Registered Nurse (RN) Utilization Review Jobs

RN Utilization Review Full-time
Baptist Health South Florida

Pool Utilization Review Registered Nurse, Case Management, Per Diem, Shift Varies (Rotating Weekends)

Baptist Health South Florida Boca Raton, FL
$47 / hour
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 and resource utilization. Coordinates with healthcare Team for optimal efficient patient outcomes, while decreasing length of stay and avoid delays and denied days. They are accountable for a designated patient caseload and provides intervention and 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 and 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 resolve payer issues and ensures, maintains effective communication with Revenue Cycle Departments. Estimated pay range for this position is $47.00 / hour depending on shift as applicable. Qualifications: Degrees: Associates. Licenses & Certifications: 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, required to complete the BSN within 3 years of hire. 3 years of hospital clinical 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, and ability to tolerate high volume production standards. Minimum Required Experience: . BSN Required 3 years of Nursing experience with 1 year of Hospital or Payor Utilization Review experience required MCG Specialist Certification ISC/HRC required within 12 months of job entry date. EOE, including disability/vets
RN Utilization Review Full-time
UF Health

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

UF Health Gainesville, FL
Overview Make an impact by supporting the right care at the right time through utilization management excellence. RN Utilization Lead under the general supervision of the Director, is responsible for department coordination of utilization, other review activities to ensure payment for services is authorized and an active and effective utilization management program is maintained. 💻 Work Style: Onsite 📍 Location: Gainesville, FL 🕒 FTE: Full-time (1.00 FTE) ⏰ Schedule: Thursday-Sunday - 5:30 AM - 4:00 PM Responsibilities Responsible to perform all duties accordance with the utilization review (UR) plan, Federal and State guidelines, as well as TJC standards. Is also responsible for operational logistics in the absence of the Director. Qualifications Minimum Education and Experience Requirements: Re gistered nurse (RN) with current Florida license with a minimum of two (2) years experience performing utilization review in a hospital setting, for a third party payer or other review agency or organization. Knowledge of diagnostic related groups (DRGs), Federal and State guidelines, commercial and other payer groups and coding preferred. Must possess strong written and verbal communication skills. Ability to type and use a computer proficiently required. Licensure/Certification/Registration: Registered Nurse.
RN Utilization Review Full-time
Havenwyck Hospital

Utilization Management Case Manager

Havenwyck Hospital Lake Angelus, MI
Responsibilities HAVENWYCK HOSPITAL (a UHS facility) Havenwyck Hospital is a Joint Commission-accredited and licensed psychiatric hospital, overlooking Lake Galloway in Auburn Hills, Michigan. We specialize in providing comprehensive, compassionate behavioral health services to children, adolescents and adults. It is the ultimate goal of our dedicated staff to build strength, confidence and knowledge within each patient, in hopes that they may continue learning and understanding their needs and practicing self-care for the rest of their lives. If you would like to learn more about this position before applying, please contact Havenwyck Hospital at 248-373-9200. POSITION SUMMARY: The Utilization Management Case Manager has a responsibility for organizing and conducting the manager care process. These duties shall be directed toward supporting the hospital's mission in the pursuit of excellence in care/service and will include (but not limited to ): conducting timely admission and continues stay record reviews with external payers, utilizing approved criteria to make determinations of medical necessity and level of care planning, verifying active treatment by completing internal audit reviews within approved time frames, assisting the treatment team when indicated in the discharge planning process, and acting as liaison with MD/Clinical Treatment Team and external agencies. Report authorizations, denials, and documentation concerns, as well as collaborate effectively across departments to minimize denials/facilitate optimal use of hospital resources. DUTIES AND RESPONSIBILITIES: Through clinical skills (experience and knowledge), reports to external insurance and review entities an accurate presentation of the medical management of a patient's illness, length of stay and care alternatives available within the confines on the client's benefits and financial resources. Communicates with the Treatment Team (physicians, nursing staff, social workers, etc.) as necessary to advocate for the patient's clinical treatment within the confines on the client's benefits and financial resources. Using clinical skills (experience and knowledge) assists the team in ensuring the completeness and accuracy of the medical records. Performs other related duties as assigned. BENEFIT HIGHLIGHTS: Challenging and rewarding work environment Competitive Compensation & Generous Paid Time Off Excellent Medical, Dental, Vision and Prescription Drug Plan 401(K) with company match and discounted stock plan Career development opportunities within UHS and its 300+ Subsidiaries Free Basic Life Insurance Tuition Reimbursement SoFi Student Loan Refinancing Program Student Loan Repayment Program - for some degrees and criteria What do our current employees value at Havenwyck Hospital and UHS? An environment that puts patient care first. One of the most rewarding aspects of this job is providing excellent care, comfort, and security to the patients and families you treat, at their most vulnerable times. Supportive and responsive leadership. You are never alone, as you are part of a large network of peer co-workers that routinely exchange ideas and review current topics within the industry. Having the opportunity to grow, learn, and advance in your career. There are very robust continuing education options and opportunities for skills diversification and career advancement with UHS. About Universal Health Services One of the nation’s largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (NYSE: UHS) has built an impressive record of achievement and performance. Growing steadily since its inception into an esteemed Fortune 300 corporation, annual revenues were $15.8 billion in 2024. During the year, UHS was again recognized as one of the World’s Most Admired Companies by Fortune; and listed in Forbes ranking of America’s Largest Public Companies. Headquartered in King of Prussia, PA, UHS has approximately 99,000 employees and continues to grow through its subsidiaries. Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory care access points, an insurance offering, a physician network and various related services located all over the U.S. States, Washington, D.C., Puerto Rico and the United Kingdom. www.uhs.com Qualifications QUALITICATIONS: Bachelor Degree in social work, psychology, counseling or nursing required. Master's degree in social work, psychology, or counseling preferred. Limited or fully licensed (LBSW, RN, LLMSW, LLP, TLLP, LPC, LMFT, etc.). A minimum of 2 years of post-graduate related experience in psychiatric or substance abuse treatment required. Hospital utilization review/utilization management experience preferred. Familiarity with manager health care process, medical terminology, experience in case management, discharge planning, and/or utilization review preferred. EEO Statement All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws. We believe that diversity and inclusion among our teammates is critical to our success. Avoid and Report Recruitment Scams At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skill set and experience with the best possible career path at UHS and our subsidiaries. During the recruitment process, no recruiter or employee will request financial or personal information (e.g., Social Security Number, credit card or bank information, etc.) from you via email. Our recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc. If you suspect a fraudulent job posting or job-related email mentioning UHS or its subsidiaries, we encourage you to report such concerns to appropriate law enforcement. We encourage you to refer to legitimate UHS and UHS subsidiary career websites to verify job opportunities and not rely on unsolicited calls from recruiters.
RN Utilization Review Full-time
University of Utah Health

