Registered Nurse (RN) Utilization Review Jobs

RN Utilization Review Per Diem
Kaiser Permanente

Case Manager Utilization RN, Per Diem Day

Kaiser Permanente 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
Kaiser Permanente

Case Management Utilization RN, 20/hr Day

Kaiser Permanente 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 Other
Baylor Scott & White Health

Utilization Review RN, PRN

Baylor Scott & White Health Dallas, TX
About Us Here at Baylor Scott & White Health we promote the well-being of all individuals, families, and communities. Baylor Scott and White is the largest not-for-profit healthcare system in Texas that empowers you to live well. Our Core Values are: We serve faithfully by doing what's right with a joyful heart. We never settle by constantly striving for better. We are in it together by supporting one another and those we serve. We make an impact by taking initiative and delivering exceptional experience. Benefits Our benefits are designed to help you live well no matter where you are on your journey. For full details on coverage and eligibility, visit the Baylor Scott & White Benefits Hub to explore our offerings, which may include: Immediate eligibility for health and welfare benefits 401(k) savings plan with dollar-for-dollar match up to 5% Tuition Reimbursement PTO accrual beginning Day 1 Note: Benefits may vary based upon position type and/or level. Job Summary Are you seeking an impactful nursing role? As a Utilization Review RN, review cases to determine medical suitability for insured patients. Your expertise shines through meticulous clinical reviews using established criteria. You play a key role in supporting the healthcare team by optimizing resources and implementing care plans. Communication with health plan departments is important to ensure services meet medical necessity standards. This includes prospective, concurrent, and retrospective reviews. Essential Functions of the Role You will review all cases. Use medical guidelines to evaluate services. Understand patient needs. Resolve complex matters when necessary. Confirm admission status is correct. Collaborate with Utilization Review coordinators when needed. You will communicate with insurance. Talk to doctors about patients. Make sure needed paperwork is completed. You'll report insurance company issues to leadership. Identify and communicate quality assurance or risk management issues promptly when they arise. You will help improve our processes by evaluating, developing, and implementing protocols, policies, and procedures. Key Success Factors Comprehensive understanding of diverse healthcare techniques, practices, and industry-related language. Proficiency in customer engagement, ensuring their concerns are heard and promptly addressed. Thorough understanding of discharge planning, care coordination, utilization assessment and care levels. Knowledge of local and national regulations is needed, like those from the Department of Insurance and Department of Labor. Centers for Medicare and Medicaid Services, Health and Human Services Commission, and National Committee for Quality Assurance are also important. Exceptional communication skills, including articulating thoughts clearly in speech and writing. Personable, with the ability to interact effectively with a diverse range of stakeholders. Problem-solving capability, equipped with critical thinking skills. Ability to juggle multiple tasks and work under time pressures. Belonging Statement We believe that all people should feel welcomed, valued and supported. Qualifications Associate degree. Prior experience of at least (3) three years in the nursing field. Must have a valid nursing registration (RN).
RN Utilization Review Full-time
VNS Health

Utilization Management RN - Utilization Management

VNS Health New York, NY
Overview Assesses member needs and identifies solutions that promote high quality and cost-effective health care services. Manages providers, members, team, or care manager generated requests for medical services and renders clinical determinations in accordance with healthcare policies as well as applicable state and federal regulations. Delivers timely notification detailing clinical decisions. Coordinates with management, subject matter experts, physicians, member representatives, and discharge planners in utilization tracking, care coordination, and monitoring to ensure care is appropriate, timely and cost effective. Works under general supervision. What We Provide Referral bonus opportunities Generous paid time off (PTO), starting at 30 days of paid time off and 9 company holidays Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life and Disability Employer-matched retirement saving funds Personal and financial wellness programs Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care Generous tuition reimbursement for qualifying degrees Opportunities for professional growth and career advancement Internal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities. What You Will Do Conducts comprehensive review of all components related to requests for services which includes a clinical record review and interviews with members, clinical staff, medical providers, paraprofessional staff, caregivers and other relevant sources as necessary. Examines standards and criteria to ensure medical necessity and appropriateness of admissions, treatment, level of care and lengths of stay. Performs prior authorization and concurrent reviews to ensure extended treatment is medically necessary and being conducted in the right setting. Reviews requests for outpatient and inpatient admission; approves services or consults with medical directors when case does not meet medical necessity criteria. Ensures compliance with state and federal regulatory standards and VNS Health policies and procedures. Participates in case conferences with management. Identifies opportunities for alternative care options and contributes to the development of patient focused plan of care to facilitate a safe discharge and transition back into the community after hospitalization. Reviews covered and coordinated services in accordance with established plan benefits, application of evidenced based medical criteria, and regulatory requirements to ensure appropriate authorization of services and execution of the plan’s fiduciary responsibilities. Identifies and provides recommendations for improvement regarding department processes and procedures. Maintains current knowledge of organizational or state-wide trends that affect member eligibility and the need for issuance of Determination Notices Improves clinical and cost-effective outcomes such as reduction of hospital admissions and emergency department visits through on-going member education, care management and collaboration with IDT members. Provides input and recommendations for design and development of, processes and procedures for effective member case management, efficient department operations, and excellent customer service. Maintains accurate record of all care management. Maintains written progress notes and verbal communications according to program guidelines. Verifies that all aspects of the clinical record are in agreement with the member’s clinical and functional status. Utilizes VNS Health and state approved assessment and documentation as well as interviews with members, family, and care providers in decision-making. Performs annual clinical co-visits for nurses as well as two initial co-visits during the first six months for new hires as follows: one within first three weeks and a second within the first six months. Provides feedback to therapist and management; assists in development of plans to address improvement needs as appropriate. For Utilization Management Only: Issues Determinations, Notices of Action, and other forms of communication to members and providers which communicate VNS Health’s determinations. Ensures all records/logs related to decision requests, Notices of Action, and other communications required by state or federal regulations are saved in the Utilization Management System. Reviews, evaluates and determines the appropriateness of requests, utilize the most appropriate clinical care guidelines based on clinical practice guidelines. Adheres to all federal and regulatory requirements. Evaluates and analyzes care and utilization trends/issues and identifies opportunities for better coordination of members’ care. Qualifications Licenses and Certifications: Current license to practice as a Registered Professional Nurse in New York State required. Certified Case Manager preferred Education: Associate's Degree in Nursing required. Bachelor's Degree or Master’s degree in nursing preferred Work Experience: Minimum two years of experience with strong cost containment /case management background or two years acute inpatient hospital experience in chronic or complex care required Must have experience and qualifications demonstrating knowledge of working with the LTSS eligible population. preferred Knowledge of Medicare and Medicaid regulations required Excellent organizational and time management skills, interpersonal skills, verbal and written communication skills. Working knowledge of Microsoft Excel, Power-Point, and Word and strong typing skills required Knowledge of Medicaid and/or Medicare regulations required Knowledge of Milliman criteria (MCG) preferred For UM Only: Experience must be with a Managed Care Organization or Health Plan. For SelectHealth ETE Only: Experience in Public Health programming, delivery and evaluation preferred Experience working with community-based organizations in underserved communities preferred Pay Range USD $85,000.00 - USD $106,300.00 /Yr. About Us VNS Health has been committed to meeting the needs of New Yorkers for over 130 years. We’re one of the largest nonprofit home- and community-based health care organizations in the country, and today, more than 11,500 team members work together to make a difference in the lives of more than 99,000 patients and members on any given day.
RN Outpatient Utilization Review Outpatient
L.A. Care Health Plan

