Registered Nurse (RN) Utilization Review Jobs

RN Utilization Review Full-time
Elliot Health System

Utilization Review RN- Care Coordination- Full Time

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

RN - Registered Nurse - Utilization Review - PRN Days

UAB Medicine Birmingham, AL
Department: Utilization Review Schedule: PRN Days Work Location: UAB ST Vincent's Birmingham Benefits for eligible positions only include: generous paid time off, paid parental leave, Associate Assistance Program, Tuition Reimbursement Program, and more What You Will Do Provide health care services regarding admissions, case management, discharge planning and utilization review. Review admissions and service requests within assigned unit for prospective, concurrent and retrospective medical necessity and/or compliance with reimbursement policy criteria. Provide case management and/or consultation for complex cases. Assist departmental staff with issues related to coding, medical records/documentation, precertification, reimbursement and claim denials/appeals. Assess and coordinate discharge planning needs with healthcare team members. May prepare statistical analysis and utilization review reports as necessary. Oversee and coordinate compliance to federally mandated and third party payer utilization management rules and regulations. What You Will Need Licensure / Certification / Registration: Licensed Associate Professional Registered Nurse credentialed from the Alabama Board of Nursing obtained prior to hire date or job transfer date required. Education Diploma from an accredited school/college of nursing and required professional licensure at time of hire. One Year of Experience is required Additional Preferences No additional preferences. About UAB St. Vincent’s UAB St. Vincent’s, a proud part of UAB Medicine, is a trusted provider of health care, serving Alabama for more than 125 years. With five hospitals and numerous clinics, we're a health care community deeply rooted in compassion, service, and respect for all, guided by the rich legacy of the St. Vincent’s name. We're committed to extending kindness and personalized care to patients, their families, and each other. We address the physical, psychological, social, and spiritual needs of our patients. We believe in the power of teamwork and unity, and foster a collaborative spirit among our more than 4,800 employees. As one of Alabama’s best hospitals as recognized by U.S. News & World Report, improving the health and lives of those we serve is at the heart of our mission. Join us in continuing our legacy of service and healing in central Alabama, where we can make a lasting impact together.
RN Utilization Review Full-time
St. Bernards Healthcare

UTILIZATION EXPERT - RN - WEEKENDS

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

Registered Nurse Utilization Review, Case Management, Part Time, 7P-7:30A

Baptist Health South Florida Miami, FL
$73,860.80 - $98,234.86 / year
Baptist Health is the region's largest not-for-profit healthcare organization, with 12 hospitals, over 29,000 employees, 4,500 physicians and 200 outpatient centers, urgent care facilities and physician practices across Miami-Dade, Monroe, Broward and Palm Beach counties. With internationally renowned centers of excellence in cancer, cardiovascular care, orthopedics and sports medicine, and neurosciences, Baptist Health is supported by philanthropy and driven by its faith-based mission of medical excellence. For 26 years, we've been named one of Fortune's 100 Best Companies to Work For, and in the 2025-2026 U.S. News & World Report Best Hospital Rankings, Baptist Health was the most awarded healthcare system in South Florida, earning 63 high-performing honors. What truly sets us apart is our people. At Baptist Health, we create personal connections with our colleagues that go beyond the workplace, and we form meaningful relationships with patients and their families that extend beyond delivering care. Many of us have walked in our patients' shoes ourselves and that shared experience fuels out commitment to compassion and quality. Our culture is rooted in purpose, and every team member plays a part in making a positive impact – because when it comes to caring for people, we're all in. At Baptist Health, we’re committed to supporting our employees at every stage of their journey, both personally and professionally. Our approach is rooted in a “grow our own” philosophy, designed to help our team members build meaningful, long-term careers with us, supported by benefits that make a real difference, including: Career growth and development opportunities , with clear pathways and ongoing support Comprehensive health and wellness resources that go beyond traditional benefits A wellness program that can help employees eliminate their medical plan deductible , reducing out-of-pocket healthcare costs Tuition reimbursement to support continued learning and advancement And so much more Together, these benefits and others reflect our commitment to caring for our people, so they can build fulfilling careers with us while making a meaningful impact every day. Description: The purpose of this position is to conduct initial, concurrent, retrospective chart review for clinical financial resource utilization. Coordinates with healthcare team for optimal/efficient patient outcomes, while decreasing length of stay (LOS) and avoid delays and denied days. They are accountable for a designated patient caseload and provides intervention, coordination to decrease avoidable delays, denial of reimbursement. Specific functions within this role include: Screens pre-admission, admission process using established criteria for all points of entry. Facilitates communication between payers, review agencies, healthcare team. Identify delays in treatment or inappropriate utilization and serves as a resource. Coordinates communication with physicians. Identify opportunities for expedited appeals and collaborates to resolve payer issues. Ensures/Maintains effective communication with Revenue Cycle Departments. Estimated salary range for this position is $73860.80 - $98234.86 / year depending on experience. Qualifications: Degrees: Associates. Licenses & Certifications: MCG Care Guidelines Specialist. Registered Nurse. Additional Qualifications: RNs hired prior to 2-2012 (10/1/2017 at Bethesda or 7/1/2019 at BRRH) with an Associates Degree in Nursing are not required to have a BSN to continue their non-leadership role as an RN. however, they are required to complete the BSN within 3 years of job entry date. MCG Specialist Certification ISC/HRC required within 12 months of job entry date. 3 years of Nursing experience preferred. Excellent written, interpersonal communication and negotiation skills. Strong critical thinking skills and the ability to perform clinical/chart review abstract information efficiently. Strong analytical, data management and computer skills. Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components. Current working knowledge of payer and managed care reimbursement preferred. Ability to work independently and exercise sound judgment in interactions with the health care team and patients/families. Knowledgeable in local, state, and federal legislation and regulations. Ability to tolerate high volume production standards. Minimum Required Experience: 3 Years EOE, including disability/vets
RN Utilization Review Outpatient Full-time
UF Health

RN, Utilization Management | Utilization Management| Day| Full Time

UF Health Tampa, FL
Overview The RN Utilization Managemen t plays a critical role in evaluating patient medical records to ensure the necessity and appropriateness of healthcare services. Involves coordinating with healthcare providers to maintain compliance with utilization management guidelines and optimizing treatment plans for effective patient care and resource utilization. Requires clear communication of authorization decisions and ongoing monitoring to support timely discharge planning. Analyzes utilization data to identify trends and collaborates with interdisciplinary teams to enhance care coordination while ensuring accurate documentation and regulatory compliance Responsibilities An incumbent in this position will • Evaluates patient medical records to ensure necessity and appropriateness of healthcare services. • Coordinates with healthcare providers to maintain compliance with utilization management guidelines. • Optimizes treatment plans for effective patient care and resource utilization. • Communicates authorization decisions clearly and supports timely discharge planning. • Analyzes utilization data to identify trends and improve care coordination. • Collaborates with interdisciplinary teams to ensure accurate documentation and regulatory compliance. Qualifications Required: Registered Nurse (RN) with a current Florida license required. • 3+ years experience in utilization review or case management • Knowledge of healthcare utilization guidelines and compliance • Experience evaluating medical necessity and treatment plans • Strong communication skills for authorization decisions • Ability to analyze utilization data and support care coordination Licensure/Certification/Registration: Registered Nurse (RN) with a current Florida license required.
RN Utilization Review Full-time
Parkland Health (TX)

