Registered Nurse (RN) Utilization Review Jobs

RN Utilization Review Full-time
Gainwell Technologies LLC

Nurse Reviewer- Registered Nurse (Remote)

Gainwell Technologies LLC
It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you’ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development. Summary We are seeking a talented individual for a Nurse Reviewer (RN) who will be responsible for performing clinical reviews to determine if the medical record documentation supports the need for the service based on clinical criteria, coverage policies, and utilization and practice guidelines as defined by review methodologies specific to the contract for which services are being provided. This involves accessing proprietary systems to audit medical records, accurately documenting findings, and providing policy/regulatory support for determinations. This position is intended for pipelining. We will accept applications on an ongoing basis. Your role in our mission Review and interpret medical records and compare them against criteria to determine appropriateness and reasonableness of care. Apply critical thinking and decision-making skills to assess if the documentation supports the need for the service, while maintaining production goals and quality standards. Document decisions and rationale to justify review findings or no findings. Determine approval or initiate a referral to the physician consultant, and process physician consultant decisions—ensuring the denial rationale is clearly detailed and completed within the contractual deadline. Perform prior authorization, precertification, and retrospective reviews; prepare decision letters as needed in support of the utilization review contract. Assist management with training new Nurse Reviewers, including daily monitoring, mentoring, feedback, and education. Maintain up-to-date knowledge of clinical criteria guidelines and complete required CEUs to maintain RN licensure. Attend training and scheduled meetings to strengthen working knowledge of clinical policies, procedures, rules, and regulations. Cross-train to perform reviews of multiple claim types to ensure workforce flexibility and meet client needs. Recommend, test, and help implement process improvements, audit concepts, and technology enhancements that increase productivity, quality, and client satisfaction. What we're looking for Proficiency in computer and typing skills (e.g., Microsoft Windows, Outlook, Excel, Word, PowerPoint, and internet browsers). Active, unrestricted RN license from the United States and in the state of primary home residency. An active compact multistate unrestricted RN license (as defined by the Nurse Licensure Compact – NLC) is required and will be verified during the post-offer background check. Minimum of 5 years clinical experience in an inpatient hospital setting. At least 2 years of utilization review or claims auditing experience. Experience using Milliman or InterQual criteria is required. Ability to work standard business hours, as this role involves regular interactions with internal teams and other departments. May occasionally require extended hours to meet business needs. What you should expect in this role This is a full-time job. Health benefits (medical, dental, vision) and paid time off begin on Day 1 of employment. Company-provided computer. Remote/work-from-home role; employees must be located within the continental U.S. Home workspace must be quiet, secure, free from distractions and recording devices. May require up to 10% travel, depending on business needs. #LI-AC1 #LI-REMOTE The pay range for this position is $65,000 - $75,000 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits , and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities. We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings. Gainwell Technologies is an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics.
RN Utilization Review Full-time
Tuba City Regional Healthcare

Case Review Registered Nurse

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

Utilization Review Nurse (Remote- Maine RN Only)

Gainwell Technologies LLC ME
It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you’ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development. The pay range for this position is [[salaryMin]] - [[salaryMid]] per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits , and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities. We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings. Gainwell Technologies is committed to a diverse, equitable, and inclusive workplace. We are proud to be an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. We celebrate diversity and are dedicated to creating an inclusive environment for all employees.