payer guidelines and regulatory standards. To be successful in this role you will have strong analytical skills, persuasive communication, and a steadfast commitment to patient advocacy. Fiscal stewardship is crucial for navigating complex clinical and financial landscapes, ensuring appropriate resource utilization. Job Requirements Required Bachelor's degree in Nursing and 3 years of professional nursing experience in a hospital setting. Experience in utilization review. Demonstrated ability to work collaboratively with all members of the care team (CNLs, MSWs, MDs) in conveyance of information that affects patient care. An understanding of variable payor rules and regulations is also required. Preferred Knowledge of core insurance coverage guidelines and financial principles. Acute care nursing experience. Where You'll Work Virginia Mason Franciscan Health brings together two award winning health systems in Washington state - CHI Franciscan and Virginia Mason. As one integrated health system with the most patient access points in western Washington our team includes 18,000 staff and nearly 5,000 employed physicians and affiliated providers. At Virginia Mason Franciscan Health you will find the safest and highest quality of care provided by our expert, compassionate medical care team at 11 hospitals and nearly 300 sites throughout the greater Puget Sound region.
RN Utilization Review Full-time
Dignity St. Mary's Medical Center San Francisco

Utilization Review RN

Dignity St. Mary's Medical Center San Francisco Houston, TX
$41.14 - $61.20 / hour
Job Summary and Responsibilities As our Utilization Management Professional, you will be a critical guardian of healthcare efficiency and quality, ensuring integrity in clinical decision-making, regulatory compliance, and responsible resource utilization. Every day, you will meticulously review medical records, authorize services, and prepare cases for physician review in partnership with UM teams. You'll monitor patient care for appropriateness, quality, and cost-effectiveness, aligning decisions with established criteria. To be successful in this role, you will possess a strong clinical background, deep UM/regulatory knowledge, and exceptional analytical/organizational skills. Your ability to manage charts, apply criteria precisely, and communicate effectively with enthusiasm, efficiency, and empathy is paramount for optimal patient care and operational flow. Conducts admission and continued stay reviews per the Care Coordination Utilization Review guidelines to ensure that the hospitalization is warranted based on established criteria and critical thinking. Reviews include admission, concurrent and post discharge for appropriate status determination. Ensures compliance with principles of utilization review, hospital policies and external regulatory agencies, Peer Review Organization (PRO), Joint Commission, and payer defined criteria for eligibility. Reviews the records for the presence of accurate patient status orders and addresses deficiencies with providers. Ensures timely communication and follow up with physicians, payers, Care Coordinators and other stakeholders regarding review outcomes. Collaborates with facility RN Care Coordinators to ensure progression of care. Job Requirements Required Diploma Of Nursing Graduate of an accredited school of nursing, upon hire and Minimum two (2) years of acute hospital clinical experience , upon hire or Registered Nurse: TX, upon hire and Preferred Bachelors Of Nursing Bachelor's Degree in Nursing (BSN) or related healthcare field. , upon hire At least five (5) years of nursing experience., upon hire Certified Case Manager, upon hire or Accredited Case Manager, upon hire or Where You'll Work Baylor St. Luke’s Medical Center is an 881-bed quaternary care academic medical center that is a joint venture between Baylor College of Medicine and CHI St. Luke’s Health. Located in the Texas Medical Center, the hospital is the home of the Texas Heart® Institute, a cardiovascular research and education institution founded in 1962 by Denton A. Cooley, MD. The hospital was the first facility in Texas and the Southwest designated a Magnet® hospital for Nursing Excellence by the American Nurses Credentialing Center, receiving the award five consecutive times. Baylor St. Luke’s also has three community emergency centers offering adult and pediatric care for the Greater Houston area.
RN Utilization Review Outpatient Other
Spectrum Healthcare Resources

Registered Nurse - Utilization Management

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

Utilization Review RN

Children's Hospital Colorado Aurora, CO
$84,558.69 - $126,838.03 / year
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: part time, 24 hours per week, eligible for benefits Shift: weekend evenings - Saturday, Sunday, Monday 1500 - 2300 This position will be primarily remote but there may be occasions when you are expected to work onsite at one of the Children's Hospital Colorado locations so all candidates must either live in Colorado already or be willing to relocate before starting. The specific details will be discussed in the interview process, and subject to change at our discretion. This position is eligible for relocation assistance, if relocating from 100 miles or greater. Duties & Responsibilities An employee in this position may be called upon to do any or all the following essential functions. These examples do not include all the functions which the employee may be expected to perform. 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 recent clinical or case management experience that includes recent UR experience in a hospital or with a Third-Party Payor Certification(s): BLS/CPR from the American Heart Association with at least 6 months left before expiration is required upon hire. Licensure(s): Registered Nurse License Salary Information Pay is dependent on applicant's relevant experience. Annual Salary Range (Based on 40 hours worked per week): $84,558.69 to $126,838.03 Benefits Information Here, you matter. 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 time off, medical/dental/vision insurance, company provided life and disability insurance, paid parental leave, 403b employer match (retirement savings), a robust wellness program, and access to professional development tools, including an education benefit to help you advance your career. 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
Mass General Brigham