Utilization Management Nurse Specialist RN II (Outpatient)

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

Utilization Management Nurse RN

UnitedHealthcare Newtown Square, PA
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. The Utilization Management Nurse will accurately and efficiently review and extract pertinent case details from patient medical records; and craft strongly defensible appeal letters per process instructions and the department's/company's guidance. The nurse will complete their case within the time expectations while providing high quality reviews. The Utilization Management Nurse will perform their job functions, adhering to both Optum and OPAS policies and procedures, which include but are not limited to the following Schedule: Monday - Friday (40 Hours a Week) Flexible start times with the ability to support evening, weekend and holiday shifts. You will enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges. Primary Responsibilities: Follows directive of composing appeal letters to include appropriate data extraction, construction of well-written appeals letters with proper grammar, utilization of appeal tools including pre-constructed templates, inclusion of appropriate medical literature references, and use of national criteria guidelines. Adheres to company policies and procedures as well as policies, procedures, and laws Understands and complies with HIPAA confidentiality requirements Support and promote OPAS, Optum, and the enterprise goals and mission Build relationships across Optum, OPAS, OGA and our clients Collaborate with peers to assure continuity of communication and execution of deliverables as needed Adheres to quality and productivity expectations Participate in and contribute to meetings as appropriate Maintains organization on the team and ensures everyone conducts themselves professionally Remains up to date with all learning modules, competencies, and state required licenses Performs other related duties, tasks, and processes as required by leadership Ability to establish priorities, be self-motivated, work independently, and follow instructions with supervision and structure Positive attitude and the ability to function as a collaborative team member 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: Associate's degree Unrestricted Registered Nurse license in your state of residence 3+ years of bedside nursing experience in adult ED/telemetry/ICU/CCU Advanced level of proficiency with Microsoft applications and software, internet navigation and utilization Ability to type 45 wpm Preferred Qualifications: Working knowledge of InterQual and MCG Prior experience with utilization management Working knowledge of Word Strong, effective verbal and written communication skills *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 salary for this role will range from $60,200 to $107,400 annually based on full-time employment. We comply with all minimum wage laws as applicable. Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records. 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. Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law. UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. #RPO, #GREEN
RN Utilization Review
UnitedHealthcare

Clinical Claim Review RN

UnitedHealthcare Plymouth, MN
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. The Medical Coding Auditor is required to determine the accuracy of claims submitted by a provider to UnitedHealth Group by comparing it to the medical record(s) submitted for the date(s) of service being reviewed. This position supports the identification of suspected Waste & Error of health insurance claims and ensures claims are accurately documented. Candidates must be able to exercise judgement/decision making on complex payment decisions that directly impacts the provider and client by following state and government compliance guidelines, coding requirements and policies. They must confidently analyze and interpret data and medical records/documentation daily to understand historical claims activity, determine validity and demonstrate their ability to provide written communication to the provider. They are responsible to investigate, review and provide clinical and/or coding expertise in a review of claims. They need to effectively manage their caseload and monthly metrics in a production driven environment and ensure they are meeting all compliance turnaround times mandated by the client. The Coding Quality Analyst must be proficient in computer skills and able to navigate multiple systems at one time with varying levels of complexity. They must have the ability to research and work independently on making decisions on complex cases. You'll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges. Primary Responsibilities: Performs clinical review of CPT, HCPCS, and modifiers assigned to codes on claims in a telecommuting work environment Determines accuracy of medical coding/billing and payment recommendation for claims This could include Medical Director/physician consultations, interpretation of state and federal mandates, applicable benefit language, medical and reimbursement policies, and consideration of relevant clinical information Determines appropriate level of service utilizing Evaluation and Management coding principles Provides detailed clinical narratives on case outcomes Ensures adherence to state and federal compliance policies, reimbursement policies and contract compliance Identifies aberrant billing patterns and trends, evidence of fraud, waste, or abuse, and recommends providers to be flagged for review Maintains and manages daily case review assignments, with accountability to quality, utilization, and productivity standards Provides clinical support and expertise to the other investigative and analytical areas Participates in team and department meetings Engages in a collaborative work environment when applicable but is also able to work independently Serves as a clinical resource to other areas within the clinical investigative team Work with applicable business partners to obtain additional information relevant to the clinical review 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: Certified Coder AHIMA (CCA, CCS, CCS-P) or AAPC Certified coder (CPC, CPC-I) 2+ years of experience as an AHIMA or AAPC Certified coder 2+ years of CPT/HCPCS/Modifiers coding experience 2+ years of strong medical record review experience 1+ years of working in a team atmosphere in a metric driven environment including daily production standards and quality standards 1+ years of experience in the health insurance business, using industry terminology and regulatory guidelines 1+ years of experience in Waste & Error principles Preferred Qualifications: Healthcare claims experience/processing experience Experience with Fraud Waste & Abuse or Payment Integrity [Internal Posting Only] 1+ year experience of UHC platforms - COSMOS, Facets, CPW, NICE, ISET, UNET Proficient and able to navigate and maneuver multiple systems at one time with varying levels of complexity Strong computer skills with the ability to troubleshoot problems Intermediate experience with Microsoft & Adobe applications (Outlook, Power Point, Word, Excel, OneNote, Teams, PDF) Soft Skills: Highly organized with effective and persuasive communication skills Strong written communication skills Open to change and new information; ability to adapt in changing environments and integrate best practices Strong communication skills with the ability to interpret data Strong analytical mindset working with medical terminology and/or coding *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 $35 to $63 per hour based on full-time employment. We comply with all minimum wage laws as applicable. Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records. 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. #RPO #GREEN
RN Utilization Review
Health & Hospital Corporation

QUALITY REVIEW NURSE (RN)