Utilization Review Nurse

University of Utah Health Salt Lake City, UT
Overview As a patient-focused organization, University of Utah Health exists to enhance the health and well-being of people through patient care, research and education. Success in this mission requires a culture of collaboration, excellence, leadership, and respect. University of Utah Health seeks staff that are committed to the values of compassion, collaboration, innovation, responsibility, integrity, quality and trust that are integral to our mission. EO/AA This position is responsible for maintaining the financial integrity of both the patient and the organization through the provision of quality based patient care focusing on the medical necessity and efficiency of the delivery of such care; achieved via managing the cost of care while providing timely and accurate information to third party payers and medical care team. This position may be required to access and administer medications within their scope of practice and according to state law. Corporate Overview: The University of Utah is a Level 1 Trauma Center and is nationally ranked and recognized for our academic research, quality standards and overall patient experience. Our five hospitals and eleven clinics provide excellence in our comprehensive services, medical advancement, and overall patient outcomes. Responsibilities Essential Functions Applies approved utilization criteria to monitor appropriateness of admissions with associated levels of care and continued stay review. Communication to third-party payers for initial and concurrent clinical review. Reviews patient chart to ensure patient continues to meet medical necessity. Documentation of all actions and information shared with care team members or third-party payer. Alerts and discusses with physician/provider and case manager/discharge planner when patient no longer meets medical necessity criteria for the inpatient stay. Discusses with physicians the appropriateness of resource utilization. Tracks length of stay (LOS) and resource utilization to identify at risk patients. Refers to UR committee any case that surpasses expected LOS, expected cost, or over/under-utilization of resources. Performs verbal/fax clinical review with payer as determined by nursing judgment and/or collaboration with the payer per university contractual obligation. Participant in UR Committee as needed. Collects data on variances in LOS, avoidable days, costs/barriers to discharge/transition and denied days. Prepares appeals on denied cases when appropriate. At the discretion of department operational and patient care needs, this position is required to work rotating schedules, which may include variable hours, weekends, nights, and holidays to meet the staffing and patient care demands of a 24/7 complex health system. Regular, reliable, and punctual attendance during assigned shifts is considered an essential function of the role. Knowledge / Skills / Abilities Demonstrated availability to work variable and rotating shifts, including nights, weekends, and holidays, in a 24/7 patient care environment. Ability to perform the essential functions of the job as outlined above. Demonstrated team leadership, relationship building, critical analysis, and written and verbal communication skills. Demonstrated knowledge of payers, payer systems, cost effective utilization management and InterQual criteria. The ability to demonstrate knowledge of the principles of life span growth and development and the ability to assess data regarding the patient's status and provide care as described in the department's policies and procedures manual. Ability to work autonomously and as a team member. Qualifications Required One year Utilization Review or Case Management experience. Licenses Required Current license to practice as a Registered Nurse in the State of Utah, or obtain one within 90 days of hire under the interstate compact if switching residency to State of Utah. Must maintain current Interstate Compact (multi-state) license if residency is not being changed to Utah. * Additional license requirements as determined by the hiring department. Qualifications (Preferred) Preferred Basic Life Support Health Care Provider card. Proficiency in application of InterQual Criteria, knowledge of ICD-9, DRG's and CPT Codes. Utilization Review Certification designation. Knowledge of CMS Regulations. Working Conditions and Physical Demands Employee must be able to meet the following requirements with or without an accommodation. This is a sedentary position in an office setting that may exert up to 10 pounds and may lift, carry, push, pull or otherwise move objects. This position involves sitting most of the time and is not exposed to adverse environmental conditions. This position does not provide care to patients. Physical Requirements Color Determination, Listening, Manual Dexterity, Sitting, Speaking, Standing, Walking
RN Utilization Review Temporary
UF Health

RN, Utilization Management | Utilization Management| Variable | PRN

UF Health Leesburg, FL
Overview Make an impact by supporting the right care at the right time through utilization management excellence. 💻 Work Style: Onsite 📍 Location: Leesburg, FL 🕒 FTE: PRN (.10 FTE) ⏰ Schedule: Variable Plays a critical role in evaluating patient medical records to ensure the necessity and appropriateness of healthcare services. Involves coordinating with healthcare providers to maintain compliance with utilization management guidelines and optimizing treatment plans for effective patient care and resource utilization. Requires clear communication of authorization decisions and ongoing monitoring to support timely discharge planning. Analyzes utilization data to identify trends and collaborates with interdisciplinary teams to enhance care coordination while ensuring accurate documentation and regulatory compliance. Responsibilities Key Responsibilities Evaluates patient medical records to determine the medical necessity and appropriateness of healthcare services. Coordinates with healthcare providers and care teams to ensure compliance with utilization management guidelines and payer requirements. Supports effective treatment planning, patient care coordination, and appropriate resource utilization. Communicates authorization decisions and utilization determinations while supporting timely discharge planning efforts. Analyzes utilization management data and trends to identify opportunities for improved care coordination and operational efficiency. Collaborates with interdisciplinary teams to ensure accurate documentation, regulatory compliance, and quality patient outcomes. Qualifications Education & Licensure Registered Nurse (RN) with a current Florida nursing license required. Experience & Skills Minimum of three (3) years of experience in utilization review, utilization management, or case management required. Knowledge of healthcare utilization guidelines, payer requirements, and regulatory compliance standards. Experience evaluating medical necessity, treatment plans, and appropriate levels of care. Strong communication and collaboration skills related to authorization determinations and care coordination. Demonstrated ability to analyze utilization data, identify trends, and support patient care and discharge planning initiatives.
RN Utilization Review Full-time
Bryan Health

Utilization Management RN Lead

Bryan Health Lincoln, NE
Summary GENERAL SUMMARY: Conducts day-to-day activities for the clinical, financial and utilization coordination of the patient’s hospital experience. Proactively consults with the interdisciplinary team which includes, but is not limited to, hospital patient care staff, physicians, patient support, and family to ensure the patient’s hospital stay meets medical necessity and insurance authorizations are obtained to facilitate the financial well-being of the patient and hospital. Acts as the contact for the Utilization Management (UM) staff for day-to-day questions and guidance. Shares meeting responsibilities with the manager representing UM in meetings inside and outside the department. Serves as the Subject Matter Expert (SME) for the whole department both inside and outside the department. Assists with scheduling, assigning workflow, and various employee instructions both educational and corrective. PRINCIPAL JOB FUNCTIONS: 1. *Commits to the mission, vision, beliefs and consistently demonstrates our core values. 2. *Acts as manager when manager is unavailable. 3. *Serves as the subject matter expert for the Utilization Management department for utilization review activities, including concurrent and retrospective reviews as required. 4. *In conjunction with the manager, assists in streamlining operations and maximization of UM tools. 5. *In conjunction with the manager, attends Operational and Revenue Cycle meetings as needed representing the Utilization Management department, and attends the UM Committee meeting. 6. *Acts as the day-to-day contact for the Utilization Department staff to approve last-minute requests for time off, assists with assignments, schedules, and helps manager with employee situations. 7. *Performs duties as a Utilization Management RN by determining the medical necessity of requests by performing first level reviews and using approved evidence-based guidelines/criteria. 8. Takes UM-RN staff shifts as needed by performing utilization review activities, including concurrent and retrospective reviews as required. 9. *Collaborates with the patient’s provider and other healthcare team members in managing the patient’s length of stay and determining the continuing medical necessity of continued stays. 10. *Refers cases to reviewing physician when the treatment request does not meet criteria per appropriate algorithm. 11. *Participates in concurrent and retrospective denials and appeals process by researching issues surrounding the denial, participating in all levels of the appeal and process follow-up. 12. *Serves as an internal and external resource regarding appropriate level of care; admission status/classification; Medicare/Medicaid rules, regulations, and policies; third party and managed care contracts; discharge planning; and length of stay. 13. Ensures appropriate resource utilization relevant to the financial, regulatory, and clinical aspects of care; proposes alternative treatment to ensure a cost effective and efficient plan of care. 14. *Maintains awareness of financial reimbursement methodology, utilization management, payer/reimbursement practices and regulations and participates in resource stewardship. 15. *Promotes quality improvement initiatives and health care outcomes based on currently accepted clinical practice guidelines and total quality improvement initiatives. 16. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise. 17. Participates in meetings, committees and department projects as assigned. 18. Performs other related projects and duties as assigned. (Essential Job functions are marked with an asterisk “*.” Refer to the Job Description Guide for the definition of essential and non-essential job functions.) Attach Addendum for positions with slightly distinct roles or work-specific differences as needed. REQUIRED KNOWLEDGE, SKILLS AND ABILITIES: 1. Maintains clinical competency as required for the unit including but not limited to age-specific competencies relative to patient’s growth and developmental needs, annual skill competency verification and mandatory education and competencies. 2. Knowledge of governmental and third-party payer regulations and requirements related to patient hospitalization and acute rehabilitation admission, stay and discharge activities (i.e. CMS). 3. Knowledge of computer hardware equipment and software applications relevant to work functions. 4. Skills in conflict diffusion and resolution. 5. Ability to communicate effectively both verbally and in writing. 6. Ability to perform crucial conversations with desired outcomes. 7. Ability to establish and maintain effective working relationships with all levels of personnel and medical staff. 8. Ability to problem solve and engage independent critical thinking skills. 9. Ability to maintain confidentiality relevant to sensitive information. 10. Ability to prioritize work demands and work with minimal supervision. 11. Ability to maintain regular and punctual attendance. EDUCATION AND EXPERIENCE: Current Registered Nurse licensure from the State of Nebraska or approved compact state of residence as defined by the Nebraska Nurse Practice Act required. Minimum of Five (5) years utilization management experience required. OTHER CREDENTIALS / CERTIFICATIONS: Basic Life Support (CPR) certification required. Bryan Health recognizes American Heart Association (for healthcare professionals), American Red Cross (for healthcare professionals) and the Military Training Network. PHYSICAL REQUIREMENTS: (Physical Requirements are based on federal criteria and assigned by Human Resources upon review of the Principal Job Functions.) (DOT) – Characterized as sedentary work requiring exertion up to 10 pounds of force occasionally and/or a negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects, including the human body.
RN Utilization Review Full-time
Bryan Health