Utilization Management Nurse, Escalation Support

Mass General Brigham Assembly Square, MA
$90,000 - $107,000 / year
Site: Mass General Brigham Health Plan Holding Company, Inc. Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham. Job Summary Given equity, this position will pay somewhere between $90,000 to $107,000 annually. Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham, we are at the forefront of transformation with one of the world’s leading integrated healthcare systems. Together, we are providing our members with innovative solutions centered on their health needs to expand access to seamless and affordable care and coverage. Our work centers on creating an exceptional member experience – a commitment that starts with our employees. Working with some of the most accomplished professionals in healthcare today, our employees have opportunities to learn and contribute expertise within a welcoming and supportive environment that embraces their unique and varied backgrounds, experiences, and skills. We are pleased to offer competitive salaries and a benefits package with flexible work options, career growth opportunities, and much more. Provides clinical review and escalation support for Utilization Management (UM) activities by triaging inquiries, calls, ticket submissions, and external requests- evaluating medical necessity, appropriateness of care, and compliance with regulatory and organizational guidelines. Collaborates with Nurse Reviewers, Medical Directors, providers, and interdisciplinary teams to address complex cases, facilitate timely determinations, and ensure accurate application of evidence-based criteria to appropriately answer and respond to provider, member, and interdisciplinary needs. Serves as a clinical resource for escalated authorizations, appeals, and coverage determinations while promoting quality outcomes, regulatory compliance, and member-centered care. Essential Functions -Serves as the primary point of contact for escalated utilization management inquiries, ensuring timely triage, assessment, and resolution of complex provider, member, and internal stakeholder requests. -Reviews and responds to escalated authorization, coverage determination, and service-related issues, coordinating with Nurse Reviewers, Medical Directors, and operational teams to facilitate appropriate next steps and ensure regulatory compliance. -Monitors escalation channels, including phone calls, shared inboxes, ticketing systems, and other referral pathways, prioritizing requests based on clinical urgency, regulatory requirements, and business impact. -Provides consultation and clinical guidance to utilization management staff regarding benefit interpretation, medical necessity criteria, workflow processes, and resolution of complex or sensitive cases. -Identifies trends, recurring issues, and process improvement opportunities through escalation review activities, collaborating with leadership and cross-functional partners to enhance operational efficiency, provider experience, and member outcomes. Qualifications Education Associate's Degree Nursing required or Bachelor's Degree Nursing preferred Licenses and Credentials Massachusetts Registered Nurse (RN) license Basic Life Support (BLS) Certification preferred Experience At least 2-3 years of case management, utilization review, or discharge planning experience preferred Knowledge, Skills, and Abilities Giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times. Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems. Ability to establish strong rapport and relationships with patients and staff. Proficient in Microsoft Office and industry-related software programs. Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions. Ability to maintain client and staff confidentiality. Understanding of diagnostic criteria for dual conditions and the ability to conceptualize modalities and placement criteria within the continuum of care. Knowledge of Healthcare and Managed Care preferred. Additional Job Details (if applicable) Working Conditions Would need to be available for “on call” for a minimum of once per month with the possibility of that increasing depending on staff availability; Approximately 6 months after hire. This is a remote role with occasional onsite team meetings in Somerville, MA. Remote Type Remote Work Location 399 Revolution Drive Scheduled Weekly Hours 40 Employee Type Regular Work Shift Day (United States of America) Pay Range $58,656.00 - $142,448.80/Annual Grade 98TEMP At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package. EEO Statement: 8925 Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran’s Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642. Mass General Brigham Competency Framework At Mass General Brigham, our competency framework defines what effective leadership “looks like” by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.
RN Utilization Review Full-time
Elliot Health System