Health & Hospital Corporation Indianapolis, IN
Health and Hospital Corporation is an organization that celebrates diversity, and seeks to employ a diverse workforce. We actively encourage all individuals to apply for employment and to seek advancement opportunities. Health and Hospital Corporation also provides reasonable accommodations to qualified individuals with disabilities as required by law. For additional questions please contact us at: hrmail@hhcorp.org. Job Role Summary The Quality Review Registered Nurse (RN) position assists the Vice President of Long Term Care and other department personnel in the review and analysis of care and services provided by Health and Hospital Corporation (HHC) owned nursing homes and licensed residential facilities. Performs on site and office review of various clinical resident care services and nursing management operations at the long term care facilities and prepares related reports for the long term care department, individual facilities and the contract management company. Assists in the analysis of various aspects of nursing home operations using professional standards of practice and industry benchmarks and in the preparation of reports for the HHC Board of Directors’ Planning Committee. This position is responsible for promoting health and wellbeing of long term care residents of Health and Hospital Corporation Marion County nursing facilities by promoting preventive, therapeutic, and supportive care based on standards of practice and in compliance with all applicable regulatory requirements.Essential Duties Responsibility 1: 70% Performs quality review oversight visits to HHC owned nursing homes and retirement communities as assigned. May serve as a member of a quality review team or at times may visit assigned facilities as the sole representative from the HHC Long Term Care Department. Maintains a professional and supportive role when interacting with the nursing home and licensed residential facility staff providing helpful observations and suggestions. Performs various auditing/review activities during the site visits including but not limited to: medication administration observations, wound care and treatment administration, personal care services, meal service, clinical record reviews and review of nursing management records. At times may assist the other members of the quality review team to complete their assigned tasks. Other review tasks may include: resident or family interviews, review of quality assurance records, in-service training records, personnel files, incident report logs, professional facility consultant reports and other records as assigned. Must be knowledgeable and mindful of potential liability and other risk management issues and methods for taking appropriate preventative or corrective action. Participates in the exit conferences held with facility management and the quality reviewers and provides summary information regarding significant observations during the facility visit including specific resident and employee identification when possible. When requested, participates in taking notes at the exit conference for exit conference reports. Prepares a written site visit report following each facility visit in cooperation with other quality review team members who participated in the facility visit. Reviews report for accuracy, and clarity. Distributes reports in a confidential manner to all parties and maintains HHC records. Assures the retention and confidentiality of all data materials from facility visits and forwards to the department Executive Assistant for proper storage/retention. Responsibility 2: 30% Participates in the compilation and completion of quarterly and other reports prepared for the HHC Board of Directors’ Planning Committee. May attend HHC Planning Committee meetings as assigned to represent the Long Term Care Department or to present a special report. Assists in the completion and follow up of any requests or directives resulting form the Planning Committee meetings as assigned. Accepts phone calls from residents, family members and interested parties in the absence of other Long Term Care Department staff or as assigned. Receives concerns or information in a manner that reflects good customer service practices and prepares detailed written information for the Vice President’s review and processing. Attends community and professional association functions and meetings representing HHC Long Term Care division as requested. Participates in the development of educational materials and staff training programs relative to long term care. Assists in development of departmental policies, procedures and forms for use in the departmental functions. In the absence of the Executive Assistant, makes travel arrangements/reservations for department staff conducting out of town facility site visits. Must be able to communicate effectively in verbal and written communications and able to adhere to deadlines and interruptions and frequent assignment changes, etc. Must have good customer service skills for interacting with facility residents and personnel on site visits as well as the general public. Qualifications Graduate of an approved school of nursing (diploma, associate or B.S. degree). Access to own vehicle and current automobile insurance. 5 – 10 years of previous experience in long term care in a nursing management role. Knowledge of local/State/Federal laws and regulations applicable to state licensure of nursing homes and residential nursing facilities, federal regulations for skilled nursing homes and participation in Medicare and Medicaid programs, communicable disease control, and other applicable long term care requirements. Licenses/Certifications Required Licensed Registered Nurse (Indiana). Valid Indiana Driver’s license. Working Environment Unconfined sitting 75% Confined sitting 15% Standing or walking 10% Steady use of hands or fingers – Typing and filing 85% Lift, carry, etc. with arms and legs – Carrying small boxes to meetings 15% Ability to perform driving functions in normal course of work day with confined sitting for several hours at times. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.
RN Utilization Review Part-time
Cleveland Clinic

PRN Utilization Management RN Reviewer NE

Cleveland Clinic Weston, FL
At Cleveland Clinic Health System, we believe in a better future for healthcare. And each of us is responsible for honoring our commitment to excellence, pushing the boundaries and transforming the patient experience, every day. We all have the power to help, heal and change lives — beginning with our own. That’s the power of the Cleveland Clinic Health System team, and The Power of Every One. Job Title PRN Utilization Management RN Reviewer NE Location Weston Facility Florida Weston Hospital Department Care Management Nursing Institute-Nursing Institute Job Code 000445 Shift Days Schedule 8:00am-4:30pm Job Summary Job Details Join Cleveland Clinic Weston Hospital’s team of caregivers that remain on the leading edge of technology and education, all while consistently providing patient-centered healthcare. As part of Cleveland Clinic’s Florida region, Weston Hospital is recognized as one of the top hospitals in the Miami-Fort Lauderdale and Florida regions. Here, you will receive endless support and appreciation while building a rewarding career with one of the most respected healthcare organizations in the world. Utilization Management (UM) Specialists perform UM activities, such as admission review, concurrent review, retrospective chart review and clinical systems review to measure clinical performance and UM issues that affect reimbursement for the patient’s hospital stay or visit. Some of the responsibilities of a Utilization Management Specialist include medical record review, providing clinical information to payers, UM data collection and reporting, concurrent denials appeals process, clinical team interaction, Physician Adviser interaction and special projects. This is a regular PRN position, with caregivers working days between 8:00 a.m. – 4:30 p.m. with weekend requirements. This remote role is limited to Florida, Ohio, and Nevada. Candidates must live within one hour of a Cleveland Clinic hospital to be eligible. A caregiver who excels in this role will: Recommend resource utilization. Prioritize and organize work to meet changing priorities. Utilize analytical abilities required to gather data. Use clinical judgment to apply predetermined criteria or use independent clinical judgment when no predetermined criteria exist to identify problems, facilitate resolution, recommend corrective action, and report results effectively. Use independent clinical judgment in reviewing records to determine status of patients stay, if proper procedures have been followed, seriousness of incidents and ability to identify need for and participate in focused reviews, special projects and identify opportunities for improvement. Make recommendations regarding appropriateness of the treatment plan for continued stay and safety of the discharge plan. Achieve a minimum of 85% on IRR quarterly. Complete utilization management for assigned patients with at least 25-30 reviews per day. Apply medical necessity guidelines accurately to monitor appropriateness of admission and continued stays. Document appropriately in UM notes to provide evidence that the UR process for the case was followed. Attend all staff meeting when scheduled to work. Other duties as assigned. Minimum qualifications for the ideal future caregiver include: Graduate of an accredited school of nursing Current state licensure as a Registered Nurse (RN) Basic Life Support (BLS) certification through the American Heart Association (AHA) or American Red Cross Three years of equivalent full-time clinical experience as a Registered Nurse Knowledge of medical terminology, anatomy and physiology, diagnosis, surgical procedures, and basic disease processes Analytical ability to gather data, decide on conformity based on predetermined criteria, identify problems and refer for resolution Basic knowledge of medical records coding standards Awareness of licensing and accreditation standards Proficient with Microsoft Office Knowledge of billing practices, identification of billing problems, adequacy of documentation, and ability to conduct research of issue at hand, as well as formulate recommendations based on findings. Knowledge and experience with Care Guidelines, Medical Necessity Criteria and/or other UM criteria sets Ability to assess medical records and make determinations on length of stay and proper procedures in accordance with policies and procedures Knowledge of and ability to use multiple Hospital information systems and Department's software Ability to use copier, fax machine and personal computer Preferred qualifications for the ideal future caregiver include: Bachelor of science in nursing (BSN) Case Management Certification (CCM) preferred within first year of eligibility Prior Utilization Management experience Case management or ED experience Physical Requirements: Requires walking, sitting, and/or standing for long periods of time. Requires constant attention to detail, reading of medical records, and meeting deadlines. Works in an environment where there is some discomfort due to dust, noise, temperature. Personal Protective Equipment: Follows standard precautions using personal protective equipment. The policy of Cleveland Clinic Health System and its system hospitals (Cleveland Clinic Health System) is to provide equal opportunity to all of our caregivers and applicants for employment in our drug free environment. All offers of employment are followed by testing for controlled substances. Cleveland Clinic Health System administers an influenza prevention program. You will be required to comply with this program, which will include obtaining an influenza vaccination on an annual basis or obtaining an approved exemption. Decisions concerning employment, transfers and promotions are made upon the basis of the best qualified candidate without regard to color, race, religion, national origin, age, sex, sexual orientation, marital status, ancestry, status as a disabled or Vietnam era veteran or any other characteristic protected by law. Information provided on this application may be shared with any Cleveland Clinic Health System facility. If applying for a Florida position, please see the following website for more information on the background screening requirements required by the Agency of Health Care Administration: https://info.flclearinghouse.com/ Please review the Equal Employment Opportunity poster . Cleveland Clinic is pleased to be an equal employment opportunity employer.
RN Utilization Review Correctional Other
US Department of Justice