Registered Nurse - Care Coordinator - Utilization Review

Parkland Health (TX) Dallas, TX
Location: Main Hospital Bldg - 1st Flr Shift- Days (10hrs) 7:30am-6pm Work Hours: Monday- Friday with rotating weekends **This position will hybrid- must be okay with coming onsite** Employment Type: Full Time Primary Purpose Establishes and maintains an efficient, cost effective care management process by determining patient financial and medical eligibility, medical necessity, and by developing, implementing and monitoring individual patient plans of care and communicating these plans to patients, families, and Parkland staff to ensure quality patient care throughout the healthcare continuum and compliance with program/Parkland policies and procedures. Responsible for the maintaining the knowledge and skill set related to utilization review, care coordination, performance improvement and professional licensure and certification. Minimum Specifications Education Must be a graduate of an accredited school of Nursing. Experience Must have two (2) years of hospital or community based patient care nursing, preferably in assigned clinical area. Equivalent Education and/or Experience Certification/Registration/Licensure Must have current, valid RN license or temporary RN license from the Texas Board of Nursing; or, valid Compact RN license. Must have current healthcare provider BLS for Healthcare Providers certification from one of the following: American Heart Association American Red Cross Military Training Network Required Tests for Placement Skills or Special Abilities Provides care to assigned patient population in accordance with the current State of Texas Nursing Practice Act, established protocols, multidisciplinary plan of care, and clinical area specific standards. Must be able to communicate and collaborate effectively with a diverse group of patients, families and healthcare staff. Must be able to demonstrate a working knowledge of specific patient populations, and be able to demonstrate knowledge of disease processes affecting this group. Must be able to demonstrate a working knowledge of PC operations and the ability to use word processing software in a Windows environment. Must be able to demonstrate a working knowledge of the laws and regulations governing Medicare, Medicaid and community-based funding sources. Must be self-directed and capable of priority setting and problem solving. Must be able to demonstrate patient centered/patient valued behaviors. Responsibilities Conducts assessment of patients on assigned Care Coordination team to develop a case management plan of care. Gathers information from patient, physicians, other pertinent members of the healthcare team. Determines funding sources for patients and potential eligibility if appropriate. Plans and develops specific objectives, goals and actions designed to meet the patient's needs as identified through the assessment process. Utilizes hospital approved review criteria to ensure appropriate bed status. Identifies at-risk populations using approved screening tool and follows established reporting procedures. Ensures appropriate admission status is documented. Collaborates with all members of the multidisciplinary team and the patient to implement the plan of care. Monitors the patient's progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective. Communicates all financial counseling as appropriate. Addresses and resolves system barriers impeding diagnostic or treatment progress. Proactively identifies and resolves delays and obstacles to discharge. Ensures/maintains plan consensus from patient/family, physician, and payer. Serves as patient advocate to secure coverage for needed community services. Mobilizes resources and coordinates the effort to the health care team to achieve a positive patient transition to appropriate next level of care. Communicates plan of care to patient and their family providing updates and reassesses the plan of care to determine effectiveness. Completes appropriate coordinator management documentation. Evaluates the plan of care at appropriate intervals to determine effectiveness in meeting outcomes and goals. Works with nursing and other disciplines to ensure that discharge needs, including teaching, are met. Collaborates with the healthcare team to identify 'best' practices for achieving patient outcomes. Develops reporting mechanisms to communicate outcomes to physicians and other members of the health care team. Responsible for Utilization Management activities for assigned patients. Applies approved utilization criteria to monitor appropriateness of admissions and continued stays, and documents findings based on department standards. Monitors length of stay (LOS) and ancillary resource use on an ongoing basis and takes action to achieve continuous improvement in both areas. Monitors and addresses outcome variances. Identifies causes of outcome variances and implements actions to improve the variances. Seeks the most efficient, cost effective ways to provide appropriate care. Supports cost containment efforts through the recommendation of performance improvement opportunities by the health care team. Communicates with Care Management team to facilitate covered-day reimbursement certification and/or authorization for assigned patients. Discusses payer criteria and issues on a case-by-case basis with clinical staff and follows up to resolve problems with payers as needed. Transitions patients through the health care system based upon individual and patient population needs. Directs liaison activities to appropriately integrate the patient into the health care continuum including procuring of services, health promotion and counseling, disease prevention, health education and screening, and community resource linkage. Engages in special projects and serves on committees, as assigned. Requisition ID: 988689
RN Utilization Review Other
Children's Mercy

Clinical Review Nurse Care Manager

Children's Mercy Kansas City, MO
Thanks for your interest in Children's Mercy! Do you envision finding a meaningful role with an inclusive and compassionate team? At Children’s Mercy, we believe in making a difference in the lives of all children and shining a light of hope to the patients and families we serve. Our employees make the difference, which is why we have been recognized by U.S. News & World Report as a top pediatric hospital, for eleven consecutive years. Children’s Mercy is in the heart of Kansas City – a metro abounding in cultural experiences, vibrant communities and thriving businesses. This is where our patients and families live, work and play. This is a community that has embraced our hospital and we strive to say thanks by giving back. As a leader in children’s health, we engage in meaningful programs and partnerships throughout the region so that we can improve the lives of children beyond the walls of our hospital. Overview The Clinical Review Nurse Care Manager utilizes clinical expertise, evidence-based guidelines, insurance knowledge, business acumen, and high level of communication skills to ensure appropriate utilization of and reimbursement for resources from admission through hospital stay to discharge. Adeptly uses evidence based clinical practice guidelines to determine the appropriate level of care and the medical necessity of continued hospitalization. Secures initial payer authorization and continued stay payer authorization per contracts for medically appropriate level of care. Manages concurrent clinical denials through completion of verbal reconsideration process. Works with physicians and multidisciplinary teams to evaluate the medical plan, length of stay, avoidable days/delays and progression of care. Works collaboratively with Revenue Cycle to ensure authorizations and denials are addressed timely for clean claims submission. This position will participate in ongoing professional development activities, quality improvement, and continuing education activities. This role Improves efficiency and reduces health care costs as evidenced by decreased lengths of stay, decreased re-admissions, decreased denials, and increased patient satisfaction. At Children’s Mercy, we are committed to ensuring that everyone feels welcomed within our walls. A successful candidate for this position will join us as we strive to create a workplace that reflects the community we serve, as well as our core values of kindness, curiosity, inclusion, team and integrity. Additionally, it’s important to us that we remain transparent with all potential job candidates. Because we value the safety of the patients and families we serve, as well as the Children’s Mercy staff, we want to let you know that the seasonal influenza vaccine is a condition of employment for all employees in our organization. New employees must be willing to be vaccinated if found non-immune to measles, mumps, rubella (MMR) and chicken pox (varicella) and/or without evidence of tetanus, diphtheria, acellular pertussis (Tdap) vaccination since 2005. If you are selected for this position, you will be asked to supply your immunization records as proof of vaccination. If you and have any concerns about receiving these vaccines, medical and/or religious exemptions can be further discussed with Human Resources. Responsibilities Evaluate appropriateness of each admission using evidence-based clinical guidelines to ensure correct bed status. Ensures medical appropriateness of care by facilitating timely and proper patient throughput progression; securing continued stay authorizations; continually reassessing medical necessity; and partnering with the multidisciplinary team. Mitigates and manages denials for patient status and continued patient stays with Attending Physician, Physician Advisor, Inpatient Nurse Care Manager, and insurance/payer. Collaborates with Revenue Cycle to improve financial processes and outcomes. Participate in ongoing professional development activities, making a meaningful contribution to quality improvement and continuing education of self and others. Qualifications Bachelor's Degree BSN and 3-5 years experience Experience as a care manager or demonstrated leadership skills in a previous role One of the following required upon hire: Licensed RN - MO, Registered Nurse Multistate License Missouri Licensed RN - Kansas, Registered Nurse Multistate License Kansas RN Compact license for all states besides KS and MO MO or KS Multistate License required within 90 days of hire Certified Case Manager (CCM) certification required within 3 years of hire OR Accredited Case Manager (ACM) certification required within 3 years of hire Refer to Nursing and Avdance Practice Provider Licensure and Certification policy for required Life Support Certifications Required Upon Hire CPN Certification Preferred Benefits at Children's Mercy The benefits plans at Children’s Mercy are one of many reasons we are recognized as one of the best places to work in Kansas City. Our plans are designed to meet the changing needs of our employees and their families. Learn more about Children’s Mercy benefits. Starting Pay Our pay ranges are market competitive. The pay range for this job begins at $36.16/hr, but your offer will be determined based on your education and experience. Remote Work/Work from Home This position is not eligible to work remotely, which means that the person hired will be required to work onsite at one of our Children’s Mercy locations and may not work from home. EEO Employer/Disabled/Vet Children’s Mercy hires individuals based on their job skills, expertise and ability to maintain professional relationships with fellow employees, patients, parents and visitors. A personal interview, formal education and training, previous work experience, references and a criminal background investigation are all factors used to select the best candidates. The hospital does not discriminate against prospective or current employees based on the race, color, religion, sex, national origin, age, disability, creed, genetic information, sexual orientation, gender identity or expression, ancestry or veteran status. A drug screen will be performed upon hire. Children’s Mercy is smoke and tobacco free. CM is committed to creating a workforce that supports the diverse backgrounds of our patients and families. We know that our greatest strengths come from the people who make up our team, so we hire great people from a wide variety of backgrounds, not just because it’s the right thing to do, but because it makes our hospital stronger and our patient care more compassionate. If you share our values and our enthusiasm for service, you will find a home at CM. In recruiting for our team, we welcome the unique contributions that you can bring, including education, ideas, culture, and beliefs.
RN Utilization Review Full-time
Silver Cross Hospital