Utilization Management RN- Denials

Bryan Health Lincoln, NE
Summary GENERAL SUMMARY: Conducts day-to-day activities for the clinical, financial and utilization coordination of the patient’s hospital experience. Proactively consults with the interdisciplinary team which includes, but is not limited to, hospital patient care staff, physicians, patient support and family to ensure the patient’s hospital stay meets medical necessity and insurance authorizations are obtained in order to facilitate the patient’s and hospitals financial well-being. PRINCIPAL JOB FUNCTIONS: 1. *Commits to the mission, vision, beliefs and consistently demonstrates our core values. 2. *Performs utilization review activities, including concurrent and retrospective reviews as required. 3. *Determines the medical necessity of request by performing first level reviews, using approved evidence based guidelines/criteria. 4. *Collaborates with the patient’s provider and other healthcare team members in managing the patient’s length of stay and determining the continuing medical necessity of continued stays. 5. *Refers cases to reviewing physician when the treatment request does not meet criteria per appropriate algorithm. 6. *Participates in concurrent and retrospective denials and appeals process by researching issues surrounding the denial, participating in all levels of the appeal and process follow-up. 7. *Serves as an internal and external resource regarding appropriate level of care; admission status/classification; Medicare/Medicaid rules, regulations, and policies; 3rd party and managed care contracts; discharge planning; and length of stay. 8. Ensures appropriate resource utilization relevant to the financial, regulatory and clinical aspects of care; proposes alternative treatment to ensure a cost effective and efficient plan of care. 9. *Maintains awareness of financial reimbursement methodology, utilization management, payer/reimbursement practices and regulations and participates in resource stewardship. 10. *Promotes quality improvement initiatives and health care outcomes based on currently accepted clinical practice guidelines and total quality improvement initiatives. 11. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise. 12. Participates in meetings, committees and department projects as assigned. 13. Performs other related projects and duties as assigned. (Essential Job functions are marked with an asterisk “*”. Refer to the Job Description Guide for the definition of essential and non-essential job functions.) Attach Addendum for positions with slightly different roles or work-specific differences as needed. REQUIRED KNOWLEDGE, SKILLS AND ABILITIES: 1. Maintains clinical competency as required for the unit including but not limited to age-specific competencies relative to patient’s growth and developmental needs, annual skill competency verification and mandatory education and competencies. 2. Knowledge of governmental and third party payer regulations and requirements related to patient hospitalization and acute rehabilitation admission, stay and discharge activities, i.e., CMS, CARF, FIM (TM). 3. Knowledge of computer hardware equipment and software applications relevant to work functions. 4. Skill in conflict diffusion and resolution. 5. Ability to communicate effectively both verbally and in writing. 6. Ability to perform crucial conversations with desired outcomes. 7. Ability to establish and maintain effective working relationships with all levels of personnel and medical staff. 8. Ability to problem solve and engage independent critical thinking skills. 9. Ability to maintain confidentiality relevant to sensitive information. 10. Ability to prioritize work demands and work with minimal supervision. 11. Ability to maintain regular and punctual attendance. ADDITIONAL JOB FUNCTIONS: In addition to the principal job functions contained on the primary job descriptions, the following duties are also required in the department noted above. 1. Responsible for performing clinical review and analysis in support of the denials team in managing patient medical denials through the request of documentation and assistance in preparing cases for presentation and evaluation. Collaborates with utilization management, case management, revenue cycle, and the physician advisor. Partners with the physician advisor to develop and defend clinical positions on denied cases 2. Reviews all denial accounts for categorization, level of appeal, and special requirements for initiating appeals evaluating medical necessity and level of care. 3. Reviews and compiles required denial documentation and submits in a timely manner to ensure compliance with required timelines. 4. Supports the appeal process by ensuring that proper documentation is provided to support appeals of unauthorized inpatient days or days denied for lack of documentation. 5. Manages new denials. Reviews hospital records for medical necessity and routes to the appropriate teams or personnel. Identifies gaps in clinical documentation and initiates appropriate clinical or operational interventions. Screens new denials and assigns preliminary denial reasons. Analyzes denial trends and determines root causes from a clinical perspective, validating or challenging payer denial rationale 6. Tracks and documents tasks to assist in preparing and following up on pending cases. Maintains documentation of clinical determinations and appeal activities, ensuring accuracy and compliance with regulatory and payer requirements. 7. Tracks and monitors concurrent and retrospective cases within electronic records. 8. Assists in auditing for administrative and medical necessity denials and identify opportunities for improvement in clinical documentation and utilization practices. Enters and schedules Peer to Peer reviews when necessary. 9. Assists with paperwork and follow-up of self-denied cases, and Condition Code W2s. 10. Assists in gathering data for performance of retrospective denials. Analyzes clinical denial data to identify trends, patterns, and opportunities for process improvement, and provides recommendations to clinical and operational leadership. EDUCATION AND EXPERIENCE: Two (2) years of utilization management experience with strong knowledge of the denials process and payor behaviors is preferred. EDUCATION AND EXPERIENCE: Current Registered Nurse licensure from the State of Nebraska or approved compact state of residence as defined by the Nebraska Nurse Practice Act. Two (2) years recent clinical experience required. Prior care coordination and/or utilization management experience preferred. OTHER CREDENTIALS / CERTIFICATIONS: Basic Life Support (BLS) certification required. Bryan Health recognizes American Heart Association (for healthcare professionals), American Red Cross (for healthcare professionals) and the Military Training Network. PHYSICAL REQUIREMENTS: (Physical Requirements are based on federal criteria and assigned by Human Resources upon review of the Principal Job Functions.) (DOT) – Characterized as sedentary work requiring exertion up to 10 pounds of force occasionally and/or a negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects, including the human body.
RN Utilization Review Part-time
UF Health

RN, Utilization Management | Utilization Management| Night | Part Time

UF Health Gainesville, FL
Overview Make an impact by supporting the right care at the right time through utilization management excellence. 💻 Work Style: Onsite 📍 Location: Gainesville, FL 🕒 FTE: Part-Time (.6 FTE) ⏰ Schedule: Wednesday – Thursday - 7:00 PM – 7:00 AM Plays a critical role in evaluating patient medical records to ensure the necessity and appropriateness of healthcare services. Involves coordinating with healthcare providers to maintain compliance with utilization management guidelines and optimizing treatment plans for effective patient care and resource utilization. Requires clear communication of authorization decisions and ongoing monitoring to support timely discharge planning. Analyzes utilization data to identify trends and collaborates with interdisciplinary teams to enhance care coordination while ensuring accurate documentation and regulatory compliance. Responsibilities Key Responsibilities Evaluates patient medical records to determine the medical necessity and appropriateness of healthcare services. Coordinates with healthcare providers and care teams to ensure compliance with utilization management guidelines and payer requirements. Supports effective treatment planning, patient care coordination, and appropriate resource utilization. Communicates authorization decisions and utilization determinations while supporting timely discharge planning efforts. Analyzes utilization management data and trends to identify opportunities for improved care coordination and operational efficiency. Collaborates with interdisciplinary teams to ensure accurate documentation, regulatory compliance, and quality patient outcomes. Qualifications Education & Licensure Registered Nurse (RN) with a current Florida nursing license required. Experience & Skills Minimum of three (3) years of experience in utilization review, utilization management, or case management required. Knowledge of healthcare utilization guidelines, payer requirements, and regulatory compliance standards. Experience evaluating medical necessity, treatment plans, and appropriate levels of care. Strong communication and collaboration skills related to authorization determinations and care coordination. Demonstrated ability to analyze utilization data, identify trends, and support patient care and discharge planning initiatives.
RN Utilization Review Other
ERP International