Nurse (Utilization Review Nurse)

US Department of Justice Stockton, CA
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 Telehealth Full-time
Penn Medicine

Full-Time Clinical Documentation Review Specialist-RN -Days-Fully Remote

Penn Medicine PA
Description Penn Medicine is dedicated to our tripartite mission of providing the highest level of care to patients, conducting innovative research, and educating future leaders in the field of medicine. Working for this leading academic medical center means collaboration with top clinical, technical and business professionals across all disciplines. Today at Penn Medicine, someone will make a breakthrough. Someone will heal a heart, deliver hopeful news, and give comfort and reassurance. Our employees shape our future each day. Are you living your life's work? Summary: The Clinical Documentation Review Specialist is responsible for collaborating with clinicians to assure accurate completion of documentation and development of effective plans of care to assure appropriate utilization and promote appropriate quality patient care and positive patient outcomes. Responsibilities: Documentation Improvement: Reviews clinical documentation for compliance with state, federal, and TJC regulations. Follows up with team for clarification if documentation is unclear. Identifies and documents delays. Collaborates with clinicians to assure accurate completion of documentation and development of effective plans of care. Elevates issues appropriately. Utilization Management: Collects and submits data as indicated. Quality Improvement and Risk Management: Reviews clinical reports for compliance with state, federal, and TJC regulations. Collects and submits data as indicated. Communicates with service line and clinical effectiveness team members. Works with department leadership to develop and implement solutions to issues identified. Credentials: RN (Required) Must have Pennsylvania RN Education or Equivalent Experience: Bachelor of Arts or Science (Required) Education Specialization: Must have BSN from an accredited school of nursing Equivalent Experience: •And 2+ years In Medicare regulations for OASIS, compliance, and coding and/or experience in home care criteria and processes. We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region. Penn Medicine employees are actively engaged and committed to our mission. Together we will continue to make medical advances that help people live longer, healthier lives. Live Your Life's Work We are an Equal Opportunity employer. Candidates are considered for employment without regard to race, ethnicity, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, age, disability, marital status, familial status, genetic information, domestic or sexual violence victim status, citizenship status, military status, status as a protected veteran or any other status protected by applicable law.
RN Utilization Review Outpatient Full-time
Denver Health

RN Registered Nurse, Utilization - Denver Health Medical Plan (Must Live In Colorado. Weekly On Site Requirement.)

Denver Health Lincoln Park, CO
We are recruiting for a mission-driven RN Registered Nurse, Utilization - Denver Health Medical Plan (Must Live In Colorado. Weekly On Site Requirement.) to join our team! We're with you for life’s journey. At Denver Health, purpose isn’t just something we believe in—it’s something we live every day, for life’s journey. Our Values Respect | Belonging | Accountability | Transparency Department Managed Care Administration * Must live in Colorado * This is a hybrid role with a requirement of being in the office 2 days per week. Job Summary Under general supervision the RN, Utilization Coordinator performs initial inpatient or outpatient utilization review activities to determine the efficiency, effectiveness and quality of medical and behavioral health services. In collaboration with the UM Supervisor, serves as liaison between ordering and service providers and the Health Plan. Makes medical determination decisions within defined protocols based on review of the service requests, clinical and non-clinical data, Member eligibility, and benefit levels in accordance with contract and policy guidelines. Convey approval or denial of requested services, identifies and reports on specific cases, and provides information regarding utilization management requirements and operational procedures to members, providers and facilities. Essential Functions : Performs clinical review of inpatient or outpatient service request using clinical judgment, nationally accepted clinical guidelines, knowledge of departmental procedures and policies within timeliness guidelines for preservice, urgent or concurrent review. (30%) Consults on cases with Supervisor, Manager, Director or Medical Director. Requests additional info from requesting providers, as needed. (20%) Creates correspondence to Members and Providers related to clinical determination; adjusts language to appropriate literacy level to support lay person understanding of medical terminology. (15%) Routes potential denials of service/care are referred to Medical Directors for review in a comprehensive, timely and professional manner. (10%) Support and collaborate with the UM and CM Managers and Supervisors in the implementation and management of UM/CM activities. (10%) Mentors and performs peer reviews. (10%) Participates in ongoing education and training related to health plan benefits and limitations, regulatory requirements, clinical guidelines, inter-rater reliability testing, community standards of patient care, and professional nursing standards of practice. (5%) Education : Associate's Degree Completion of a nursing education program that satisfies the licensing requirements of the Colorado State Board of Nursing for Registered Nurses required Work Experience : 1-3 years clinical experience in a hospital, acute care, home health/hospice, direct care or case management required - Or - 1-3 years experience in care coordination, case management or member navigation required Medicaid and Medicare Managed Care experience preferred Home care/field-based case management, or working with the needs of vulnerable populations who have chronic medical, behavioral health or social needs preferred Certification in Case Management preferred Licenses : RN-Registered Nurse - DORA - Department of Regulatory Agencies required Knowledge, Skills and Abilities : Knowledge and understanding of case management/coordination of care principles, programs, and processes in either a hospital or outpatient healthcare environment. Effectively collaborate with and respond to varied personalities in differing emotional conditions, and maintain professional composure at all times. Strong customer service orientation and aptitude. Problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action. Ability to communicate verbally and in writing complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others. * Must live in Colorado * This is a hybrid role with a requirement of being in the office 2 days per week. Shift Days (United States of America) Work Type Regular Salary $71,400.00 - $107,100.00 / yr Benefits At Denver Health, we take care of the people who take care of our community. Our benefits are built to support your life, your family, and your future — with generous paid time off, fully paid parental leave, exceptional retirement contributions, comprehensive health coverage, and nationally recognized well-being programs. We invest in your growth through tuition assistance, career advancement pathways, and professional development — while also offering meaningful financial advantages through loan forgiveness eligibility and employer contributions. When you join Denver Health, you’re joining a mission-driven organization that invests in you. Here is a small list of our benefit programs: Paid time off starting at 28 days per year, inclusive of vacation, personal/sick, and 7 Holidays 100% paid parental leave up to 6 weeks Immediate eligibility for retirement plans with employer contribution up to 9.5% Generous medical, dental, vision plans in addition to employer paid disability and life insurance. Comprehensive well-being programs including on-site employee fitness center located on Denver Health main campus and nationally recognized RESTORE Center Free RTD EcoPass (public transportation) Childcare discount programs & exclusive perks on large brands, travel, and more Tuition reimbursement & assistance Education, coaching, and professional development opportunities through the Workforce Development Center (WFDC) that support internal career growth and advancement pathways Professional clinical advancement program & shared governance Public Service Loan Forgiveness (PSLF) eligible employer+ free student loan coaching and assistance navigating the PSLF program National Health Service Corps (NHCS) and Colorado Health Service Corps (CHSC) eligible employer About Denver Health Denver Health is an integrated, high-quality academic healthcare system considered a model for the nation that includes a Level I Trauma Center, a 555-bed acute care medical center, Denver’s 911 emergency medical response system, 10 family health centers, 19 school-based health centers, Rocky Mountain Poison & Drug Safety, the Public Health Institute at Denver Health, Denver Health Medical Plan and Denver Health Foundation. As Colorado’s primary, and essential, safety-net healthcare system, Denver Health is a mission-driven organization that has provided millions in uncompensated care for the uninsured each year. Located near downtown Denver, Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer. Denver Health is an equal opportunity employer (EOE). We value the unique ideas, talents and contributions reflective of the needs of our community. All job applicants for safety-sensitive positions must pass a pre-employment drug test, once a conditional offer of employment has been made. Applicants will be considered until the position is filled.
RN Utilization Review Home Health
UnitedHealthcare