Utilization Review Nurse

Silver Cross Hospital New Lenox, IL
$34.73 - $45.15 / hour
Silver Cross Hospital is an extraordinary place to work. We’re known for our culture of excellence and delivery of unrivaled experiences for our patients, their families, the communities we serve…and for each other. Come join us! It’s the way you want to be treated. Position Summary: Performs medical record review for severity of illness and intensity of service; liaison function with external review agencies to ensure compliance with regulations affecting financial reimbursement; identifies variance from established pathways Essential Duties and Responsibilities: Collects information from clinical medical record for severity of illness and intensity of service and documents such in clinical database Monitors all levels of care for appropriateness and communicates variance; evaluates plan of care to ensure it is based on accepted standards Provides information to external review organizations, documents pertinent communications Refers to designated physician advisor those patients not meeting criteria as well as quality of care concerns Maintains knowledge and incorporates current standards into practice Required Qualifications : Knowledge of clinical norms; excellent communication skills; critical thinking skills; organized and efficient time management skills Education and Training : Nurse, Registered (RN) licensure BSN preferred. 2-5 years previous Utilization Review experience preferred. Current CPR Relevant hospital nursing; hospital case management; insurance case management or utilization management experience preferred Work Shift Details: Days, Primarily remote; onsite orientation requirement; weekend and holiday rotation; on site requirement for meetings and mandatory training Department: CONTINUUM OF CARE Benefits for You At Silver Cross Hospital, we care about your health and well-being and that is why we work hard to provide quality and affordable benefit options for you and your eligible family members. Silver Cross Hospital and Silver Cross Medical Groups offer a comprehensive benefit package available for Full-time and Part-time employees which includes: · Medical, Dental and Vision plans · Life Insurance · Flexible Spending Account · Other voluntary benefit plans · PTO and Sick time · 401(k) plan with a match · Wellness program · Tuition Reimbursement Registry employees who meet eligibility may participate in our 401(k) Savings plan with a potential match. However, registry employees are ineligible for Health and Welfare benefits. The final pay rate offered may be more than the posted range based on several factors including but not limited to: licensure, certifications, work experience, education, knowledge, demonstrated abilities, internal equity, market data, and more. The expected pay for this position is listed below: $34.73 - $45.15
RN Utilization Review Full-time
Tuba City Regional Healthcare