Registered Nurse - Utilization Manager

ERP International Nellis Air Force Base, NV
$34.26 - $60 / hour
Overview ERP International is seeking a full time Registered Nurse (RN) Utilization Manager at Mike O’Callaghan Military Medical Center, Nellis AFB, Las Vegas, NV. Be the Best! Join our team of exceptional health care professionals across the nation. Come discover the immense pride and job satisfaction ERP Employees experience in providing care for our Military Members, their Families and Retired Military Veterans! ERP International is honored to have been named one of The Washington Post’s 2025 Top Workplaces ! Connect With Us! Apply online today and discover more about this exceptional employment opportunity. www.erpinternational.com * Excellent Compensation & Exceptional Comprehensive Benefits! * No Weekends! No Holidays! No Call! * Paid Vacation, Paid Sick Time, Paid Federal Holidays! * Medical/Dental/Vision, STD/LTD/Life Insurance, Health Savings Account and more available! * Annual CME Stipend and License/Certification Reimbursement! * Matching 401K! About ERP International, LLC: ERP is a nationally respected provider of health, science, and technology solutions supporting clients in the government and commercial sectors. We provide comprehensive enterprise information technology, strategic sourcing, and management solutions to DoD and federal civilian agencies in 40 states. Founded in 2006, ERP is headquartered in Laurel, MD and maintains satellite offices in Montgomery, AL and San Antonio, TX - plus project locations nationwide. ERP is an Equal Opportunity Employer - Disability and Veteran. Responsibilities Work Schedule: Monday - Friday, 8 to 10 hour shifts, between 7am and 6pm No Call, No Weekends, No Holidays! Job Specific Position Duties: • Provides Utilization Management activities and functions by using MTF specific Quality Improvement processes to identify areas for review from data, suspected problem areas, and input from departments/services within the facility. Identifies gaps between desired and actual program outcomes and develops an action plan to fix gaps. Determines effectiveness of the plan and continually evaluates the impact of implementation. Incorporates applicable utilization review tasks to ensure patients receive the appropriate level of care with the right care, at the right time, in the right place, with the right provider, at the right cost. Collaborates with staff, facility departments and outside agencies to determine the best, most cost-efficient care. Provides cross coverage for those medical management clinical services both inpatient and outpatient which overlap across medical management disciplines to include discharge planning and referrals for case management.• Utilization management duties incorporate discharge planning to ensure that hospital stays meet the requirements and that a safe discharge guides placement of those patients who are unable to be discharged to home due to need for extended care services.• Mandatory knowledge and skills:• Must have knowledge of medical privacy and confidentiality (Health Insurance Portability and Accountability Act [HIPAA]), accreditation standards of Accreditation Association for Ambulatory Health Care (AAAHC), the Joint Commission (TJC), and VA DoD Clinical Practice Guidelines (CPGs). • Must have a working knowledge of computer applications/software to include Microsoft Office programs (Outlook, Excel, PowerPoint, Publisher and Access, Skype), Tiger Connect and internet familiarity is required.• Must have a working knowledge of Ambulatory Procedure Grouping (APGs), Diagnostic Related Grouping (DRGs), International Classification of Diseases-Current Version (ICD), and Current Procedural Terminology-Current Version (CPT) coding; and McKesson (InterQual) and/or Milliman Care Guidelines.• Must have experience in Patient Advocacy, Patient Privacy, and Customer Relations.• Must be able to perform prospective, concurrent, and retrospective reviews to justify medical necessity for requested medical care and to aid in collection and recovery from multiple insurance carriers, including but not limited to Tricare, Medicare, Medicaid, and Health Net Federal Services.• Must be able to collect clinical data from inpatient and outpatient sources; provide documentation for appeals or grievance resolution; apply critical thinking skills and expertise in resolving complicated healthcare, social, interpersonal, and financial patient situations; apply problem-solving techniques to articulate medical requirements to patients, families/care givers, medical and non-medical staff in a professional and courteous way.• Communication. Demonstrate ability to utilize verbal and written communication to work as a member of a team employing team building concepts in both multi -and inter-disciplinary setting to maintain medical and utilization management goals. Must be able to provide oral reports/briefings to leadership on utilization management data and make recommendations regarding needed corrections to maximize revenue while decreasing costs associated with admissions; utilize customer service skills via phone, secure messaging and in person contacts to promote positive staff and patient interactions.• Must be able to interpret data to ensure compliance with requirements for length of stay, obtain needed pre-authorizations and referrals to assist with post hospitalization safe discharge of patients.• Working knowledge of the military health care system including TRICARE/ Health Net health benefits (is preferred).• Develops and implements a comprehensive Utilization Management plan/program in accordance with the facility’s goals and strategic objectives.• Performs data/metrics collection on identified program areas; analyzes and trends results, including over- and under- utilization of healthcare resources. Identifies areas for improvement and cost containment. Reports utilization patterns/trends and provides feedback in a timely manner.• Analyzes medical referrals/appointments and general hospital procedures and regulations by monitoring specialty care referrals for appropriateness, covered benefits, and authorized surgery/medical procedures, laboratory, radiology, pharmacy and durable medical equipment.• Performs medical necessity review for planned inpatient and outpatient surgery; and performs concurrent review to include length of stay (LOS) for the facility’s inpatients using appropriate criteria.• Reviews previous and present medical care practices for patterns; trends incidents of under-or over-utilization of resources incidental to providing medical care.• Acts as referral approval authority for designated referrals per local/AF/DoD/national guidelines and standards. Refers all first-level review failures to the Chief of Medical Staff (SGH) or other POC for further review and disposition.• Verifies eligibility of beneficiaries using Defense Eligibility Enrollment Reporting System (DEERS). Obtains pertinent information from patients/callers and updates data in MHS GENESIS, local referral database, and other office automation software programs as appropriate and directed.• Ensures and monitors specialty care referrals for appropriateness, medical necessity, and if the appointment, diagnostic testing, or procedure requested is a covered benefit according to appropriate health plan. Collaborates, coordinates with TOPA and Referral Management Director when needed in accordance with TRICARE Operations manual.• Receives and makes patient telephone calls, written, or e-mail correspondence regarding specialty clinic appointments and referrals following MTF-specific processes.• Monitors routinely referral management MHS GENESIS queue to ensure patients referrals are appointed and closed out per MTF guidelines.• Ensures Line of Duty paperwork is on file prior to authorization for all reserve and guard member referrals.• Keeps abreast of MTF and local market services and capabilities. Updates capability report as needed/directed.• Conducts referral reconciliation report as directed, identifying all open referrals and provides notification to appropriate personnel for resolution.• Monitors active duty, reserve/guard admissions, including all eligible beneficiaries, to civilian hospitals and notifies Clinical Nurse Case Manager and Patient Administration Element as required.• Serve as a liaison with headquarters (99th ABW) TRICARE regional offices, Manage Care Support Team, MTF staff and professional organizations concerning Utilization Management practices.• Collaborates with staff/departments, including, but not limited to: Executive Management, Resource Management, Medical Records, Patient Administration, Group Practice Managers, Health Care Integrator Consultants, Medical Management team, SGH (Chief of Medical Staff), Coders/Coding Auditors, Medical Management, Referral Management, TRICARE Operations, patient care teams, Quality Improvement, and the Managed Care Support Contractors.• Coordinates and participates in interdisciplinary team meetings, designated facility meetings, discharge planning meetings/rounds and Care Coordination meetings. Shares knowledge and experiences gained from own clinical practice and education relevant to nursing and utilization management.• Participates in the orientation, education, and training of other staff. May serve on committees, work groups, and task forces at the facility. Provides relevant and timely information to these groups and assists with decision-making and process improvement. Participates in customer service initiatives, performance and quality improvement measures and medical readiness activities designed to enhance health services.• Must maintain a level of productivity and quality consistent with: complexity of the assignment; facility policies and guidelines; established principles, ethics and standards of practice of professional nursing; the Case Management Society of America (CMSA); American Accreditation Healthcare Commission/Utilization Review Accreditation Commission (URAC);Comprehensive Accreditation Manual for Hospitals (CAMH); Health Services Inspection (HSI); and other applicable DoD and Service specific guidance and policies. Must also comply with the Equal Employment Opportunity (EEO) Program, infection control and safety policies and procedures. • Adheres to applicable local MTF/AF/DoD, DHA, VA instructions, policies and guidelines.• Completes medical record documentation and coding, and designated tracking logs and data reporting as required by local MTF/AF/DoD, DHA, VA instructions, policies and guidance.• Completes all required electronic medical record training, MTF- specific orientation and training programs, and any AF/DoD mandated Utilization Management training. Includes (but is not limited to) all training on the use of utilization management data base applications (i.e. Defense Health Agency (DHA),,Military Health System Population Health Portal (MHSPHP) CarePoint 4G , AFMS , TOPA applications to obtain necessary data for Preventative Healthcare Screening, Healthcare Effectiveness Data and Information Set (HEDIS).• Ensures a safe work environment, employee safe work habits and patient safety IAW regulatory agencies, infection control policies, and process improvement initiatives. Promote and contribute quality performance, performance improvement programs, and nursing practice in a setting that supports professional practice and sets a positive example; identify and deliver excellence in the delivery of nursing services and care to patients/residents; introduces and disseminates best practices in nursing services. Proactively identifies process issues that could lead to negative patient outcomes and/or delays in discharge placement and participates in the appropriate safety reporting processes for the facility. Qualifications Minimum Qualifications: * Degree/Education: Shall be a graduate from a baccalaureate degree program in nursing with a BSN, accredited by a national nursing accrediting agency recognized by the US Department of Education, the Commission on Collegiate Nursing Education (CCNE), or Accreditation Commission for Education in Nursing (ACEN). * Experience: Must have at least 3 years of total nursing experience in a direct patient care clinical inpatient and outpatient setting. Must have utilization management experience for 2 years in recent consecutive months including case management care and discharge planning for patients ranging in age from 0-95 years and including children, families, seniors, and groups. * Licensure/Certification: Active, unrestricted Registered Nursing license to practice nursing in a State, District of Columbia, the Commonwealth of Puerto Rico, or a territory of the United States. Certification (preferred) or eligible in a relevant specialty, such as Certified Managed Care Nurse through the American Board of Managed Care Nursing or the American Association of Managed Care Nurses or Certified Informatics Nursing, Ambulatory Care Nursing, Medical-Surgical Nursing or Nursing Case Management through the American Nurses Credentialing Center. * Life Support Certification: BLS from American Red Cross or American Health Association. * Security: Must possess ability to pass a Government background check/security clearance. Pay Scale: $34.26 - $60 to be determined based on employment options, qualifications, experience, and location ** $2,000 Sign-On Bonus **
RN Outpatient Labor and Delivery OB/GYN Utilization Review Wound Care OR Psych Outpatient Other
ERP International