Utilization Case Manager RN - In-Home Services - Milwaukee, WI

UnitedHealthcare Milwaukee, WI
$60,200 - $107,400 / year
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 Utilization Case Manager serves Milwaukee County with occasional coverage in surrounding counties. This position offers the flexibility to work from the office and at home with field-based work in the local community approximately 25% of the work week. This role requires you to reside within a commutable distance of Milwaukee, WI and surrounding areas. Primary Responsibilities: Making outbound calls to assess members' current health status Conducting face to face assessments in the member's home Assisting members in identifying unmet needs Documenting assessment details and applying State guidelines to requests for services Documenting and tracking findings Identifying gaps or barriers in treatment plans Providing patient education to assist with self- management Interacting with Medical Directors on challenging cases Coordinating care for members Making referrals to outside sources Coordinating services as needed (home health, DME, etc.) Educating members on disease processes Encouraging members to make healthy lifestyle changes 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 Wisconsin 2+ years of experience in a hospital setting, acute care, direct care experience or experience as a Home Health Case Manager Basic level of experience with Microsoft Office and other electronic medical record applications Reliable transportation to travel to member's homes within the geographical area Willing to travel up to 25% to member homes Preferred Qualifications: Home Health Case Management experience Experience in utilization review, concurrent review and / or risk management Experience working with the needs of vulnerable populations who have chronic or complex bio-psychosocial needs Experience with the Personal Care Screening Tool (PCST) or the Long Term Care Functional Screen (LTCFS) A background in Medicaid / Medicare managed care Bilingual Spanish Bilingual Hmong 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 salary for this role will range from $60,200 - $107,400 annually based on full-time employment. We comply with all minimum wage laws as applicable. #UHCPJ 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 Manager Utilization RN, 32 Day

Kaiser Permanente Los Angeles, 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
Kaiser Permanente

Case Manager Utilization RN

Kaiser Permanente Bellflower, 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
Kaiser Permanente

Case Manager Utilization RN

Kaiser Permanente Los Angeles, 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
University of Rochester Medical Center

RN, Utilization Management

University of Rochester Medical Center Rochester, NY
$81,307 - $109,761 / year
As a community, the University of Rochester is defined by a deep commitment to Meliora - Ever Better. Embedded in that ideal are the values we share: equity, leadership, integrity, openness, respect, and accountability. Together, we will set the highest standards for how we treat each other to ensure our community is welcoming to all and is a place where all can thrive. Job Location (Full Address): 601 Elmwood Ave, Rochester, New York, United States of America, 14642 Opening: Worker Subtype: Regular Time Type: Full time Scheduled Weekly Hours: 40 Department: 500009 Utilization Management Work Shift: UR - Day (United States of America) Range: UR URCD 215 Compensation Range: $81,307.00 - $109,761.00 The referenced pay range represents the minimum and maximum compensation for this job. Individual annual salaries/hourly rates will be set within the job's compensation range, and will be determined by considering factors including, but not limited to, market data, education, experience, qualifications, expertise of the individual, and internal equity considerations. Responsibilities: Works collaboratively with various departments across the entire health care system to review clinical documentation, utilizing evidence based criteria to support medical necessity and appropriate level of patient care for services provided. Reports outcome trends and patterns to UM leadership to help identify educational opportunities and performance improvement initiatives across the health care continuum. Adapts to process changes and assists with education efforts that support ongoing improvement. ESSENTIAL FUNCTIONS Determines level of care per regulatory requirements. Provides level of care notifications to patients and families as needed. Works collaboratively with payers to ensure authorization for dates of service. Collaborates with HIM, providers, Financial Counseling and Patient Financial Services. Monitors all UM hold bills and unplanned readmission reports. Conducts initial and concurrent reviews, utilizing evidence based criteria through Interqual. Supports discharge appeal process. Responsible for departmental denials and appeal activity. Documents according to regulatory guidelines and UM RN workflow protocols. Conducts clinical documentation improvement efforts through query process. Meets productivity expectations established by UM department. Provides and supports ongoing educational needs for all UM customers. Other duties as assigned. MINIMUM EDUCATION & EXPERIENCE Associate's degree in Nursing and 3 years of acute hospital experience required Bachelor's degree in Nursing (BSN) preferred Or equivalent combination of education and experience Utilization Management experience preferred KNOWLEDGE, SKILLS AND ABILITIES Database experience including: Interqual, Sharepoint, eRecord, ePARC, Cobius preferred LICENSES AND CERTIFICATIONS RN - Registered Nurse - State Licensure and/or Compact State Licensure NYS Registered Nurse license upon hire required The University of Rochester is committed to fostering, cultivating, and preserving an inclusive and welcoming culture to advance the University’s Mission to Learn, Discover, Heal, Create – and Make the World Ever Better. In support of our values and those of our society, the University is committed to not discriminating on the basis of age, color, disability, ethnicity, gender identity or expression, genetic information, marital status, military/veteran status, national origin, race, religion, creed, sex, sexual orientation, citizenship status, or any other characteristic protected by federal, state, or local law (Protected Characteristics). This commitment extends to non-discrimination in the administration of our policies, admissions, employment, access, and recruitment of candidates, for all persons consistent with our values and based on applicable law.
RN Utilization Review
UCLA Health

Utilization Management Nurse Auditor

UCLA Health Los Angeles, CA
$98,200 - $214,600 / year
Description Patient Business Services Provide clinical review, audit, analytical, and quality improvement support for utilization management, medical necessity determinations, and denial prevention and response efforts across the health system. As the Utilization Management Nurse Auditor, you will conduct concurrent and retrospective case reviews, support denial appeals, analyze utilization and denial trends, and collaborate with Care Coordination, Clinical Documentation Integrity, Revenue Cycle, and Physician Advisor teams. This role helps strengthen level-of-care determinations, clinical documentation, payer compliance, and operational and financial performance. In this role, you will: • Review concurrent and retrospective clinical denials to assess admission status, level of care, length of stay, medical necessity, and other factors contributing to denials. • Prepare clinical summaries and supporting documentation for first- and second-level appeals, support payer, RAC, and Medi-Cal audit responses, and collaborate with Revenue Cycle and Physician Advisor teams to strengthen appeal strategies. • Analyze denial and audit findings to identify trends, root causes, documentation gaps, avoidable delays, and opportunities to improve utilization management performance. • Evaluate cases using established utilization review criteria, including InterQual, MCG, organizational guidelines, and payer requirements, and escalate complex or questionable cases as appropriate. • Partner with Physician Advisors, Care Coordination teams, and clinical staff to improve documentation supporting medical necessity, status designation, and accurate level-of-care determinations. • Prepare reports, dashboards, presentations, case summaries, trend analyses, and recommendations for leadership and Utilization Management Committee review. • Support performance improvement initiatives focused on length of stay, avoidable days, denial rates, status accuracy, utilization outcomes, and data integrity. • Serve as a clinical resource while collaborating with clinical and operational leaders across the health system to support utilization management, clinical quality, patient safety, care progression, discharge planning, and continuous improvement efforts. Salary Range: $98,200 to $214,600 annually
RN Utilization Review Outpatient
Tampa General Hospital