Case Review Registered Nurse

Tuba City Regional Healthcare Tuba City, AZ
Navajo Preference Employment Act In accordance with Navajo Nation and federal law, TCRHCC has implemented an Affirmative Action Plan pursuant to the Navajo Preference in Employment Act. Pursuant to this Plan and corresponding TCRHCC Policy, applicants who meet the necessary qualifications for this position and (1) are enrolled members of the Navajo Nation, Hopi Tribe, or San Juan Southern Paiute Tribe will be given preference in hiring and employment for this position, (2) are legally married to enrolled members of the Navajo Nation, Hopi Tribe, or San Juan Southern Paiute Tribe and meet residency requirements will be given secondary preference, and (3) are enrolled members of other federally-recognized American Indian Tribes will be given tertiary preference. Overview POSITION SUMMARY This position facilitates the analysis of medical staff quality and performance data for the organization through coordination of information including data collection, analysis and trending of required medical staff quality and peer review activities, and other select clinical outcome measurements. This position serves as assisting the medical staff with practitioner specific quality monitoring and reporting. This position manages issues that are brought up regarding the quality of practice by providers, evaluates and investigates quality issues. Responsible for managing Ongoing Professional Practice Evaluations/Focused Professional Practice Evaluations. Supporting the Peer Review Committee and other Quality related projects. This Registered Nurses will be evaluating the quality and appropriateness of care provided by their peers, aiming to improve patient safety and practice standards through a non-punitive, continuous learning process. The role of the Case Review RN is to establish, promote and monitor seamless care for TCRHCC patients. Qualifications NECESSARY QUALIFICATIONS Education: Bachelor’s degree in nursing and Master’s Degree in Business Administration or other Master’s degree in healthcare. License: A valid, current, full and unrestricted Professional Nursing License to practice nursing in any state of the United States of America, The Commonwealth of Puerto Rico, or a territory of the United States Experience: Five (5) years of supervisory experience in discharge planning, case management, or utilization review in an acute-care health care setting or related healthcare clinical leadership Other Skills and Abilities: A record of satisfactory performance in all prior and current employment as evidenced by positive employment references from previous and current employers. All employment references must address and indicate success in each one of the following areas: Accessing community resources for patient referrals Elimination of potential conflicts of interest including professional, organizational, and/or personal bias inherent to review programs performed or supported with internal review. Providing a systematic and scalable approach ensuring review criteria and results are accurate, reliable which reduces risk by identifying trends and potential issues of clinical staff performance, deficiencies, and errors. Knowledge of diagnosis related groups (DRG) and documentation requirements Positive working relationships with others Possession of high ethical standards and no history of complaints Reliable and dependable; reports to work as scheduled without excessive absences Ability to sense varying skill levels and direct instruction accordingly Detail oriented, well organized, and applies critical thinking, reasoning, deduction, and inference skills Knowledge of report writing, graphical analysis, and working with computer spreadsheets and database programs Completion of and above-satisfactory scores on all job interviews, demonstrating to the satisfaction of the interviewees and TCRHCC that the applicant can perform the essential functions of the job Successful completion of and positive results from all background and reference checks, including positive employment references from authorized representatives of past and current employers demonstrating to the satisfaction of TCRHCC a record of satisfactory performance and that the applicant can perform the essential functions of the job Successful completion of fingerprint clearance requirements, physical examinations, and other screenings indicating that the applicant is qualified to be employed by TCRHCC and demonstrating to the satisfaction of TCRHCC that the applicant can perform the essential functions of the job Submission of all required employment-related documents, applications, resumes, references, and other required information free of false, misleading or incomplete information, as determined by TCRHCC MENTAL AND PHYSICAL EFFORT The physical and mental demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform essential functions. Physical: The work involves prolonged periods of sitting in an office setting operating a personal computer, walking throughout the hospital to obtain and review medical records, and standing while inquiring with providers and clinical staff. The Incumbent may occasionally need to drive, bend, climb, kneel, crouch, twist, maintain balance, and reach. There may be times of distant travel for ongoing and advanced training. Occasional travel to the satellite health centers for on-site reviews. The Incumbent will frequently need to be able to lift, pull, and push up to 10 pounds. This position requires the sensory ability for frequent use of far vision, near vision, color vision, depth perception, seeing fine details, hearing normal speech, telephone use, and hearing overhead pages over a loudspeaker. The incumbent must be able to utilize hand manipulation to do simple grasping and use of keyboard for prolonged time during work day. The position requires frequent firm grasping and fine manipulation. Mental: The work requires the ability to deal relatively independently with the interrelated elements that affect data analyzing and reporting, to resolve complications and controversial matters. This position requires the mental & emotional requirement ability to cope with high levels of stress; make decisions under high pressure; copy with anger/fear/hostility of others in a calm way; manage altercations; concentrate; handle a high degree of flexibility; handle multiple priorities in a stressful situation; work alone; demonstrate a high degree of patience; and work in areas that are close and crowded. May occasionally be required to adapt to shift work. Environmental: The incumbent may be exposed to the following environmental situations: Infectious Diseases, chemical agents, dust, fumes, gases, extremes in temperature or humidity, hazardous or moving equipment, unprotected heights, and loud noises. Responsibilities ESSENTIAL FUNCTIONS: Reviews patient records and clinical documentation to assess the appropriateness and necessity of healthcare services, ensuring quality and cost-effectiveness of care Resolves informal/formal complaints and grievances within jurisdiction and refers appropriately to a higher level of management if needed. As appropriate, refers instances of inappropriate patient care, discharge delays, and so on to the Risk Manager and /or Clinical Division. Review patient records, thoroughly examine patient charts, clinical documentation, and billing information to assess the appropriateness and necessity of services provided. Perform chart reviews to identify quality, timeliness, and appropriateness of patient care. Refer cases as appropriate to physician advisors for review and determination. Requires experience in performance improvement methodologies; quality measurement; and data analysis using statistical principles. Prior experience in hospital or clinical management preferred. Requires computer knowledge. Windows application: Skilled in the use of select Microsoft Office Applications, e.g. Word; Excel and PowerPoint or other database management applications. Requires strong written and verbal communication skills and the ability to work effectively with all levels of the organization and with members of the medical staff. Requires strong public speaking skills and the ability to deliver effective presentations and education to large groups of physicians and staff. Requires ability to prioritize multiple projects and the flexibility to accommodate changing priorities. Effectively communicates and coordinates processes to assure the continuity of patient care to outside providers and promote patient advocacy among Navajo Area Indian Health Services/Service Units, and Federal and State entities. Develops and implements policies and procedures regarding case management eligibility, alternate resource programs, referral/notification process, interdepartmental relationship and responsibilities; promote patient access to the appropriate level of care, prevent over or under utilization of resources, maximize the use of alternate resources, and supports continuity of care. Assists with review, research, and decision of first level appeal process with Purchase Referred Care Provides clinical expertise, skills, and behaviors appropriate to the population(s), served, and based on specific criteria and/or age-specific considerations. Supports, educates, and oversees the overall quality and completeness of clinical documentation by performing admission/continued stay reviews using clinical documentation enhancement guidelines for selected patient populations. Collaborates with the Physician Advisor or designee in leading and facilitating the Utilization Review Committee, develops and interprets reports (i.e. statistical, financial, trends), provides data for the PI Committee and submits reports, as required, on outcomes, clinical quality documentation and insurance medical necessity criteria. Complete task training for all routine cleaning and decontamination processes for all surfaces contaminated by a communicable disease to ensure a high level of patient, visitor, employee, and external customer Performs other assigned duties as needed
RN Manager/Supervisor Utilization Review Home Health Full-time
Personal Touch Home Aides of New York

(RN) Quality Review Manager- Registered Nurse

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

Clinical Guide Part A: Utilization Management Nurse

Devoted Health
$85,000 - $95,000 / year
Job Description Schedule: The weekly schedule choice is either Monday - Friday 10am-7pm EST OR Tuesday - Saturday 9am-6pm EST A bit about this role: The Clinical Guide Part A will be part of the Utilization Management team, responsible for inpatient, behavioral health, and/or post-acute authorization review in alignment with CMS and Medicare Advantage regulations. Reviews medical records to evaluate the medical necessity and appropriateness of requested inpatient and/or post-acute services in accordance with established clinical criteria and CMS guidelines. Your Responsibilities and Impact will include: Review Medical Records: Conduct prospective (pre-service), concurrent, and retrospective utilization review to evaluate medical necessity, appropriate level of care (Inpatient vs. Observation), and post-acute services in accordance with established clinical criteria and CMS guidelines. Evaluate Treatment Plans: Assess the appropriateness, timing, and setting of requested services, ensuring alignment with medical necessity criteria and Medicare Advantage requirements. Recommend alternative levels of care when clinically appropriate. Inpatient & Behavioral Health Review: Perform initial, concurrent, and discharge reviews for inpatient and behavioral health admissions. Ensure admission status accuracy and regulatory compliance with CMS timeliness (TAT) standards. Post-Acute Review: Conduct initial authorization and concurrent review for post-acute services (SNF, LTACH, ARU, Home Health), evaluating ongoing medical necessity and appropriate length of stay. Issue NOMNC when coverage criteria are no longer met. Medical Director Collaboration: Refer cases that do not meet criteria to the Medical Director for secondary review and final determination. Prepare clinical summaries and coordinate peer-to-peer (P2P) discussions. Manage authorization reopen requests as appropriate. Resource Stewardship: Monitor utilization of inpatient and post-acute services to promote appropriate resource use while maintaining high-quality, member-centered care. Regulatory & Documentation Compliance: Maintain accurate, defensible documentation of all determinations. Ensure adherence to CMS regulations, Medicare Advantage requirements, and internal compliance standards. Required skills and experience: Unrestricted RN license with a minimum of 4 years of clinical experience. Minimum 3 years of Utilization Management or Inpatient UR experience within a health plan or hospital setting. Strong knowledge of CMS regulations and Medicare Advantage requirements. Experience preparing cases for Medical Director review Able to work in a fast paced environment that is constantly evolving. Desired skills and experience: Experience with AI/LLM Certified in InterQual #LI-Remote #LI-DS1 Salary Range: $85,000-$95,000 / year The pay range listed for this position is the range the organization reasonably and in good faith expects to pay for this position at the time of the posting. Once the interview process begins, your talent partner will provide additional information on the compensation for the role, along with additional information on our total rewards package. The actual base salary offered will depend on a variety of factors, including the qualifications of the individual applicant for the position, years of relevant experience, specific and unique skills, level of education attained, certifications or other professional licenses held, and the location in which the applicant lives and/or from which they will be performing the job. Our Total Rewards package includes: Employer sponsored health, dental and vision plan with low or no premium Generous paid time off $100 monthly mobile or internet stipend Stock options for all employees Bonus eligibility for all roles excluding Director and above; Commission eligibility for Sales roles Parental leave program 401K program And more.... *Our total rewards package is for full time employees only. Intern and Contract positions are not eligible. Founded in 2017, Devoted Health is on a mission to dramatically improve the health and well-being of older Americans by caring for everyone like they are family, and that includes our employees. Our robust and seamlessly integrated care platform merges advanced data and AI access with world-class clinical and service experiences to create a member experience that is unlike the industry norm. To continue building upon our mission, we want to bring together those who share our values, embrace change and advancement, and are enthusiastic about where we're going — all the while bringing their own unique qualities, experiences, and expertise, in hopes of further changing the healthcare experience. Devoted is an equal opportunity employer. We are committed to a safe and supportive work environment in which all employees have the opportunity to participate and contribute to the success of the business. We value diversity and collaboration. Individuals are respected for their skills, experience, and unique perspectives. This commitment is embodied in Devoted’s Code of Conduct, our company values and the way we do business. As an Equal Opportunity Employer, the Company does not discriminate on the basis of race, color, religion, sex, pregnancy status, marital status, national origin, disability, age, sexual orientation, veteran status, genetic information, gender identity, gender expression, or any other factor prohibited by law. Our management team is dedicated to this policy with respect to recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, employee activities and general treatment during employment.
RN Utilization Review Part-time
Silver Cross Hospital