Registered Nurse - Family Practice (Temp)

ERP International Nellis Air Force Base, NV
$65 - $77 / hour
Overview ERP International is seeking a temporary Registered Nurse (RN) for a full-time position in support of The Family Medicine Residency Clinic at David Grant Medical Center, Travis AFB, CA . Apply online today and discover more about this exceptional employment opportunity. www.erpinternational.com Be the Best! Join our team of exceptional health care professionals across the nation. Come discover the immense pride and job satisfaction ERP Employees experience in providing care for our Military Members, their Families and Retired Military Veterans! ERP International is honored to be named a 2026 Top Workplace by WTOP News! 7 Years Running. About ERP International, LLC: ERP is a nationally respected provider of health, science, and technology solutions supporting clients in the government and commercial sectors. We provide comprehensive enterprise information technology, strategic sourcing, and management solutions to DoD and federal civilian agencies in 40 states. Founded in 2006, ERP is headquartered in Laurel, MD and maintains satellite offices in Montgomery, AL and San Antonio, TX - plus project locations nationwide. ERP is an Equal Opportunity Employer - Disability and Veteran. Responsibilities Work Schedule: Monday - Friday, 7:30am - 4:30pm, including aone-hour lunchNo weekends, No Call, No Holidays! Job Specific Position Duties: The duties include, but are not limited to the following: • Provides care within ethical and legal boundaries.• Provide health promotions, counseling, and education.o Assess patient needs telephonically. • Participate in monthly Nurse Peer Reviews. • Trained in Telephone Triage per AFMS and MTF protocol (STCC - Schmitt-Thompson Clinical Content)• Assist with clinic colonoscopy procedures.o Administer conscious sedation under direct supervision of provider.o Monitor patient’s airway/breathing, and vital signs during procedure.o Provide pre and post procedure care to patient including inserting intravenous catheters, monitoring patient, and taking vital signs per clinic’s protocol/guidelines.• Excellent oral communication skills for patient/family education and telephone triage of patients. • Telephone and in-person assessment/evaluation includes the determination of optimal time and location for patient management (ER, clinic, homecare) and follow-up care as required. • Prescribes and communicates treatment plans and patient teaching in accordance with established protocols. • Collects and assesses significant patient history information and performs all necessary patient teaching.• Excellent written communication skills to perform accurate documentation, both written and electronic, of all activity, including telephone contacts, in accordance with requirements. • Ensures for proper documentation of procedures and treatments.• Ensures a safe work environment, employee safe work habits and patient safety IAW regulatory agencies, infection control policies, and process improvement initiatives. Qualifications Minimum Qualifications: * Education: Minimum Associates Degree of Nursing * Experience: Minimum 2 years experience, within the past 3 years, in a primary care setting; experience working in military health strongly preferred * License: Active, unrestricted RN license * Board Certification: None * Life Support Certifications: BLS * Security: Must be able to pass a Government background check and obtain a Government security clearance. Pay Scale: $65/hr to $77/hr, to be determined based on employment options, qualifications, experience, and location
RN Utilization Review Full-time
Texoma Medical Center

CASE MANAGER (RN) - UTILIZATION REVIEW (FULL TIME)

Texoma Medical Center Denison, TX
Responsibilities Texoma Medical Center, a 414-bed acute care facility has been providing quality health care to the residents of North Texas and Southern Oklahoma since 1965. Our main campus is located in Denison, Texas, approximately one hour north of the Dallas/Fort Worth area and just south of the Texas/Oklahoma border. In addition, we have numerous facilities in locations throughout the Texoma region. Since 1965, TMC has forged a special relationship with the people of North Texas and Southern Oklahoma. Texoma residents have come to depend on TMC to meet a spectrum of physical, mental and spiritual needs. TMC has responded with unique services to provide the kind of sophisticated, experienced care that was once available only in major metropolitan areas. We offer major specialty services including open heart surgery and neurosurgery. Advanced resources such as certified trauma care support TMC's role as a regional specialty center. One of the nation’s largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (UHS) has built an impressive record of achievement and performance. During the year, UHS was again recognized as one of the World’s Most Admired Companies by Fortune; and listed in Forbes ranking of America’s Largest Public Companies. Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory care access points, an insurance offering, a physician network and various related services located all over the U.S. States, Washington, D.C., Puerto Rico and the United Kingdom. www.uhs.com Under the direction of the Director, Case Management, this position is responsible to collaborate with patients, patient family members, physicians and other healthcare professionals to design, implement, and evaluate plans of care specific to each patient's needs, maintaining high quality, cost effective patient care. Qualifications Requirements Education - Per RN licensure requirements. Bachelor's Degree preferred. Experience At least three (3) years previous clinical and/or case management/utilization management experience preferably in a high volume acute care hospital/healthcare facility. Licenses - Valid, current RN state license or compact. Must demonstrate excellent interpersonal, communication and problem solving skills necessary to gather and exchange data, both internally and externally) with key medical professionals, patients and patient family members. Able to effectively utilize critical thinking and problem resolution skills. Must be able to effectively communicate with key community stakeholders in order to appropriately assist patients EEO Statement All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws. We believe that diversity and inclusion among our teammates is critical to our success. Notice At UHS and all subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates with matching skillset and experience with the best possible career at UHS and our subsidiaries. We take pride in creating a highly efficient and best in class candidate experience. During the recruitment process, no recruiter or employee will request financial or personal information (Social Security Number, credit card or bank information, etc.) from you via email. The recruiters will not email you from a public webmail client like Hotmail,Gmail, Yahoo Mail etc. If you feel suspicious of a job posting or job-related email, let us know by contacting us at: https://uhs.alertline.com or 1-800-852-3449
RN Utilization Review Full-time
University of Rochester Medical Center

RN, Utilization Management

University of Rochester Medical Center Rochester, NY
$80,923 - $105,208 / 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: $80,923.00 - $105,208.00 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 Full-time
Bryan Health

Utilization Management RN

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

Supervisor, Utilization Management (RN)

Centene North Sacramento, CA
$75,300 - $135,400 / year
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. Position Purpose: Supervises Prior Authorization, Concurrent Review, and/or Retrospective Review Clinical Review team to ensure appropriate care to members. Supervises day-to-day activities of utilization management team. Monitors and tracks UM resources to ensure adherence to performance, compliance, quality, and efficiency standards Collaborates with utilization management team to resolve complex care member issues Maintains knowledge of regulations, accreditation standards, and industry best practices related to utilization management Works with utilization management team and senior management to identify opportunities for process and quality improvements within utilization management Educates and provides resources for utilization management team on key initiatives and to facilitate on-going communication between utilization management team, members, and providers Monitors prior authorization, concurrent review, and/or retrospective clinical review nurses and ensures compliance with applicable guidelines, policies, and procedures Works with the senior management to develop and implement UM policies, procedures, and guidelines that ensure appropriate and effective utilization of healthcare services Evaluates utilization management team performance and provides feedback regarding performance, goals, and career milestones Provides coaching and guidance to utilization management team to ensure adherence to quality and performance standards Assists with onboarding, hiring, and training utilization management team members Leads and champions change within scope of responsibility Performs other duties as assigned Complies with all policies and standards Education/Experience: Requires Graduate of an Accredited School Nursing or Bachelor's degree and 4+ years of related experience. Knowledge of utilization management principles preferred. License/Certification: RN - Registered Nurse - State Licensure and/or Compact State Licensure required CA RN LICENSE REQUIRED Pay Range: $75,300.00 - $135,400.00 per year Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
RN Outpatient Utilization Review Outpatient Full-time
IU Health