Case Manager, RN- Utilization Review

Tampa General Hospital Tampa, FL
Case Manager, RN- Utilization Review Location: Tampa, Florida, United States Posted: Sep 10, 2026
RN Utilization Review Per Diem
MarinHealth

Utilization Review RN II, Care Coordination, Per Diem, Days

MarinHealth Kentfield, CA
$66.03 - $99.04 / hour
ABOUT MARINHEALTH Are you looking for a place where you are empowered to bring innovation to reality? Join MarinHealth, an integrated, independent healthcare system with deep roots throughout the North Bay. With a world-class physician and clinical team, an affiliation with UCSF Health, an ever-expanding network of clinics, and a new state-of-the-art hospital, MarinHealth is growing quickly. MarinHealth comprises MarinHealth Medical Center, a 327-bed hospital in Greenbrae, and 55 primary care and specialty clinics in Marin, Sonoma, and Napa Counties. We attract healthcare’s most talented trailblazers who appreciate having the best of both worlds: the pioneering medicine of an academic medical center combined with an independent hospital's personalized, caring touch. MarinHealth is already realizing the benefits of impressive growth and has consistently earned high praise and accolades, including being Named One of the Top 250 Hospitals Nationwide by Healthgrades, receiving a 5-star Ranking for Overall Hospital Quality from the Centers for Medicare and Medicaid Services, and being named the Best Hospital in San Francisco/Marin by Bay Area Parent, among others. Company: Marin General Hospital dba MarinHealth Medical Center Compensation Range: $66.03 - $99.04 Work Shift: 8 Hour (days) (United States of America) Scheduled Weekly Hours: 0 Job Description Summary: The Utilization Review Nurse is responsible for completion of admission, concurrent and retrospective reviews for designated health plans. This function includes appropriate application of standardized criteria and concurrent documentation. As appropriate, the UR nurse will assess for clinical stability and coordinate transfer back to Marin General for continued care when patients are admitted to non-contracted hospitals. The UR nurse is also responsible for initial RAC review prior to submission to Physician Advisor and will appeal medical necessity denials. Denials submitted to the case management department from Patient Financial Services will be reviewed to determine if the medical record has sufficient medical necessity documentation prior to a written appeal. The UR nurse will escalate cases to the Medical Director (as necessary) to ensure the provision of appropriate and effective patient care. Job Requirements, Prerequisites and Essential Functions: Education: Bachelor of Science degree in Nursing preferred. Experience: Three (3) or more years of experience in an acute patient care setting preferably in medical/surgical or critical care. Substantial recent experience in utilization review and/or discharge planning in an acute care setting is strongly preferred. Experience in applying evidence-based criteria related to utilization management. Experience using case management software License and Certifications: California RN license (RN) required at hire Basic Life Support (BLS) required at hire Prerequisite Skills: Must have the ability to read, write, and follow English verbal and written instructions, and have excellent oral and written communication, interpersonal, problem-solving, conflict resolution, presentation, time management, and positive personal influence and negotiation skills. Able to carry out review function and access medical records. Must have the ability to work independently with a minimum of direction, anticipate and organize work flow, prioritize and follow through on responsibilities. Utilization review/discharge planning services appropriate to patients with complex Strong attention to detail and accuracy is required. Must have the ability to work in a high volume case load environment and deal effectively with rapidly changing priorities. Demonstrated ability to work constructively with a broad spectrum of health care professionals is required. Must be assertive and creative in problem solving, system planning and management. Proficient computer skills are required including use of Electronic Health Record. Microsoft Office Suite Products. Primary Customer Served (Age Specific Criteria): (X) Infants: Birth up to 1 year (X) Toddlers: 1 up to 3 years (X) Preschool Children: 3 up to 6 years (X) School Age Children: 6 up to 12 years (X) Adolescents: 12 up to 18 years (X) Early Adults: 18 up to 45 years (X) Middle Adults: 45 up to 61 years (X) Late Adults: 61 up to 80 years (X) Late, Late Adults: 80 years and up Employees in this position must be able to demonstrate the knowledge and skills necessary to provide care and/or service based on the physical, psycho/social, educational, safety, and related criteria appropriate to the age of the patients served in his/her assigned service area. Patient Privacy (HIPAA Compliance): Employees in this position have access to protected health information. The protected health information a person in this position can access includes demographics, date of service, insurance/billing, medical record summary information, and all other information that may be contained in patient records. This position requires patient health information to perform the functions outlined as part of this position description. Duties And Responsibilities: Essential (Not Modifiable) Utilization Review Applies medical necessity criteria by completing an admission review upon hospital notification same day or within 24 hours. Documents the review within 24 hours of notification. Completes continued stay review and verifies treatment plan, that services ordered are appropriate, and determine if patient is stable for repatriation to Marin for designated health plans. Subsequent reviews are scheduled based on clinical findings and /or at the request of Medical Director. All reviews are conducted utilizing the approved criteria as defined by Marin General Utilization Management Plan. Issues a denial to the facility in the absence of medical necessity with approval of the Medical Director. Reviews discharge criteria and determine with treating facility if patient is ready for a safe discharge. Works with the treating facility to ensure the plan of care is expedited and barriers to efficient throughput are identified and corrected. Identifies the reported plan of care that outlines the key interventions and outcomes to be achieved each day of the inpatient stay. Identifies and refers quality and risk management concerns to appropriate level for corrective action plans and trending. The chain of command is utilized, or case is referred to Medical Director when appropriate and documented. Denials and Appeal Management Reviews RAC medical necessity denials to determine if appeal is appropriate. Works with the Medical Director on complex RAC denials to determine if case will be appealed by third party reviewer. Submits an appeal letter following policy and procedure. Reviews non-RAC denials submitted by the Patient Financial Services and submit an appeal letter as appropriate. Recommends process or policy changes as necessary to avoid lost revenue as a result of denials/RAC requests/audits. Works directly with Medical Director to educate physicians on utilization and medical necessity. Follows timeline for appeal submission indicated by payors or regulatory agencies. Avoidable day entries are entered in MIDAS as indicated. Tracks response to appeals on a weekly basis and communicates with Patient Financial Services as needed for resolution of denied accounts. Reviews, processes, and issues denials to client/responsible party following regulatory guidelines and facility protocols. Collects data for the appeals process. Uses personal judgment within broad guidelines to initiate review of inappropriate utilization by physicians and follows-through to resolution (e.g., attending, department chair, utilization management medical director). Department Operations and Development Actively participates in department meetings and operations, including process development or improvement (e.g., department orientation, internal mentor/training programs and initiates, disease and population management strategies, appropriate measures for evaluation of outcomes) and establishment of department goals, objectives, and budget. Ensures all applicable department and regulatory targets for productivity and department performance process improvement are attained (e.g., hospital length of stay, average cost per discharge, and re-admission rates, etc.). Complies with all reporting requirements for mandated, risk management, and other medical/legal situations consistent with confidentiality policies and department standards. Actively contributes to the development and maintenance of a care delivery system which is sensitive to individual patient needs, promotes effective resource utilization, and supports physician practice, while emphasizing coordination across the continuum. Positively contributes to team’s decision-making process, effectively collaborates with other team members on interdependent tasks, and actively supports implementation of plans to accomplish team objectives. Prepares and conducts presentations to multidisciplinary teams related to special projects, case management, etc. Adheres to department and facility policies and procedures and supports philosophies and initiatives. Maintains accurate, current, and legible patient records using approved forms and format, according to department and entity standards, including patient assessments, plans, interventions, patient/family involvement, outside agency communications, and interdisciplinary contacts. Secondary (Modifiable) Actively participates in ongoing department interviews for Case Managers and Department Assistants, effectively recommending selected applicants for hire. Recommends or provides necessary training to staff. Other duties as assigned. Other duties as assigned. Accommodation: Qualified applicants with disabilities may request reasonable accommodation during the application process by contacting Human Resources at 415-925-7040 or TalentAcquisition@mymarinhealth.org . C.A.R.E.S. Standards: MarinHealth seeks candidates ready to model our C.A.R.E.S. standards—Communication, Accountability, Respect, Excellence, Safety—which foster a healing, trust-based environment for patients and colleagues. Health & Immunizations: To protect employees, patients, and our community, MarinHealth requires measles, mumps, varicella, and annual influenza immunizations as a condition of employment (and annually thereafter). COVID-19 vaccination/booster remains strongly recommended. Medical or religious exemptions will be considered consistent with applicable law. Compensation: The posted pay range complies with applicable law and reflects what we reasonably expect to pay for this role. Individual pay is set by skills, experience, qualifications, and internal/market equity, consistent with MarinHealth’s compensation philosophy. Positions covered by collective bargaining agreements are governed by those agreements. Equal Employment: All qualified applicants will receive consideration for employment without regard to race, color, religion, national origin, sexual orientation, gender identity, protected veteran status or disability status, and any other classifications protected by federal, state, and local laws.
RN Manager/Supervisor Utilization Review Home Health Full-time
Personal Touch Home Aides of New York

