Please note- Candidates must have COS-C, HCS-O or COQS and HCS-D or BCHH-C in order to be considered, there is no flexibility around this requirement. BAYADA Home Health Care has an immediate opening for a Full Time, OASIS and Coding Review Manager with OASIS and Coding certification to work remotely. RN, PT, OT, and SLP's with certifications will be considered for this role. BAYADA believes that our clients and their families deserve home health care delivered with compassion, excellence, and reliability. Apply your skills and knowledge of OASIS and ICD-10 coding to help clients receive the home health care services they need. BAYADA Perks: This is a fully remote position. Base Salary: $77,000 - $81,000 / year BAYADA offers a comprehensive benefits plan that includes the following: Paid holidays, vacation and sick leave, vision, dental and medical health plans, employer paid life insurance, 401k with company match, direct deposit, and employee assistance program Responsibilities: Review clinical information for appropriateness, congruency, and accuracy as it relates to the OASIS and ICD 10 coding while using the Medicare PDGM billing model and CMS guidelines. Review and communicate OASIS edit recommendations to each clinician to promote OASIS accuracy. Perform final review and lock OASIS. Timely review and coding of OASIS documents with productivity maintained at the quarterly target set by the Director of MCM. Prevent or decrease the occasion of Medicare denials by assuring proper coding on the plan of care and accurate OASIS documentation. Provide support and communication to all disciplines within the service. Provide customer service/education and act as a resource to Medicare Certified Offices with regards to CMS guidelines, Home Care Coding, PDGM guidelines and billing related issues. Provide ongoing communication with service offices via e-mail, zoom, or telephone (specific to the service office needs). Communication with service offices monthly and as appropriate with a focus on documentation trends, star ratings and potential revenue impact. Perform related duties, or as required or requested by Manager/Director. Qualifications: Competency in PC skills required to perform job function Active State RN Nursing License, Physical (PT), Occupational (OT) or Speech (SLP) Therapists with required certifications with a minimum of 2 years clinical experience. Please note, while this is a clinical opening, BAYADA does have non-clinical openings available COS-C or HCS-O or COQS OASIS Certification and experience required BCHH-C or HCS-D Home Health Care Coding Certification and experience required HCHB, SHP, and Coding Center experience, a plus! Be part of a caring, professional team that is instrumental in providing the highest quality care while developing your career with an industry leader. Apply now for immediate consideration. OASIS Review, Utilization Review, Quality Assurance, Remote, Home Health Coding, Coder, Medicare As an accredited, regulated, certified, and licensed home health care provider, BAYADA complies with all state/local mandates. BAYADA is celebrating 50 years of compassion, excellence, and reliability. Learn more about our 50th anniversary celebration and how you can join in here. BAYADA Home Health Care, Inc., and its associated entities and joint venture partners, are Equal Opportunity Employers. All employment decisions are made on a non-discriminatory basis without regard to sex, race, color, age, disability, pregnancy or maternity, sexual orientation, gender identity, citizenship status, military status, or any other similarly protected status in accordance with federal, state and local laws. Hence, we strongly encourage applications from people with these identities or who are members of other marginalized communities.