Utilization Review Nurse

Silver Cross Hospital New Lenox, IL
$34.73 - $45.15 / hour
Silver Cross Hospital is an extraordinary place to work. We’re known for our culture of excellence and delivery of unrivaled experiences for our patients, their families, the communities we serve…and for each other. Come join us! It’s the way you want to be treated. Position Summary: Performs medical record review for severity of illness and intensity of service; liaison function with external review agencies to ensure compliance with regulations affecting financial reimbursement; identifies variance from established pathways Essential Duties and Responsibilities: Collects information from clinical medical record for severity of illness and intensity of service and documents such in clinical database Monitors all levels of care for appropriateness and communicates variance; evaluates plan of care to ensure it is based on accepted standards Provides information to external review organizations, documents pertinent communications Refers to designated physician advisor those patients not meeting criteria as well as quality of care concerns Maintains knowledge and incorporates current standards into practice Required Qualifications : Knowledge of clinical norms; excellent communication skills; critical thinking skills; organized and efficient time management skills Education and Training : Nurse, Registered (RN) licensure BSN preferred. 2-5 years previous Utilization Review experience preferred. Current CPR Relevant hospital nursing; hospital case management; insurance case management or utilization management experience preferred Work Shift Details: Various, Day; weekend rotation; holiday rotation; occasional on site requirement for meetings and mandatory training Department: CONTINUUM OF CARE Benefits for You At Silver Cross Hospital, we care about your health and well-being and that is why we work hard to provide quality and affordable benefit options for you and your eligible family members. Silver Cross Hospital and Silver Cross Medical Groups offer a comprehensive benefit package available for Full-time and Part-time employees which includes: · Medical, Dental and Vision plans · Life Insurance · Flexible Spending Account · Other voluntary benefit plans · PTO and Sick time · 401(k) plan with a match · Wellness program · Tuition Reimbursement Registry employees who meet eligibility may participate in our 401(k) Savings plan with a potential match. However, registry employees are ineligible for Health and Welfare benefits. The final pay rate offered may be more than the posted range based on several factors including but not limited to: licensure, certifications, work experience, education, knowledge, demonstrated abilities, internal equity, market data, and more. The expected pay for this position is listed below: $34.73 - $45.15
RN Utilization Review
Health & Hospital Corporation

LONG-TERM CARE QUALITY REVIEW NURSE ANALYST

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 Provides support to Vice President of Long Term Care and the Director of Quality Review gathering clinical data , formulating reports and conducting statistical analysis for the Long Term Care (LTC) Division. Managing datasets and provides data quality assurance and identifying needs to inform leadership in health-related decisions. Assists in collection of Capital related financial invoices from managing partner. Accompanies and participates as a member of the LTC Quality Review Team on site visits to the HHC Nursing Homes as assigned. Essential Duties Responsibility 1: 50%Collaborates with the Vice President and Director of Quality Review to design, conduct and interpret statistical analyses and determine quality indicators to monitor and report via the various data sources internal and external for the nursing homes and assisted living facilities owned and operated by HHC. Manages and maintains datasets, providing quality assurance and identifying needs for information to inform health related decisions. Assists in preparation of reports and presentations on Long Term Care issues and statistics for the HHC Long Term Care Committee to aide in the oversight of the HHC owned Long Term Care Facilities. Extracts and interprets data and reports in a format that a variety of LTC, financial and medical personnel can use. Assists in the completion and follow up of any requests or directives resulting from the LTC Committee meetings as assigned.Works with managing partner to obtain data analysis for review. Responsibility 2: 40%Participates as a member of the quality review team on assigned facility site visits.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. Prepares data for the quality review team prior to the facility site visits to assist in determining specific areas to review. Performs various auditing/review activities during the site visits as assigned. Assists in the preparation of a written site visit report following each facility visit in cooperation with other quality review team members Responsibility 3: 10%Must be detail oriented, able to adhere to deadlines, deal with frequent interruption and regular requests for assistance from department staff and have good customer service skills for addressing concerns and interacting with facility residents and personnel on site visits.Maintains confidentiality of all client records and information as specified by the Health Insurance Portability and Accountability Act of 1996 (HIPAA).Serve as a driver on facility site visits out of town when necessary, using a LTC Department Van or personal vehicle (with approval and appropriate mileage reimbursement).Other Duties and Responsibilities:Works with LTC Sr. Financial Analyst responsible for financial and quality analysis for LTC Division.Participates in the compilation, completion and distribution of quarterly and other reports prepared for the HHC Board of Directors Long Term Care Committee. Qualifications Registered nurse (RN)Experience with computerized health data analysis, and data managementKnowledge, Skills & Abilities Good judgment and discretion in communication (written, verbal and non-verbal).Must be able to prioritize work, meet deadlines, and work well under pressure. Flexibility to adjust to changing program/department needs and activities. Strong skills in programming, including data management and data analysis Statistical knowledge Excellent verbal and written skills. Must be proficient with Microsoft Office, Word, Excel, Power Point, Internet Explorer, and all usual and customary office equipment. Must possess the ability to work independently, and as part of a team. Must be able to display good customer service skills Must be able to take initiative and prioritize workload. Must be proficient in proof reading skills Working Environment MENTAL/VISUAL/PHYSICAL STRAIN: 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 – 15% Ability to perform driving functions in normal course of workday 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 Manager/Supervisor Utilization Review Telehealth
L.A. Care Health Plan