RN Quality Review Manager- Registered Nurse

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

RN-Order/Medical Review

Baptist Memorial Health Care Memphis, TN
Overview Job Summary Coordinates precertification/authorization services for patients across the continuum of care, promoting quality care, and effective utilization of resources. Provides leadership when dealing with patient preauthorization functions, including inpatient and outpatient services. Coordinates efforts between departments to ensure accurate precertification, resulting in timely billing of claims. Some overtime and call back may be required. Reports to the Director of CPAC. Performs other duties as assigned. Job Responsibilities Job Responsibilities • Assesses and evaluates clinical and financial information available and recommends the most appropriate delivery of services, including level of care in order to optimize resource consumption and reimbursement. • Precertifies patient care services that require precertification, in a timely, efficient manner, in order to optimize reimbursement for the patient as well as health care providers. • Communicates recommendations, clinical information, and fiscal information to appropriate internal and external customers in order to facilitate optimal delivery of services and customer satisfaction. • Reviews orders for accuracy and medical necessity to facilitate delivery of services and appropriate reimbursement. • Addresses issues identified with retrospective reviews for all payers. • All outpatient procedures will be timely precerted when applicable. • Works to improve the QI/PI process. • Assumes responsibility for personal growth and development by attendance and / or participation in inservices and continuing education programs. • Completes assigned goals. Experience Description Minimum Required Preferred/Desired 3 years of clinical experience. Prefer experience in utilization/case management. Education Description Minimum Required Preferred/Desired Training Description Minimum Required Preferred/Desired Special Skills Description Minimum Required Preferred/Desired Advanced communication, conflict management, organizational and planning skills; advanced computer literacy skills. Prefer certification in CPHQ, CCM, ACM Licensure Description Minimum Required Preferred/Desired RN CCM;ACM
RN Utilization Review Telehealth Full-time
Molina Healthcare

Care Review Clinician (RN) Kentucky

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

UTILIZATION REVIEW NURSE RN

Health & Hospital Corporation Indianapolis, IN
Division:Eskenazi Health Sub-Division: Hospital Req ID: 26738 Schedule: Full Time Shift: Days Salary Range: Eskenazi Health serves as the public hospital division of the Health & Hospital Corporation of Marion County. Physicians provide a comprehensive range of primary and specialty care services at the 327-bed hospital and outpatient facilities both on and off of the Eskenazi Health downtown campus as well as at 10 Eskenazi Health Center sites located throughout Indianapolis. FLSA Status Exempt #EXPRNJob Role Summary The Utilization Review Nurse works behind the scenes to maximize the quality and cost efficiency of health care services. Through regular reviews and audits, ensures that patients receive the care they need without burdening the health care system with unnecessary procedures, ineffective treatments or overlong hospital stays. This position is responsible for ensuring the provision of quality patient care, effective utilization of available health services, review of medical necessity of admissions, and necessity for continued stay in hospital; analyzes patient records to ensure compliance with government and insurance company reimbursement policies and accrediting standards.Essential Functions and Responsibilities Work behind the scenes to maximize the quality and cost efficiency of health care services. Through regular reviews and audits, ensure that patients receive the care they need without burdening the health care system with unnecessary procedures, ineffective treatments or overlong hospital staysCommunicates secondary review decisions determining appropriate patient status provided by secondary reviewer processEnsuring the provision of quality patient care, effective utilization of available health services, review of medical necessity of admissions, and necessity for continued stay in hospital; analyzes patient records to ensure compliance with government and insurance company reimbursement policies and accrediting standardsResponsible for managing each patient's plan of care, monitoring for appropriate resource utilization, and collaborating with the inpatient team as well as outpatient providers to coordinate the patient's transition plan of care Serves as a patient advocate, ensuring that efficient health care is provided. The role is to provide primary nurse support through all aspects of utilization management across the continuum of care and is not limited to the initial review processAssesses degree of medical necessity for any patient seen in the Emergency Department and perform Utilization Review using the Eskenazi Health approved clinical decision support criteriaReviews patients' admissions for appropriateness and type. Refers case to Medical Director and/or Department leadership for review when case fails to meet admission standardsCoordinates the most accurate and appropriate patient status for care Identifies strategies to reduce the length of stay and resource consumption within the appropriate length of stayAssesses patient's health status through collection of information from EMR, interview any other relevant sources to collect specific information in an attempt to provide the necessary determination for patient's status for appropriate medical regimenTrack readmissions and Emergency Department visits for patients assignedCompletes an admission review even when the patient under assessment has been relocated to an admitted or observation bedCollaborates with Emergency Physicians and Attending Physicians to ensure that patients meet criteria for Admission, Placement on Observation Status or neitherOversees the initial admission review, utilizing criteria, within 24-48 hours of the patient's admission to the hospital to ensure appropriateness of the assigned level of care and timely implementation of the treatment plan Applies appropriate clinical criteria to complete initial reviews within 24-48 hours of patient presentationCommunicate with the Inpatient Case Manager to ensure appropriate status and level of care for patient, and that transition plan is implemented with determined goals in mindCommunicates with Payor Specialist for UR/UM to ensure proper status change and accurate billing practicesEvaluatesthe active funding for each patient and communicates with Inpatient Case Manager/Social Worker to facilitate initiation of appropriate funding applicationsDemonstrates knowledge of levels of care of Inpatient and Outpatient statusEnsures that transitions to post-acute services such as Acute Rehabilitation Centers is appropriate and streamlined, and home care services, as well as durable medical equipment is appropriately utilizedEnsure the need for any services not provided at Eskenazi Health is evaluated and appropriate authorization is given and documentedJob Requirements Current Indiana nursing license requiredMinimum of 4 years clinical nursing experience requiredKnowledge, Skills & Abilities Must demonstrate knowledge of the Utilization Management managed care processesCompetency in the following areas required: interpersonal, written/verbal communication, and negotiation skills diplomacy, flexibility, and professionalism cohesive networking with the Interdisciplinary Team Accredited by The Joint Commission and named one of the nation’s 150 best places to work by Becker’s Hospital Review for four consecutive years and Forbes list of best places to work for women, and Forbes list of America’s best midsize employers’ Eskenazi Health’s programs have received national recognition while also offering new health care opportunities to the local community. As the sponsoring hospital for Indianapolis Emergency Medical Services, the city’s primary EMS provider, Eskenazi Health is also home to the first adult Level I trauma center in Indiana, the first verified adult burn center in Indiana, the first community mental health center in Indiana and the Eskenazi Health Center Primary Care – Center of Excellence in Women’s Health, just to name a few.
RN ER Utilization Review Full-time
GBMC Healthcare