Registered Nurse – Outpatient – Urology – Ambulatory Referral Review

IU Health Indianapolis, IN
Overview Part and Full-time roles are eligible for a $30,000 sign-on bonus — apply today to learn more! We are seeking an individual with a minimum of one year of RN experience for this role. Are you an upcoming nurse graduate or recent nurse graduate? Please apply through our pipeline requisition here: https://iuhealth.org/applyrn . This pipeline requisition allows the IU Health Talent Acquisition team to pair upcoming & recent nurse graduates with the best opportunities available to them based on their unique skillset and interests. Thanks for your interest in joining the team! IU Health is seeking expert RN's who will have the opportunity to collaborate with the brightest minds in medicine. At IU Health, you will develop in significant ways, advancing healthcare for all! Being an IU Health nurse means building a professional nursing career designed with competitive benefits, a culture that accepts your outstanding strengths, and supports your personal and professional goals. If you are seeking an organization where you can engage expertly, develop clinical expertise, embrace learning, cultivate new relationships, and fuel your spirit of inquiry, apply today! Position Overview: Join our dynamic healthcare team as a Registered Nurse specializing in Ambulatory Referral Review, supporting the Urology service line. This innovative role leverages your clinical expertise to coordinate and manage patient care referrals from an off-site, system-wide call center. Working Monday through Friday during the day shift with flexible hours, this remote/hybrid position offers a balanced work environment with comprehensive training to ensure your success. Work Environment: This position is primarily remote, with initial hybrid training to ensure seamless onboarding and integration into the team. Key Responsibilities: Utilize the nursing process (assessment, diagnosis, outcome identification, planning, implementation, and evaluation) to review inbound patient care referrals efficiently and accurately. Analyze electronic health records, test results, and clinical documentation in accordance with specialty care protocols and scheduling workflows. Assess patient acuity and prioritize scheduling based on clinical needs. Collaborate closely with specialty physicians and interdisciplinary teams to ensure patients receive timely, appropriate care. Maintain adherence to organizational policies, ensuring quality and compliance in referral management. Qualifications: Associate's Degree is required. Bachelor's Degree is preferred. Requires 0-3 years of relevant experience. 2+ years of Urology experience preferred. Requires that the RN has graduated from a nationally accredited nursing program. Requires an active Registered Nurse (RN) license in the state of Indiana or an active Nurse Licensure Compact (NLC) RN license. Requires basic life support (BLS) certification through the AHA annually. Other advanced life support certifications may be required per unit/department specialty according to patient care policies. Requires the ability to assess patients without face-to-face interaction. Why Join Us? Be part of a forward-thinking healthcare organization dedicated to delivering patient-centered care. This role offers an excellent opportunity to utilize your nursing skills in a specialized, fast-paced environment while enjoying the flexibility of remote work.
RN Utilization Review Full-time
Confluence Health

Nurse Utilization RN

Confluence Health Wenatchee, WA
$44.64 - $71.24 / hour
Salary Range $44.64 - $71.24 Overview Located in the heart of Washington, we enjoy open skies, snow-capped mountains, and the lakes and rivers of the high desert. We are the proud home of orchards, farms, and small communities. Confluence Health actively supports the communities we serve and their quality of life through our community support program and through our individual efforts as involved community members. Full Time Employees of Confluence Health receive a wide range of benefits in addition to compensation. Medical, Dental & Vision Insurance Flexible Spending Accounts & Health Saving Accounts Paid Time Off Generous Retirement Plans Life Insurance Long-Term Disability Gym Membership Discount Tuition Reimbursement Employee Assistance Program Adoption Assistance Shift Differential For more information on our Benefits & Perks, click here! Summary Performs utilization review in accordance with all state mandated regulations. Maintains compliance with regulation changes affecting utilization management. Reviews patients records and evaluates patient progress. Performs continuing review on medical records and identification and need of on-going hospitalization. Obtains and reviews necessary medical reports and subsequent treatment plan requests. Conducts reviews and validates physician's orders, reports progress and unusual occurrences on patients. Ensures appropriate and cost-effective healthcare services to patients. Documents review information in computer. Monitors all Outpatient in a Bed & Inpatient surgeries for correct status. Reviews the insurance prior authorizations for correct status. Uses the Medicare Inpatient Only list of surgery CPT codes for correct status/class to ensure reimbursement for surgeries. Reviews all denials from insurance companies for correct status/class. Pursues peer to peer discussions between our hospitalists and insurance MD, reconsideration, appeal, administrative rate, or change in status/class. Position Reports To: Director of Utilization Management Essential Functions Prepares and organizes initial and continued stay utilization reviews. Complete admission review per MCG guidelines. Coordinates provider certification of Medicare inpatient hospital stays as required in the Medicare Benefit Manual, Final Rule etc. Utilizes clinical information located in the patient record to support patient status decisions and recommendations. Documents this information in MCG. Collaborates with other departments regarding review results. Issues MOON letters to patients per Medicare guidelines to notify them of their Observation status and billing of Medicare Part B. Communicates to care management staff when payers deny the patient stay. Complies with Medicare and other regulations for second level review by the UR Committee, notification of patient, physician, and hospital of particular status changes. Follows the A/B Rebill flow maps as indicated. Ensures written notification to the patient, physician, and hospital when the final outcome of a second level review is A/B Rebill. Notifies patient accounts to hold submission of a bill when a case has been sent for second level review and the patient has been discharged. Notifies patient accounts to submit the bill when the results of the second level review is known, along with the results. Participates in tracking and monitoring second level reviews as directed. Adheres to Workflows and Process Maps specific to UM functions. Follows process flow maps and established workflows. Participates in standard work. Assist in identifying processes and procedure improvements to positively affect work flows. Issues Notices of Non-coverage according to policy and procedure. Complies with the various private contracts regarding review, pre-authorization, phone calls, deliver non-coverage letters as required and/or appeal denials. Provides Clinical information to payers as requested and per contract. Facilitates concurrent Peer to Peer discussions between providers when a payer denies all or part of a hospital stay when the denial occurs prior to discharge. Communicates the results of Peer to Peer discussions, if known, with business office and patient accounts. Tracks all discussions with payers in the appropriate billing system, according to facility. Assist with the process following an appeal of discharge, as outlined in the Important Message from Medicare. Provide requested clinical information to the QIO following a patient’s appeal of the discharge decision. Deliver a HINN-12 notification following a decision from the QIO to uphold a decision to discharge, according to procedure. Performs other duties as assigned. Demonstrate Standards of Behavior and adhere to the Code of Conduct in all aspects of job performance at all times. Qualifications Required: Associate's Degree in Nursing. Three (3) years experience in an acute care setting as a Health Care Professional with demonstrated expertise in specific clinical area. Current licensure in the state of Washington (RCW 18.88) or licensure through Multistate Nurse Licensure Compact (SSB 5499). Demonstrated skills in the areas of negotiation, communication (verbal and written), conflict, interdisciplinary collaboration, management, creative problem solving, and critical thinking. Knowledge of healthcare financing, community and organizational resources, patient care processes, and data analysis. Excellent verbal and written communication skills. Demonstrates flexibility via an ability to adapt to changing priorities and regulations. Must possess basic computer skills related to Windows navigation, email communication. Desired : Bachelor's Degree in Nursing (BSN) or related field. Accreditation in ACMA. Physical/Sensory Demands O = Occasional, represents 1 to 25% or up to 30 minutes in a 2 hour workday. F = Frequent, represents 26 to 50% or up to 1 hour of a 2 hour workday. C = Continuous, represents 51% to 100% or up to 2 hours of a 2 hour workday. Physical/Sensory Demands For This Position: Walking - O Sitting/Standing - C Reaching: Shoulder Height - O Reaching: Above shoulder height - O Reaching: Below shoulder height - O Climbing - O Pulling/Pushing: 25 pounds or less - O Pulling/Pushing: 25 pounds to 50 pounds - O Pulling/Pushing: Over 50 pounds - O Lifting: 25 pounds or less - O Lifting: 25 pounds to 50 pounds - O Lifting: Over 50 pounds - O Carrying: 25 pounds or less - O Carrying: 25 pounds to 50 pounds - O Carrying: Over 50 pounds - O Crawling/Kneeling - O Bending/Stooping/Crouching - F Twisting/Turning - O Repetitive Movement - C Working Conditions: Work is performed in a hybrid setting with remote work as well as in an office environment. Involves frequent contact with staff, leadership and practitioners. Work may be stressful at times. Job Classification: FLSA: Non-Exempt Hourly/Salary: Hourly Physical Exposures For This Position: Unprotected Heights - No Heat - No Cold - No Mechanical Hazards - No Hazardous Substances - No Blood Borne Pathogens Exposure Potential - No Lighting - Yes Noise - Yes Ionizing/Non-Ionizing Radiation – No Infectious Diseases - No
RN Utilization Review Telehealth Full-time
L.A. Care Health Plan