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. **** NOTE: This fully remote role supports utilization management and quality improvement efforts by identifying outlier provider performance, conducting comprehensive clinical record reviews, and delivering individualized coaching to providers. The position also synthesizes findings into clear, actionable presentations for providers and health plan leadership. Preference will be given to applicants who (1) reside in either central or eastern time zone with (2) experience in mental health settings, (3) utilization management / review, as well as (4) applicants who are presenting to leadership/providers and advising providers on performance. **** Additional Details: • Department: BH Utilization Mgmt. – Partnerships in Care • Business Unit: Corporate • Schedule: Monday through Friday 8-5 PM CT or ET with 1 hour lunch Position Purpose: Performs a clinical review and assesses care related to mental health and substance abuse. Monitors and determines if level of care and services related to mental health and substance abuse are medically appropriate. Evaluates member’s treatment for mental health and substance abuse before, during, and after services to ensure level of care and services are medically appropriate Performs prior authorization reviews related to mental health and substance abuse to determine medical appropriateness in accordance with regulatory guidelines and criteria Performs concurrent review of behavioral health (BH) inpatient to determine overall health of member, treatment needs, and discharge planning Analyzes BH member data to improve quality and appropriate utilization of services Provides education to providers members and their families regrading BH utilization process Interacts with BH healthcare providers as appropriate to discuss level of care and/or services Engages with medical directors and leadership to improve the quality and efficiency of care Formulates and presents cases in staffing and integrated rounds 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 2 – 4 years of related experience. License to practice independently, and/or have obtained the state required licensure as outlined by the applicable state required. Master’s degree for behavioral health clinicians required. Clinical knowledge and ability to review and/or assess treatment plans related to mental health and substance abuse preferred. Knowledge of mental health and substance abuse utilization review process preferred. Experience working with providers and healthcare teams to review care services related to mental health and substance abuse preferred. License/Certification: LCSW- License Clinical Social Worker required or LMHC-Licensed Mental Health Counselor required or LPC-Licensed Professional Counselor required or Licensed Marital and Family Therapist (LMFT) required or Licensed Mental Health Professional (LMHP) required or RN - Registered Nurse - State Licensure and/or Compact State Licensure required Pay Range: $27.02 - $48.55 per hour 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
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. Schedule: Mon - Friday 10-7 or 11-8 cst Position Purpose: Drafts correspondence letters based on review outcomes in accordance with National Committee for Quality Assurance (NCQA) standards. Works with senior management to identify and implement opportunities for improvement. Performs clinical review of outcomes including creating and editing denial letters with the correspondence team based on denial determinations in accordance with National Committee for Quality Assurance (NCQA) standards Contributes to correspondence letter template creation and maintenance with the correspondence team Investigates denials through comprehensive review of clinical documentation, clinical criteria/guidelines, and policy, including insurance rejections due to coding issues and provides supplemental information to resolve denial claims Assists with issues and/or questions related to correspondence with the state, local, and federal agencies including third party payer to ensure issues are resolved in a timely manner Maintains and monitors cases to ensure timely resolution and logs of actions and/or decisions are appropriately documented Coordinates with interdepartmental teams on training needed within the utilization management team based on trends Provides feedback to leadership to improve clinical processes and procedures to prevent recurrences based on industry best practices Performs other duties as assigned Complies with all policies and standards Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. License/Certification: LPN - Licensed Practical Nurse - State Licensure required and For Superior Plan: RN license Pay Range: $27.02 - $48.55 per hour 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
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. Schedule: Mon - Friday 10-7 or 11-8 cst Position Purpose: Drafts correspondence letters based on review outcomes in accordance with National Committee for Quality Assurance (NCQA) standards. Works with senior management to identify and implement opportunities for improvement. Performs clinical review of outcomes including creating and editing denial letters with the correspondence team based on denial determinations in accordance with National Committee for Quality Assurance (NCQA) standards Contributes to correspondence letter template creation and maintenance with the correspondence team Investigates denials through comprehensive review of clinical documentation, clinical criteria/guidelines, and policy, including insurance rejections due to coding issues and provides supplemental information to resolve denial claims Assists with issues and/or questions related to correspondence with the state, local, and federal agencies including third party payer to ensure issues are resolved in a timely manner Maintains and monitors cases to ensure timely resolution and logs of actions and/or decisions are appropriately documented Coordinates with interdepartmental teams on training needed within the utilization management team based on trends Provides feedback to leadership to improve clinical processes and procedures to prevent recurrences based on industry best practices Performs other duties as assigned Complies with all policies and standards Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. License/Certification: LPN - Licensed Practical Nurse - State Licensure required and For Health Net of California: RN license and For Superior Plan: RN license Pay Range: $27.02 - $48.55 per hour 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