Utilization Review RN- Care Coordination- Full Time

Elliot Health System Manchester, NH
Come work at the best place to give and receive care! ​Job Description: RN Utilization Review Who We Are: Elliot Health System’s Care Coordination Department, located in Manchester, NH, plays a vital role in ensuring seamless, patient-centered care across the healthcare continuum. Our team is dedicated to care management, discharge planning, and patient advocacy, working closely with providers, social workers, and community resources to enhance patient outcomes. By developing individualized care plans, facilitating smooth transitions between care settings, and offering proactive support, we help patients navigate complex healthcare needs while improving overall access to high-quality, coordinated care. About the Job: Under the direction of the Director of Care Coordination, the Utilization Review RN (UR RN) is responsible for ensuring the effective and efficient use of hospital services in alignment with the hospital’s utilization review plan. What You’ll Do: Complete admission reviews to determine the appropriate level of care. Document continued stay reviews to assess the necessity of inpatient care, procedures, and estimated length of stay. Communicate and collaborate with payer care managers to prevent denials by ensuring timely clinical reviews. Address potential denials proactively, working with physicians and payer representatives to minimize retrospective denials. Screen all patients upon admission or the next business day to determine appropriate level of care using medical necessity tools, Medicare Inpatient Only List, and payer requirements. Monitor observation status patients to ensure appropriate utilization, and collaborate with admitting physicians if documentation does not support the current level of care. Perform concurrent reviews to justify extended stays, working with attending physicians to ensure accurate documentation of medical necessity. Refer cases that do not meet admission or continued stay guidelines to the Utilization Review Physician Advisor after discussions with attending physicians. Who You Are: Graduate of an accredited nursing program (Bachelor’s degree in Nursing required for nurses hired after May 2015 or commitment to obtain within a specified timeframe). Minimum of three (3) years of experience in hospital case management or utilization management. Active New Hampshire or Compact State RN license required. CCM or ACM certification preferred. Why You’ll Love Us: Health, dental, prescription, and vision coverage for full-time & part-time employees Short-term, long-term disability, life & pet insurance Tuition reimbursement 403(b) Retirement savings plans Continuous earned time accrual Work Shift: 8:00-4:30 SolutionHealth is an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, disability status, veteran status, or any other characteristic protected by law.
RN Utilization Review Full-time
Nemours Children's Health

Utilization Management Nurse

Nemours Children's Health Wilmington, DE
Job Description Nemours is seeking a Full-Time Utilization Management RN to join our team in Wilmington, DE! The Utilization Management Nurse is responsible for the monitoring patient plan of care for timely completion and efficient use of resources by facilitating diagnostic and treatment services, tests, consultations and procedures. Oversees appropriateness of care using pre-established, health industry standards ensuring the appropriate allocation and use of hospital resources. Facilitates patient flow during the inpatient stay, identifies and proactively addresses potential denials of payment. Ensures timely and efficient patient throughput of assigned patient populations. Identifies barriers and works collaboratively with the medical and ancillary teams to resolve and expedite safe discharge. Ensures all regulatory requirements related Delaware, New Jersey, Pennsylvania, Maryland and other state agencies are met/updated; further guarantees that care is aligned with: The Joint Commission (TJC) Centers for Medicare/Medicaid Services American Case Management Association Standards of Practice and Scope of Services (ACMA) The Utilization Management Nurse is accountable for adherence to policies and procedures of Nemours Children’s Hospital, Delaware Valley, and other affiliated hospitals to which Nemours-delegated patients are admitted/seek care. The Utilization and Nurse Case Management Manager is expected to maintain all state and federal clearances for DE. Essential Functions Conducts initial clinical reviews within 24 hours of patient admission. All reviews are to follow unit standards as per UM concurrent review guidelines. Provides concurrent admission, continued stay and retrospective review to insurance company staff as contractually required. Communicates anticipated Length of Stay and insurance review results to interdisciplinary team. Participates in interdisciplinary rounds as indicated. Identifies patients who do not meet current patient class criteria and takes action to communicate and change to appropriate level of care as indicated with attending physician and interdisciplinary team. Converts observation to admission and, conversely, admission to observation status; communicates change to team and others as needed. Mediates between physicians and insurance companies to avoid denials by monitoring patient plan of care and intervening as needed to assure timely completion of care at appropriate level of care. Facilitates the timely completion of diagnostic tests, procedures and treatment services, consultations and discharge planning activities in collaboration with the case management staff. Monitors payer authorization for continued stay Collaborates with patient care team to ensure efficient patient throughput. Communicates length of stay authorizations and barriers to discharge to unit based team daily; working within the team to identify and resolve issues. Monitors and facilitates correct patient class and accommodation codes via the EMR for every patient. Adheres to and participates in revisions to all policies and procedures within the department. Qualifications BSN Degree required RN licensure in the state of DE required 5+ years of related experience About Us Nemours Children's Health is an internationally recognized pediatric health system serving more than 1.7 million patient encounters each year. We deliver care across six states through two freestanding children’s hospitals — Nemours Children's Hospital, Delaware and Nemours Children's Hospital, Florida — along with a network of more than 80 primary, urgent, and specialty care practices and more than 40 hospital partnerships. Backed by the Nemours Foundation and Alfred I. duPont Trust, our $1.7B nonprofit system is dedicated to improving children's health through clinical care, research, education, advocacy, and prevention. Our Whole Child Health approach focuses equally on prevention and treatment, partnering with communities to help every child thrive. Inclusion and belonging guide our strategy and growth. We are committed to culturally relevant care, reducing health disparities, and fostering an environment where every associate, patient, and family feels supported and valued. Learn more at Nemours.org .