Utilization Review Nurse (Full-Time)

GBMC Healthcare Towson, MD
$68,281.18 - $110,274.20 / year
Under general supervision, provides consultative support to the admitting teams concerning patient status determinations and utilization of hospital resources facilitating quality, cost-effective patient outcomes for patients requiring hospital services. Works collaboratively with interdisciplinary staff internal and external to the organization facilitating appropriate status determinations through the utilization review process supporting quality, cost-effective patient outcomes. Responsible for analyzing clinical information and performing timely initial and concurrent reviews using InterQual screening software to identify appropriate medical necessity, length of stay, and level of care based upon evidence based clinical guidelines Education: Bachelor of Science in Nursing (BSN) OR Associate of Science in Nursing and currently enrolled in a BSN program with an expected graduation date within three (3) years. Licensure, Certifications: Current state of Maryland Registered Nurse license Bachelor of Science in Nursing (BSN) Certification in Utilization Management and/or Care Management highly desired. Experience: Five (5) years diversified, progressive experience in acute care and/or other settings within the continuum required. Two (2) years of Utilization Review and Case Management experience which includes utilization review processes and discharge planning, and working with Re-Admission Initiatives preferred. Skills: · Advanced knowledge of InterQual and/or MCG admission criteria · Knowledge of healthcare regulatory standards · Advanced skill in using computer software · Advanced skill in oral and written communication · Advanced skill in critical thinking · Ability to work independently and resolve complex problems · Ability to remain calm under pressure and intense time constraints · Ability to assess discharge needs for patients · Strong analytical and problem-solving skills · Strong interpersonal communication and influencing skills necessary to interact effectively with physicians, payers, regulatory agencies, staff, and other health professional · Strong organizational and time management skills · Ability to operate independently and balance multiple priorities · Proficiency in electronic medical record review Principal Duties and Responsibilities: Reviews available electronic medical records during the pre-admission process to determine appropriate patient status, optimizing correct patient classification and corresponding payer notifications. Reviews the appropriateness of admission and continued stay criteria for a defined group of patients Develops initial admission reviews for patients requiring hospital services and provides timely status recommendations to admitting providers a concurrent stay and/or discharge plan of care in accordance with departmental and payer clinical guidelines. Maintains a working knowledge of contractual and clinical criteria guidelines. Coordinates services with managed care companies and other third party payers. Discusses on-site reviewer issues with payer, either via the telephone or in person Assures timely utilization compliance with all payers who require authorizations and clinical submission. Demonstrates knowledge of reimbursement mechanisms. Considers patient’s financial resources for meeting healthcare needs (insurance reimbursement, managed care plans, entitlement programs, and personal resources). Participates as an active partner with physicians and interdisciplinary teams, providing education ancillary, and nursing staffregarding admission decisions including status determinations, financial and clinical outcomes, and documentation requirements and standards. Maintains current knowledge on all regulatory changes that affect care delivery or reimbursement of acute care services. Uses knowledge of national and local coverage determinations to appropriately advise physicians. Identifies system obstacles that affect patient outcomes and participates in interdisciplinary decisions and care of the patient. consults with interdisciplinary team members to address problems, and makes recommendations to problem solve. Assists with discharge planning, by preventing un-necessary hospital utilization, assist in the appropriate return of and placement of patients to post acute care, community based care and appropriate alternate levels of care. Demonstrates mastery in InterQual level of care guidelines. Possesses proficiency in utilization review systems, clinical support systems, and business support applications. Promotes use of evidence-based protocols to influence high quality and cost-effective care. Escalates clinically and financially complex cases to leadership, offering possible solutions through discussion and feedback. Engages regularly in formal and informal dialogue about quality; directly addressing concerns and promoting continuous improvement. Performs concurrent reviews and additional duties as assigned. All roles must demonstrate GBMC Values: Respect I will treat everyone with courtesy. I will foster a healing environment. Treats others with fairness, kindness, and respect for personal dignity and privacy Listens and responds appropriately to others’ needs, feelings, and capabilities Excellence I will strive for superior performance in every aspect of my work. I will recognize and celebrate the accomplishments of others. Meets and/or exceeds customer expectations Actively pursues learning and self-development Pays attention to detail; follows through Accountability I will be professional in the way I act, look and speak. I will take ownership to solve problems. Sets a positive, professional example for others Takes ownership of problems and does what is needed to solve them Appropriately plans and utilizes required resources for various job duties Reports to work regularly and on time Teamwork I will be engaged and collaborative. I will keep people informed. Works cooperatively and collaboratively with others for the success of the team Addresses and resolves conflict in a positive way Seeks out the ideas of others to reach the best solutions Acknowledges and celebrates the contribution of others Ethical Behavior I will always act with honesty and integrity. I will protect the patient. Demonstrates honesty, integrity and good judgment Respects the cultural, psychosocial, and spiritual needs of patients/families/coworkers Results I will set goals and measure outcomes that support organizational goals. I will give and accept help to achieve goals. Embraces change and improvement in the work environment Continuously seeks to improve the quality of products/services Displays flexibility in dealing with new situations or obstacles Achieves results on time by focusing on priorities and manages time efficiently Pay Range $68,281.18 - $110,274.20 Final salary offer will be based on the candidate's qualifications, education, experience and alignment with our organizational needs. Equal Employment Opportunity GBMC HealthCare and its affiliates are Equal Opportunity employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity and expression, age, national origin, mental or physical disability, genetic information, veteran status, or any other status protected by federal, state, or local law.