JOB DESCRIPTION Job SummaryProvides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care. Must be licensed in CA. Essential Job Duties • Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines. • Analyzes clinical service requests from members or providers against evidence based clinical guidelines. • Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. • Conducts reviews to determine prior authorization/financial responsibility for Molina and its members. • Processes requests within required timelines. • Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner. • Requests additional information from members or providers as needed. • Makes appropriate referrals to other clinical programs. • Collaborates with multidisciplinary teams to promote the Molina care model. • Adheres to utilization management (UM) policies and procedures. Required Qualifications • At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience. • Registered Nurse (RN). License must be active and unrestricted in state of practice. • Ability to prioritize and manage multiple deadlines. • Excellent organizational, problem-solving and critical-thinking skills. • Strong written and verbal communication skills. • Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications • Certified Professional in Healthcare Management (CPHM). • Recent hospital experience in an intensive care unit (ICU) or emergency room. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $30.37 - $59.21 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
Job Requirements This role is full-time. Monday - Friday 8:00 am - 4:30 pm EST Responsible for performing utilization management. Proactively review, identify and document potentially avoidable utilization and patient quality/efficiency concerns. Work collaboratively with internal team as well as external entities to reduce potentially avoidable utilization and denials. Evaluates utilization documentation and recommends processes related to optimal reimbursement and compliance. Perform compliance tasks related to utilization. Orient new team members to acute care criteria. Work Experience Education & Training: Current Maryland RN license required. Bachelors of Science degree in Nursing preferred. Work Orientation & Experience: Minimum of 3 years’ acute care experience required. Experience in utilization management, case management and discharge planning preferred. Basic computer skills required. Skills & Abilities: Demonstrate skill in a) performing complete clinical assessments; b) effective critical thinking skills both written and oral; and c) age appropriate interpersonal interactions (patients may range from newborn to geriatric adult.) Ability to a) communicate and collaborate effectively with both internal and external customers (colleagues, Medical Staff, liaisons, and patient/family); b) assess, adapt, and calmly respond to changing and/or crisis environment; c) make independent decisions consistent with current policies, procedures, and ethical standards; d) prioritize work assignments and manage time effectively to complete duties; and e) assist in data analysis. REPORTING RELATIONSHIPS: Supervised by: Director of Utilization Management Supervision provided to: None. Additional Information All your information will be kept confidential according to EEO guidelines. Compensation: Pay Range: $38.67 - $58.05 Other Compensation (if applicable): Review the 2025-2026 UMMS Benefits Guide Benefits Additional Information All your information will be kept confidential according to EEO guidelines. Compensation: Pay Range: $38.67 - $58.05 Other Compensation (if applicable): Review the 2025-2026 UMMS Benefits Guide
The Utilization Management Registered Nurse (UM RN) is responsible for evaluating the medical necessity, appropriateness, and efficiecny 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 medcial necessity, both for admission to the hospital as well as continued stay. This function ensurses 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 minimzes risks of denials.
This Work from Home position requires that you live and will perform the duties of the position; within 60 miles of an HCA Healthcare Hospital (Our hospitals are located in the following states: FL, GA, ID, KS, KY, MO, NV, NH, NC, SC, TN, TX, UT, VA). Do you have the career opportunities as a Clinical Reviewer LPN you want with your current employer? We have an exciting opportunity for you to join Parallon which is part of the nations leading provider of healthcare services, HCA Healthcare. Job Summary and Qualifications The Clinical Reviewer LPN is responsible for performing retrospective medical reviews based on patient eligibility and contract requirements. Responsibilities: Perform a retrospective review of medical records using clinical expertise and Medicaid guidelines to determine medical necessity for emergent inpatient admissions and outpatient services. Perform clinical reviews and maintain clinical documentation in accordance with HCA policy, procedures, and job aids Submit authorization request based on state deadlines using various State portals Review deferred accounts and update according to payer request Review denied account to determine justification for Appeal requests Maintains clinical documentation according to HCA’S documentation policy Meet productivity requirement as established by leadership Assists in the orientation and training of new clinical staff Education: Successful completion of an accredited Licensed Practical/Vocational Nurse Program RN licensure is preferred Experience: A minimum of one-year experience reviewing medical records for medical necessity in a managed care, health plan, and/or hospital setting A minimum of one-year experience with denials and appeals in a clinical setting preferred A minimum of one-year experience in a patient care setting Experience working in a remote setting Work from home roles require employees must have high speed internet 60 MB download and 10 MB upload. Certificate/License: Currently licensed in applicable state Maintains an active LPN/LVN license in good standing Benefits Parallon, offers a total rewards package that supports the health, life, career and retirement of our colleagues. The available plans and programs include: Comprehensive benefits for medical, prescription drug, dental, vision, behavioral health and telemedicine services Wellbeing support, including free counseling and referral services Time away from work programs for paid time off, paid family leave, long- and short-term disability coverage and leaves of absence Savings and retirement resources , including a 401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service), Employee Stock Purchase Plan, flexible spending accounts, preferred banking partnerships, retirement readiness tools, rollover support and financial wellbeing counseling Education support through tuition assistance, student loan assistance, certification support, dependent scholarships