Supervisor, Utilization Management RN

L.A. Care Health Plan Los Angeles, CA
$102,183 - $163,492 / year
Salary Range: $102,183.00 (Min.) - $132,838.00 (Mid.) - $163,492.00 (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 Supervisor of Utilization Management (UM) RN is responsible for executing the day-to-day operations of the UM department, and monitoring the Care Management (CM) staff’s responsibilities and activities. This includes, but not limited to, ensuring proper staffing and coverage; monitoring and evaluating departmental operations to ensure optimal efficiency, productivity, and effectiveness; documenting and appropriately addressing excellence or deviations in work, departmental, and organizational expectations; and conducting intermittent and annual performance evaluations. This role assists in triaging identified issues/problems and forming resolution within the scope of work/licensure. The Supervisor is a subject matter expert (SME) in Care/Case/Utilization Management and supporting regulations, policies, protocols, and procedures. This position serves as a formal and informal instructor, and escalates issues/concerns to the appropriate person when outside of their scope. This position is responsible in assisting with and development and maintenance of a successful and cohesive unit, with high level of productivity and accuracy to achieve the department's overall performance metrics. The Supervisor ensures all functions of the UM department are operating in accordance with the organization's mission, values and strategic goals, which are focused on quality care delivery and continuous improvement; and are provided in a manner that is responsive and sensitive to the needs of L.A. Care's culturally diverse membership. The position supports the UM Manager/Director. This role also assists UM Educator/Manager/Director in identification of training needs including, but not limited to, collaborating in development of programs, training materials, competency checklist, and orientation checklists necessary to meet education and training needs of UM staff. The position supervises all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports. Duties Ensures adequate/appropriate distributions of workforce, assignments and time off requests. Participates in the hiring and termination process providing recommendations with appropriate supporting documentation. Monitors of staff's performance including productivity and compliance with regulatory requirements, compliance with policies. Identifies, communicates and coaches to improve staff performance. Develops tools, job aids, and workflows to optimize the process flow, performance and productivity of the UM team. Completes intermittent and annual staff evaluations. Serves as the primary resource for all business-related questions/issues raised by staff; escalates to appropriate leader/team when necessary. Recommends and implements process improvement measures to achieve department's performance measures outcomes and goals. Plans and oversees UM activities according to model of care, program description and policy and procedures to provide timely, quality care and services to members. Maintains all assigned reporting responsibilities, conducts regular audits to ensure compliance with community, industry and organizational standards including regulatory requirements. Serves as a super-user on electronic programs and systems used by the department. Assists in the development of programs, workflows, tools, training materials, orientation checklists, and competency checklist necessary to meet educational needs. Trains new staff, remediation of seasoned staff and cross training as needed in specified business lines. Serves as a leader and role model as well as technical and informational resource for staff and peers. Duties Continued Fosters a culture that encourages employee contribution to ensure that the department maintains an environment in which quality flourishes. Services as member/resource/liaison to the Interdisciplinary Care Team. Recommends resources to improve performance standards in terms of Utilization Management. Collaborates with peers and colleagues within the organization to address process improvements, member's needs, department and organizational enhancements and communicate development as appropriate. Participates on internal and external committees as delegated or assigned. Serves as a consultant to other departments or organizations as needed. Responsible for the daily workflow and leading the work of assigned staff. This role will mentor, coach, act as a resource and provide feedback on performance of assigned staff. Performs other duties as assigned. Education Required Associate's Degree in NursingEducation Preferred Bachelor's Degree in NursingExperience Required: Minimum of 7 years of acute/clinical care experience. Minimum of 2 years of experience in Case/Care/Utilization Management in an acute care or health plan setting. Minimum of 3 years leading process, program, or staff or supervisory experience. Equivalency: Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement. Skills Required: Knowledge of state, federal and regulatory requirements in Care/Case/Utilization Management. Strong verbal and written communication skills. Computer literacy with proficiency with Microsoft Word, Excel, etc. and ability to learn core departmental computer systems and software. Excellent organizational, time management, and interpersonal skills. Must be detailed-oriented, energetic, and an enthusiastic team player. Must be able to work independently. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California LicenseLicenses/Certifications Preferred Required Training Physical Requirements LightAdditional Information Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. L.A. Care offers a wide range of benefits including Paid Time Off (PTO) Tuition Reimbursement Retirement Plans Medical, Dental and Vision Wellness Program Volunteer Time Off (VTO)
RN Utilization Review Telehealth
L.A. Care Health Plan

Utilization Management Nurse Specialist RN II

L.A. Care Health Plan Los Angeles, CA
$88,854 - $142,166 / year
Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job Summary The Utilization Management Nurse Specialist RN II facilitates, coordinates, and approves medically necessary referrals that meet established criteria. Assures timely and accurate determination and notification of referrals and reconsiderations based on the referral determination status. Generates approval, modification and denial communications, to include member and provider notification of referral determination. Actively monitors for admissions in any inpatient setting. Performs telephonic and/or onsite admission and concurrent review, and collaborates with onsite staff, physicians, providers, member/family interaction to develop and implement a successful discharge plan. Works with the UM Manager and Physician Advisor on case reviews for pre-service, concurrent, post-service and retrospective claims medical review. Monitors and oversees the collection and transfer of data (medical records) and referral requests by Providers. Acts as a department resource for medical service requests /referral management and processes. Receives incoming calls from providers, professionally handles complex calls, researches to identify timely and accurate resolution steps. Follows up with caller to provide response or resolution steps. Answers all inquiries in a professional and courteous manner. Duties Promote and support team engagements, programs and activities to create and ensure a positive and productive workplace environment. Perform telephonic and/or onsite admission and concurrent review, and collaborates with onsite staff, physicians, providers, the member and significant others to develop and implement a successful discharge plan. Process, finalize and facilitate inbound requests that are received from providers. Generate appropriate member and provider communication for all determinations within the required timelines as defined by the most current department policy. Facilitate/review requests for Higher level of care or skilled nursing/discharge planning needs. Research for appropriate facilities, specialty providers and ancillary providers to utilize for all lines of business. Identification of potential areas of improvement within the provider network. Identify and initiate referrals for appropriate members to the various L.A. Care programs/processes and external community based programs or Linked and Carve Out Services (e.g. DDS/CCS/MH). Potential quality of care/potential fraud issues are identified and documented per L.A. Care policy. High risk/high cost cases and reports are maintained and referred to the Physician Advisor/UM Director. Document in platform/system of record. Utilize designated software system to document reviews and/or notes. Receive incoming calls from providers, professionally handle complex calls, research to identify timely and accurate resolution steps. Follow up with caller to provide response or resolution steps. Answer all inquiries in a professional and courteous manner. Perform other duties as assigned. Duties Continued Education Required Associate's Degree in 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 Full-time
Renown Health

Utilization Management RN-Acute

Renown Health Reno, NV
Position Purpose Under the supervision Hospital Care Management, incumbent promotes appropriate utilization, high quality care and cost effective outcomes. Incumbent is also responsible for utilization review, coordination of acute inpatient denials, performs admission and concurrent reviews and communication with physicians and payers regarding the medical necessity for services. Nature and Scope Conduct medical certification review for medical necessity for acute care facility and services. Use nationally recognized, evidence-based guidelines approved by medical staff to recommend level of care to the physician and serve as a resource to the medical staff on issues related to admission qualifications, resource utilization, national and local coverage determinations, and documentation improvement opportunities. This position also provides information (certified LOS and reimbursement issues) to the care team (RN, physicians, and case manager) as needed to ensure the appropriate and timely disposition of the client. The Utilization Management RN, documents all chart and phone reviews, identifies and communicates potentially avoidable/non-reimbursed days, quality indicators (such as readmissions). Delivers non-covered letters as set forth by payer and/or regulatory compliance. This position will be required to work a flexible schedule that may include evenings and weekends to provide coverage for the department as needed. This position participates in Quality Improvement initiatives. Knowledge, Skills & Abilities Strong interpersonal communication skills both verbal and written. Knowledge of applicable regulatory requirements and community resources Knowledge of continuous quality improvement process. Philosophy consistent with the strategic plan of Renown Health The ability to understand and resolve complex problems in a timely and effective manner using critical thinking skills. The ability to keep current with new developments and acquire the needed knowledge for the position in order to keep skill sets up to date. The ability to work under stress and to meet deadlines. This position does not provide patient care. Disclaimer The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job. Minimum Qualifications Requirements - Required and/or Preferred Name Description Education: Must have working-level knowledge of the English language, including reading, writing and speaking English. English. Appropriate education to obtain and maintain Registered Nursing licensure in the State of Nevada. Experience Applicants with 1 year previous managed care and/or case management experience including acute hospital case management is preferred. Minimum of one-year in hospital setting required. License(s) Ability to obtain and maintain State of Nevada Registered Nurse license. Certification(s) Utilization or Case Management Certification preferred. Certification in Case Management (CCM), Certified Managed Care Nurse (CMCN), or ABQAURP HCQM is preferred. Computer / Typing Must possess, or be able to obtain within 90 days, the computers skills necessary to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.
RN Utilization Review Full-time
IU Health