Utilization Management Claims Review Nurse 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 (UM) Claims Review Nurse RN II is responsible for conducting clinical review of medical claims to ensure services were medically necessary, appropriately documented, accurately billed, and compliant with established clinical policies and regulatory standards. This position supports payment integrity initiatives through retrospective and pre-payment review processes, helps reduce unnecessary denials, and monitors for potential fraud, waste, and abuse (FWA). The UM Claims Review Nurse RN II collaborates closely with internal teams to ensure accurate adjudication and compliance. This position collaborates closely with internal stakeholders and external entities to support compliance with state, federal, and accreditation requirements. Duties Perform claims pre-payment review by supporting the Claims team in evaluating flagged claims prior to adjudication to ensure services are medically necessary, documentation supports billed services, coding is accurate and aligned with authorization when applicable, and unnecessary denials are reduced through accurate clinical validation. Conduct comprehensive retrospective reviews, applying established clinical criteria, policies, and regulatory guidelines to determine medical necessity and appropriateness of services rendered. Complete Provider Dispute Review (PDR) clinical evaluations for disputed claims requiring medical necessity scrutiny and clinical determination. Apply internal and external clinical policies, including those developed by the Clinical Policy team, to ensure compliance with guidelines intended to limit fraud, waste, and abuse (FWA). Ensure adherence to federal and state regulations, and accreditation standards. Monitor trends related to contested claims and identify potential FWA concerns; escalate findings in accordance with organizational compliance protocols. Collaborate with internal teams to support payment integrity initiatives. Provide clear, well-documented clinical rationales supporting approval, denial, or adjustment decisions. Maintain productivity and quality standards consistent with departmental expectations. Participate in audits, regulatory readiness activities, and quality improvement initiatives as assigned. Document review outcomes clearly and accurately within designated systems, ensuring audit readiness and traceability. Remain current with evolving clinical guidelines, coding standards, reimbursement methodologies, and regulatory requirements. Perform other duties as assigned. Duties Continued Education Required Associate's Degree in Nursing Education Preferred Bachelor's Degree in Nursing Experience Required: At least 5 years of experience in Clinical Nursing. At least 3 years of experience with Medi-Cal and Medicare in a managed care environment. Experience in performing and creating clinical documentation. Experience in regulatory compliance for a health plan. Preferred: Experience with Provider Dispute Review (PDR) processes. Experience applying clinical guidelines (e.g., InterQual, MCG, or internally developed criteria) in processes. Prior experience in payment integrity, compliance, or fraud, waste, and abuse (FWA) monitoring. Skills Required: Knowledge of medical necessity criteria, reimbursement principles, and managed care operation. Working knowledge of clinical policies. Working knowledge of CPT/HCPC Codes, and ICD-10. Proficient in claims processing systems and electronic medical record platforms. Strong problem-solving skills and the ability to identify discrepancies, assess risk, and recommend actionable solutions. Strong verbal and written communication skills. Ability to work independently with a high degree of initiative, organization, and self-direction. Ability to work effectively with diverse teams in cross-functional work groups. Ability to multitask, re-prioritize tasking, and streamline day-to-day operations. Familiarity with regulatory and accreditation standards (e.g., CMS, Medi-Cal, NCQA). Understanding of the managed care industry and market conditions. High organizational and time-management skills. Preferred: Strong analytical and investigative skills with the ability to synthesize clinical and claims information into clear, defensible determinations are highly valued. Advanced knowledge of medical necessity criteria tools such as InterQual or MCG. Extensive knowledge in claims reviews includes retrospective reviews, pre-payment claims review, and medical necessity determinations. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California License Licenses/Certifications Preferred Required Training Physical Requirements Light Additional 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 Full-time
Albany Medical Center

Utilization Management Specialist (RN): Salary, 40hrs/week - DAYS

Albany Medical Center Albany, NY
$84,783 - $131,414 / year
Department/Unit: Care Management/Social Work Work Shift: Day (United States of America) Salary Range: $84,783.00 - $131,414.00 Under direction of the Manager of Utilization Management, the Utilization Management Specialist is responsible for the coordination, processing and tracking of all potential utilization concerns from the third party payors for Albany Medical Center; and to do other related work as required. This individual will act as a liaison with all payors and review agents, providing required acuity information regarding patients and issuing notice of non-coverage as appropriate. This position is also responsible for the processing of adverse determinations received from third party payors, coordinating with Patient Financials Services, Admitting/Access Operations, attending physicians, Medical Director and AMC Case Managers and R1 Physician advisory services. Requirements: Graduate of a professional academic nursing program in which a Diploma, Associate Degree or Baccalaureate Degree is conferred. Bachelor's degree preferred. A Bachelor’s Degree in a Health-related field is required. Registered nurse with a New York State current license A minimum of 5 years clinical experience in acute care setting with at least two years in case or utilization management. Skills and Knowledge: Knowledge of care delivery documentation systems and related medical record documents. Strong broad-based clinical knowledge and understanding of pathology/physiology. Excellent written and verbal communication skills and critical thinking skills. Experience with Milliman MCG, InterQual criteria, and knowledge of IPRO and retrospective review process. Ability to work independently and demonstrate organizational and time management skills. Computer literacy and familiarity with basic office equipment and software. Working knowledge of Medicare reimbursement system and coding structures preferred. Essential Duties & Responsibilities , including but not limited to: Mission, Core Values and Service Excellence: Contributes to the creation of a compassionate and caring environment for patients, families and colleagues through displays of kindness and active listening. Recognizes and appreciates that each employee’s work is valuable and contributes to the success of the Mission. Demonstrates excellence in daily work. Actively participates in performance and quality improvement activities and works toward enhancing customer/patient satisfaction. Exhibits positive service excellence skills to patients, visitors and coworkers by greeting others in a friendly manner, keeping customers/patients/colleagues informed about progress, delays and changes. Demonstrates effective teamwork by interacting in a positive manner with colleagues and creating a collaborative work environment. Initiates open communication, conveys positive intent, offers assistance. Contributes to a safe and secure environment for patients, visitors, colleagues by following established procedures and protocols, which address the needs of a diverse patient population and workforce. Demonstrates stewardship by thoughtful and responsible use of resources including maintaining a clean and hospitable environment, starting work on time, displaying a consciousness regarding costs, supplies and department finances. Demonstrates respect for individual differences of each person by acknowledging the essence of each person, appreciating and responding to unique, spiritual, personal and cultural backgrounds of patients, families and colleagues. Strategic and Operational Planning Supports the Manager in planning, organizing, directing of the Utilization Management services of AMC; and to do other related work as required. Participates in the development of departmental goals and develops plans to achieve those goals. Planning and Program Development Act as contact person for payors regarding utilization issues, i.e., carve outs, denials, downgrading and potential utilization concerns, providing required communication regarding patient acuity. Coordination of appeal of adverse determination, working with Service Case manager, Attending physician, Case manager, Medical Director, R1 Physician advisory services. for concurrent resolution of issue, prevention of retrospective denial and delay in payment for the institution. Maintain all correspondence and provide follow up with third party payors, commercial insurers, and IPRO. In conjunction with the service Case Manager, issue HINN notice and reinstatement to patients when indicated with focus on accuracy, timeliness, and diplomacy. Demonstrate in-depth knowledge of utilization criteria for Medicare, Medicaid, and private insurers. Delegates and coordinates the work of Utilization Review ASA support staff. Tracks denials and develops action plans to decrease bad debt. Maintain database of utilization issues and identify trends in payor activity through generation of statistical reports. Complete end of month reports. Educational Leadership Working knowledge of how to research changes in CMS and payor regulations and project impact of these changes on AMC and communicate this information. Demonstrates proper use of MCG and documentation requirements through case review and inter-rate reliability studies. Attends all mandatory hospital in-service education. Ability to analyze data and identify trends and project expected response to changes in health care reimbursement system. Hospital-wide Leadership Models AMC cares standards Demonstrates wiliness to participate in hospital wide initiatives. Patient Safety Assists in the development of policies and procedures, standards of care and practice, and in the monitoring processes in relations to those standards. Maintains complete confidentiality of patient information, in addition to hospital and individual physician practice pattern data. Provides information and in services as necessary to physicians and ancillary staff. Practices in an environmentally safe and healthy manner. Thank you for your interest in Albany Med Health System!​ Albany Med Health System is an equal opportunity employer. This role may require access to information considered sensitive to Albany Med Health System, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that: Access to information is based on a “need to know” and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Med Health System policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification.
RN Utilization Review Telehealth Full-time
L.A. Care Health Plan