Registered Nurse-Utilization Management (Acute Rehab Unit)

IU Health Muncie, IN
Overview Registered Nurse – Utilization Management (Acute Rehab Unit) Ball Memorial Hospital | Muncie, Indiana Full-Time | Day Shift Monday-Friday | 8:00 AM - 4:30 PM No Call • No Weekends • No Holidays Join Our Team Ball Memorial Hospital is seeking a dedicated Registered Nurse - Utilization Management to support our Acute Rehabilitation Unit . This role offers an excellent opportunity for an experienced RN who enjoys combining clinical expertise with care coordination, utilization review, and patient advocacy to ensure patients receive the right care at the right time throughout their healthcare journey. In this position, you will serve as a critical liaison between patients, providers, payers, and the interdisciplinary care team to promote quality outcomes, appropriate resource utilization, and seamless transitions of care. What You'll Do Conduct utilization review activities for inpatient admissions, outpatient procedures, and ancillary services. Perform pre-certification, concurrent, and retrospective reviews to ensure medical necessity and appropriate levels of care. Apply established clinical review criteria, regulatory requirements, and payer guidelines to assess appropriateness of services. Collaborate with physicians, rehabilitation specialists, case managers, and interdisciplinary care teams to optimize patient outcomes. Coordinate and support discharge planning efforts to facilitate safe and timely transitions across the continuum of care. Advocate for patients by expediting access to medically necessary services and removing barriers to care. Monitor compliance with documentation, quality standards, and utilization management policies. Promote efficient, cost-effective healthcare delivery while maintaining a strong focus on quality and patient-centered care. Serve as a clinical resource related to utilization management, reimbursement, and care coordination processes. Why You'll Love This Opportunity Day shift schedule with excellent work-life balance No call requirements No weekends No holidays Opportunity to leverage your clinical expertise in a collaborative, multidisciplinary environment Make a meaningful impact on patient outcomes and care transitions Professional growth within a highly respected healthcare organization Qualifications Requires an Associates of Nursing (ASN). Bachelors of Nursing (BSN) preferred. Requires an active Registered Nurse (RN) license in the state of Indiana or an active Nurse Licensure Compact (NLC) RN license. Requires that the RN has graduated from a nationally accredited nursing program. Requires 3-5 years of relevant experience. Inpatient nursing experience preferred. Basic Life Support certification through the AHA or other advanced life support certifications may be required per unit/department specialty according to patient care policies. Requires proficiency in Microsoft Office and applications. Requires understanding of medical record requirements, regulations and policies.
RN Utilization Review Full-time
Palmetto General Hospital

Utilization Review RN, Case Management/UR, Full Time, Day Shift, Job ID # 1815702

Palmetto General Hospital Miami Lakes, FL
Position Summary: Performs Case Management activities to assure medical necessity of admissions and appropriateness of continued stay utilizing the Interqual Criteria guidelines. Monitors the utilization of resources of all patients reviewed. Working with clients, family and friend support networks and health care professionals to put care plans in place. Evaluating clients' progress daily and making adjustments as needed to improve outcomes. Maintains confidential communication with physicians and multi-disciplinary personnel to meet individual needs or the patients served. Functions as an independent contributor as well as a team member. Position Qualification: Communication is an essential skill requiring the ability to see, hear, and speak. Fluent in written and spoken English. Must be able to fulfill the essential functions of the position. Possess three or more years of acute care hospital experience preferred. Familiar with the operations of the healthcare industry and healthcare delivery systems. Able to use the medical record in order to obtain clinical information to perform Interqual reviews. Utilize Outlook, and the computer based systems to perform reviews/CM assessments/CM tasks. Work experience in Medical-Surgical, Telemetry, Critical Care, and/or Pediatrics, NICU preferred. Required Licenses/Certifications: Current Florida RN Licensure BLS Certification. Must possess a solid clinical background to accomplish extensive Medical Record review. Computer skills Communication Skills: Ability to effectively communicate in writing and orally with all levels of the organization
RN Utilization Review Full-time
Atlanticare

Registered Nurse - Utilization Management - Full Time

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

Registered Nurse - Utilization Management - Per Diem

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

RN, Quality Management Coordinator, Peer Review

Community Medical Centers Fresno, CA
Overview * All positions are located in Fresno/Clovis CA * We are looking for an RN Quality Management Coordinator to join our growing team. In this fast-paced environment, you will have the opportunity to collaborate with a close-knit team, all while caring for a wide acuity of patients. As the management coordinator, you will provide in-depth clinical analysis on confidential patient safety, peer, quality and risk issues. From facilitating and coordinating performance improvement projects to data tracking from a facility-specific, you will be provided endless personal and professional growth opportunities at every corner. The Community Health System is a locally owned, not-for-profit, public-benefit organization based in Fresno, California. Community is the region's largest healthcare provider and private employer. We operate a physician residency program with one of the nation's top medical schools – the University of California, San Francisco. We are home to the only Level 1 Trauma Center and comprehensive burn center between Los Angeles and Sacramento and also serve as the area's "safety net provider." In fiscal year 2021, Community provided nearly $231 million in uncompensated services and programs. Because we know our ability to provide the highest level of care begins with our incredible staff, we provide excellent benefits. On top of competitive pay, hearty retirement plans, and other core benefits, we provide extras like free concierge services to run your errands while you work, on-demand well-being, a free employee gym with free personal training, and more. Your Career at Community | Opportunity. Challenge. Growth. Responsibilities In your role, you will: Perform in-depth clinical analysis for confidential staff and physician issues related to patient safety, peer and quality. Provide oversight to non-clinical Quality Management staff. Complete responsibilities in a busy, demanding environment with competing priorities. Coordinate, direct and ensure completeness of the FMEA (Failure Mode Effectiveness Analysis), Safe Start of Tracer processes for vulnerable, high-risk operational processes. These processes require a high degree of legal, ethical, financial, clinical and organizational knowledge. Work with employees and physicians to investigate confidential quality, behavioral and patient safety concerns. Understand and make appropriate referrals to Risk Management, Peer, Quality Management or clinical operations as needed. Coordinate and facilitate hospital, CSTCC or departmental involvement with quality measures (e.g. Core Measures, Patient Safety Indicators and other preventable events) including analysis, comparative data, trending and tracking. Demonstrate ability to develop data spreadsheets and provide the analysis and communication to interpret data into information in order to drive quality and change. Facilitate turning data into information for point of service staff and performance improvement. Develop and assist with implementation of action plans focusing on quality outcomes and performance improvement projects using physician and staff input. Qualifications Education• Bachelor's Degree in Nursing or related field required Experience• 5 years of experience in Quality Assurance, Case Management, Discharge Planning, Utilization Review, Infection Control or nursing project development/education required Licenses and Certifications• RN - Current State of California Registered Nurse license required• One of the following is preferredo CPHQ - Certified Professional Healthcare Qualityo CPHRM - Certified Healthcare Risk Managemento CJCP - Certified Joint Commission Professionalo Clinical certification in area specialty Click HERE to learn more about our awesome benefits offerings as well! Disclaimers • Pay ranges listed are an estimate and subject to change.• If any bonuses are noted, they are only applicable to external hires meeting criteria.
RN Utilization Review Full-time
Infirmary Health

Physician Peer Review RN Coordinator (not a remote position)

Infirmary Health Mobile, AL
Overview Responsibilities Coordinates, organizes, and facilitates Mobile Infirmary Medical Center (MIMC) physician peer review and professional practice evaluation processes. Ensures timely, objective, and confidential review of clinical events, supports medical staff leaders in evaluating practitioner performance, and maintains compliance with all Infirmary Health (IH), regulatory, and accreditation standards. Qualifications Minimum Qualifications: Bachelor of Science in Nursing (BSN) 3 of the most recent 5 years’ experience in acute care clinical setting Strong analytical and critical thinking skills Ability to perform with a high level of professionalism, discretion, and confidentiality Proficient computer skills in Microsoft Office and EHR systems (i.e. Epic) Licensure, Registration, Certification: One of the following: Current Alabama RN license Current Multi State RN License in accordance with Nurse Licensure Compact (NLC) for Alabama* *Infirmary Health abides by the NLC requirements and guidelines for the state of Alabama Desired Qualifications: Master of Science in Nursing (MSN) Working knowledge of quality, peer review, risk management, or medical staff services and processes Experience working or coordinating physician peer review in a hospital setting Working knowledge of clinical care standards and physician practice patterns Knowledge of FPPE/OPPE and Joint Commission standards Licensure, Registration, Certification: Certified Professional in Healthcare Quality (CPHQ) through the National Association for Healthcare Quality (NAHQ) Certified Professional in Patient Safety (CPPS) through the Certification Board for Professionals in Patient Safety (CBPPS)
RN Utilization Review Full-time
The Christ Hospital Health Network

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

The Christ Hospital Health Network Cincinnati, OH
Job Description To maintain high-quality, medically necessary, evidence-based care, and efficient treatment of all patients, regardless of payment source, by ensuring the patients receive the right care, at the right time, in the right place. Case Management Model: utilize an Integrated Case Management Model. Under this model the Case Managers will follow patients through the continuum while facilitating the functions of utilization review, utilization management, and cost containment. Track and trend denials and payor issues to provide feedback and education to payer relations and the case management department. Responsibilities Clinical review of 100% acute bedded patients admitted to Inpatient or Observation status at The Christ Hospital against medical necessity criteria (Interqual and MCG) for appropriateness of admission. Demonstrate understanding of evidenced based medical necessity criteria. Maintains efficient methods of ensuring the medical necessity and appropriateness of all hospital admissions. Identify/facilitate patient status from observation to inpatient as patient clinical condition warrants. Compliance with all Medicare regulatory requirements Work with external payers completing/securing authorization for all services provided. Monitors cases for appropriateness of continued stay, level of care and services, and quality of care using approved screening criteria. Communicate with physicians when alternatives to inpatient care are indicated by clinical review. Identify cases needed for second level of review- refers cases to the Physician Advisor that do not meet established guidelines for admission or continued stay. Consistent collaboration with the RN Case Manager to prevent extended length of stays and appropriate status determination. Identifies potential delays in service or treatment and refers to the appropriate individuals within the multidisciplinary patient care teams for action/resolution. Track and trends avoidable day information in Midas per process. Identifies problems related to the quality of patient care and refers such problems to the Performance Improvement Department. Adherence to department productivity standards. Initial, concurrent, and retro reviews should be completed timely including all necessary information for approval of claims. All reviews should contain information only pertinent to IS/SI (Intensity of Service/Severity of Illness). Compliance with documentation methods for monthly reporting and statistics for presentation to the Utilization Review Committee. Interfaces with patient registration and patient financial services etc. to collaborate on financial issues. Establish an effective rapport and relationship with third party payers to promote cost effective clinical outcomes. Assist in denial and appeal process Performs other duties as assigned, including but not limited to: Demonstrates professional responsibility required for a Utilization Review Nurse Complies with department and hospital policies at all times Maintains compliance with State/Federal Guidelines and standards Conforms to all requirements of Medicare Keep current on changing laws and requirements of Medicare Demonstrate a positive attitude at all times Qualifications KNOWLEDGE AND SKILLS: Please describe any specialized knowledge or skills, which are REQUIRED to perform the position duties. Do not personalize the job description, credentials, or knowledge and skills based on the current associate. List any special education required for this position. EDUCATION: Bachelor’s Degree. Graduate of an accredited school of nursing with current licensure OR actively enrolled in a BSN program with completion date within 3 years of hire date and a graduate of an accredited school of nursing with current licensure. YEARS OF EXPERIENCE: 3-5 years of medical/surgical nursing necessary and a minimum of 3 years of utilization review experience required. REQUIRED SKILLS AND KNOWLEDGE: Experience with case management, utilization review, and discharge planning that is related to the clinical or operational functional areas. Knowledge and application of a wide variety of advanced case management tools and methods. Knowledge of clinical and operations research methodology and design. Proficient in state of the art business trends, benchmarking, and case management tools and techniques. Ability to operate PC based software programs or automated database management systems. Expertise in meeting regulatory and accreditation requirements. Strong presentation, written and oral communication skills, with strong analytical and problem-solving skills as well as time/project management skills. Ability to work with a variety of disciplines and levels of staff across departments and the organization is required. LICENSES & CERTIFICATIONS: Licensed to practice in the State of Ohio Certified Case Management (CCM) or Accredited Case Management (ACM) preferred.
RN Utilization Review Telehealth Full-time
Astrana Health

UM Review Nurse

Astrana Health Monterey Park, CA
$34 - $47 / hour
UM Review Nurse Department: HS - UM Employment Type: Full Time Location: 1600 Corporate Center Dr., Monterey Park, CA 91754 Reporting To: Phillip Vasquez Compensation: $34.00 - $47.00 / hour Description Astrana Health is looking for a CA-licensed Utilization Review Nurse to assist our Health Services Department. In this position, you will utilize your clinical judgement to approve or deny outpatient medical services for patients based on Medical Necessity Criteria, respective to various Health Plans. This position requires open availability between Monday through Sunday, 8 A - 8 P. You would be scheduled for 5 shifts per week. This is a remote position for CA-licensed nurses. Candidates must live in California. We are seeking nurses with at least one year of outpatient Utilization Management experience in a fast-paced setting. Our Values: Put Patients First Empower Entrepreneurial Provider and Care Teams Operate with Integrity & Excellence Be Innovative Work As One Team What You'll Do Complete prior authorization/retrospective review of elective inpatient admissions, outpatient procedures, post-homecare services, and durable medical equipment Refer cases to Medical Directors as needed/appropriate Maintain knowledge of state and federal regulations and accreditation standards Comply with internal policies and procedures Perform any other job duties as requested Qualifications Active and unrestricted LVN license in CA. At least 1 years of outpatient UM experience Experience with Microsoft applications such as Word, Excel, and Outlook You’ll be Great for this Role If: At least two (2) years of health plan, IPA or MSO experience Strong interpersonal skills Ability to collaborate with co-workers, senior leadership, and other management Experience educating and training staff Environmental Job Requirements and Working Conditions This is a remote position. Our office is located at 1600 Corporate Center Drive in Monterey Park, CA. Candidates who live within a 30 mile radius of the office may be expected to work hybrid. Typical business hours are Monday - Friday from 8:30 AM to 5 PM, however, this position requires open availability between 8 AM - 8 PM PST, M-Su. Your schedule will be compromised of 5 shifts per week. Nurses rotate weekend and holiday coverage. Overtime is required in this position. The national target pay range for this role is $34.00 - $47.00 per hour. Actual compensation will be based on job level, geographic location (current or future), experience, and other job-related factors. Astrana Health is proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based on race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. All employment is decided based on qualifications, merit, and business need. If you require assistance in applying for open positions due to a disability, please email us at humanresourcesdept@astranahealth.com to request an accommodation. Additional Information: The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.