Utilization Management Clinical Quality Nurse Reviewer 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 Clinical Quality Nurse Reviewer RN II, under the purview of the Utilization Management (UM) Department Leadership Team, is responsible for conducting and tracking targeted and random internal department documentation audits. This role ensures that UM practices and supporting documentation are compliant with all regulatory requirements. The Incumbent also serves as a Subject Matter Expert during external audits as well as leads pre- and post-audit preparation/follow-up. This position actively participates in the development and review of policies and procedures to certify compliance with regulatory guidelines and mandates. This position focuses on UM cases for all lines of business to identify areas of opportunity for increasing positive audit outcomes and improved service to L.A. Care’s membership. This position is responsible for identifying and monitoring staff (non-clinical, nurse, and physician) performance against key performance indicator trends that warrant recognition or remediation. This position performs data mining and analysis and creates reports on audit findings, as well as makes recommendations, to submit to the department's Quality Assurance Team and UM Management. Duties Facilitates the development, review, and revision of organizational and departmental process flows to ensure compliance with relevant regulatory, organizational, and departmental guidelines. Keenly focuses on practices and documentation of clinical staff, serving as a resource on state and federal industry mandates applicable to UM functions. Generates results of findings, enhances, and analyzes various reports related, but not limited to, quality and accuracy of case documentation. Works with department leadership to assess for all opportunities related to quality improvements. Compiles and presents quality report cards that measure adherence to quality and regulatory compliance. Keeps UM Leadership apprised of departmental and industry trends, deficiencies, and any potential risks, and collaborates with the team to develop and execute mitigation efforts. Serves as a consultant to the organization's Compliance team on an ad hoc basis. Performs other duties as assigned. Duties Continued Education Required Associate's Degree in Nursing Education Preferred Bachelor's Degree Master's Degree in Nursing Experience Required: At least 5 years of experience in Clinical Nursing. Minimum of 2 years of auditing clinical documentation. Active participation in at least two state regulatory audits and one federal regulatory audits. Previous experience with Medi-Cal and Medicare in a managed care environment and experience with mitigation planning and implementation. Preferred: Experience performing clinical documentation for a health plan. Active participation in at least three state regulatory audits, at least one National Committee for Quality Assurance (NCQA) audit and/or Centers for Medicare and Medicaid Services (CMS) audit. Background in teaching and/or clinical education. Skills Required: Superior verbal and written communication skills. Advanced computer proficiency in both Microsoft Word and Excel. Strong analytical and team building skills. Ability to work independently and be self-directed. Ability to work effectively with diverse team members. Strong problem-solving skills. Ability to multitask and streamline day-to-day operations. Ability to translate regulatory requirements into auditable tools. Preferred: Proven ability to lead successful performance improvement projects. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California License Licenses/Certifications Preferred Required Training Physical Requirements Light Additional 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 Full-time
South Texas Health System McAllen

Case Manager RN Utilization Review FT McAllen

South Texas Health System McAllen McAllen, TX
Responsibilities POSITION SUMMARY: RN Case Manager responsible to manage resource utilization and clinical outcomes for patients as well discharge needs of the patients. RN will also be responsible to help with the denial management process. There may be occasions when it will be necessary to work weekends, holidays, evenings, nights, and/or on-call/call-back status. Demonstrates Service Excellence standards at all times. Qualifications QUALIFICATIONS: 1. 1 years previous acute care RN experience required. (Previous defined as: ‘within the last three years’) 2. Bilingual preferred (Spanish). 3. Experience in Health Care Coordination preferred. 4. Must demonstrate commitment and adherence to STHS’s Compliance Program and Code of Conduct through compliance with all policies and procedures, the Code of Conduct, attendance at required training and immediately reporting suspected compliance issue(s) to the Compliance Officer. EDUCATION / LICENSURE: 1. Licensed in the State of Texas 2. Registered Nurse currently licensed in the State of Texas, or part of a compact state license, or has a valid temporary RN license for the State of Texas while waiting to receive the permanent license. BSN preferred. 3. Effective January 6, 2016, must possess an Associate Degree, Baccalaureate Degree or Diploma from a School of Nursing or University. EEO Statement All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws. We believe that diversity and inclusion among our teammates is critical to our success. Notice At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skillset and experience with the best possible career path at UHS and our subsidiaries. We take pride in creating a highly efficient and best in class candidate experience. During the recruitment process, no recruiter or employee will request financial or personal information (Social Security Number, credit card or bank information, etc.) from you via email. The recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc. If you are suspicious of a job posting or job-related email mentioning UHS or its subsidiaries, let us know by contacting us at: https://uhs.alertline.com or 1-800-852-3449. Authorized by Corporate Human Resources
RN ER Utilization Review Full-time
Albany Medical Center

Utilization Review Nurse: Emergency Dept

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

RN, Utilization Management | Utilization Management

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

PRN Utilization Review RN - M-F Days

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

Registered Nurse Utilization Review

St. Luke's University Health Network Allentown, PA
St. Luke's is proud of the skills, experience and compassion of its employees. The employees of St. Luke's are our most valuable asset! Individually and together, our employees are dedicated to satisfying the mission of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care. The Registered Nurse Utilization Review will be responsible for substantiating medical necessity and clinical appropriateness of services in order to achieve quality outcomes and ensure appropriate reimbursement. JOB DUTIES AND RESPONSIBILITIES: Screens selected medical records in accordance with contractual agreements and departmental policies for appropriateness of admission; performing initial, continued stay, and retrospective reviews if applicable. Submits initial reviews and updates using established criteria and communicates with payers as appropriate, using established processes. Utilize established processes with the Physician Advisors to manage second level and peer to peer reviews. Ensure patient status and levels of care are appropriate on admission and prior to discharge. Makes timely contact with payers and provides information as appropriate. Documents all utilization review outcomes and activities appropriately in the medical record. Complies with all applicable payer, state and federal regulations as well as The Joint Commission requirements regarding Care Management and Utilization Review processes. Acts as resource for and provides updates to the care management staff and care team for issues related to utilization review processes. Engages providers with concerns regarding medical necessity and appropriateness of services. Escalate concerns related to medical necessity and appropriateness of services to the Physician Advisors. Works collaboratively with the Denials Specialist and Physician Advisors to manage retrospective appeals and documents according to established policy. Works collaboratively with the business office/finance to ensure proper reimbursement. PHYSICAL AND SENSORY REQUIREMENTS: Sitting for one to two hours at a time. Standing for up to 2 hours per day, up to 10 minutes at a time. Walk on all surfaces for up to 3 hours per day, and climb stairs. Must be capable of driving a car. Fingering and handling objects frequently, uses fingers to turn pages. Frequently uses hands to write and/or type. Rarely uses hands or fingers for firm grasping or twisting/turning. Frequently uses upper extremities to lift and carry object up to 10 lbs. Rarely may be required to lift, carry, push, and/or pull objects weighing up to 75 pounds. Occasionally stoops, bends, squats, kneels and reaches above shoulder level. Must have the ability to hear as it relates to normal conversations and high and low frequencies and to see as it relates to general and peripheral vision. Must have the ability to touch as related to telephone and computer keyboard. EDUCATION: Graduate of professional nursing program. Registered Nurse with current license to practice in the State of Pennsylvania or seeking Pennsylvania licensure through reciprocity. NJ RN licensure required upon hire. Advanced degree preferred. TRAINING AND EXPERIENCE: At least 3 years of clinical experience as a registered nurse in an acute setting. Either 2 years of hospital or payor based utilization review experience preferred. Knowledge of Interqual and Milliman criteria preferred. Care Management certification preferred. Please complete your application using your full legal name and current home address. Be sure to include employment history for the past seven (7) years, including your present employer. Additionally, you are encouraged to upload a current resume, including all work history, education, and/or certifications and licenses, if applicable. It is highly recommended that you create a profile at the conclusion of submitting your first application. Thank you for your interest in St. Luke's!! St. Luke's University Health Network is an Equal Opportunity Employer.
RN Utilization Review Full-time
St. Joseph's Health

Utilization Management Registered Nurse

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