and a partnership with Galen College of Nursing Additional benefits for fertility and family building, adoption assistance, life insurance, supplemental health protection plans, auto and home insurance, legal counseling, identity theft protection and consumer discounts Learn more about Employee Benefits Note: Eligibility for benefits may vary by location. " Parallon provides full-service revenue cycle management, or total patient account resolution, for HCA Healthcare. Our services include scheduling, registration, insurance verification, hospital billing, revenue integrity, collections, payment compliance, credentialing, health information management, customer service, payroll and physician billing. We also provide full-service revenue cycle management as well as targeted solutions, such as Medicaid Eligibility, for external clients across the country. Parallon has over 17,000 colleagues, and serves close to 1,000 hospitals and 3,000 physician practices, all making an impact on patients, providers and their communities. HCA Healthcare has been recognized as one of the World’s Most Ethical Companies® by the Ethisphere Institute more than ten times. In recent years, HCA Healthcare spent an estimated 3.7 billion in cost for the delivery of charitable care, uninsured discounts, and other uncompensated expenses. " "Bricks and mortar do not make a hospital. People do." - Dr. Thomas Frist, Sr. HCA Healthcare Co-Founder If you are looking for an opportunity that provides satisfaction and personal growth, we encourage you to apply for our Clinical Reviewer LPN opening. We promptly review all applications. Highly qualified candidates will be contacted for interviews. Unlock the possibilities and apply today! We are an equal opportunity employer. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours. Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function. Typical office working environment with productivity and quality expectations. Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor. Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment. Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding. Effective communication skills, both verbal and written Required Qualifications - 2+ years of experience as a Registered Nurse in adult acute care/critical care setting - Must have active current and unrestricted RN licensure in state of residence - Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours Preferred Qualifications - 2+ years of clinical experience required in med surg or specialty area - Managed Care experience preferred, especially Utilization Management - Preference for those residing in CT zones Education Associates Degree required BSN preferred Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $32.01 - $68.55 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan . No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 04/30/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours. Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function. Typical office working environment with productivity and quality expectations. Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor. Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment. Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding. Effective communication skills, both verbal and written Required Qualifications - 2+ years of experience as a Registered Nurse in adult acute care/critical care setting - Must have active current and unrestricted RN licensure in state of residence - Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours Preferred Qualifications - 2+ years of clinical experience required in med surg or specialty area - Managed Care experience preferred, especially Utilization Management - Prefe rence for those residing in Eastern Standard Time (EST) zone. Education Associates Degree required BSN preferred Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $29.10 - $62.32 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan . No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 04/18/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
Job Description: The role of the inpatient case manager is one of patient advocate of appropriate utilization of resources. The inpatient case manager applies the process of assessment, planning, implementation, monitoring, evaluation and coordination of care to meet the patient’s health care needs through hospitalization and transition back to the community and does this in coordination with the interdisciplinary health team. The RN Case Manager is expected to function within the full scope of the nursing practice with specialized focus on care coordination, compliance, transition management, education, and utilization management. Education: Bachelor's Degree Accredited School of Nursing Required Experience: 3 years Nursing - Medical/Surgical Preferred or 3 years Nursing - Critical Care Preferred 2 years Care Coordination - Case Management Preferred or Equivalent Work Experience Certifications/Licensures: RN Registered Nursing - California Board of Nursing Required BLS Basic Life Support - American Heart Association Required ACM Accredited Case Manager - ACMA American Case Management Association or CCM Certified Case Manager - CCMC Commission for Case Manager Certification Strongly Preferred Skills: Strong written and verbal communication skills. Effectively motivates teams. Strong knowledge of Medicare and Medi-Cal guidelines and benefit resources as applicable to hospitalization and transition planning. Working know ledge of common diagnoses and procedures and the impact this w ill have to patients/families and their ability to manage their care outside of the hospital. Specialized know ledge may be required for certain areas of practice. Knowledge of individual and family development over the life span, and the influences of cultural and spiritual values in health care. General knowledge of commercial coverage plans and usually covered benefits. Strong understanding of various reimbursement models and impact to care delivery, patient management and reimbursements such as ACOs, DRGs, Full Risk, etc. Strong understanding of the criteria, rules and regulations around Inpatient, Observation and Outpatient levels of patient management. Strong know ledge of geriatrics and the impact to health and function in the aged as w ell as a working know ledge of chronic/progressive disease states such as CHF, COPD, Diabetes and End Stage Renal Disease, etc. Clear understanding of the role of the inpatient Social Worker and Palliative Care Resources. Ability to plan, organize, manage time and prioritize work in collaboration with others. Ability to work independently and as a part of a multidisciplinary team. Effective problem solving and conflict resolution skills. Ability to work respectfully and creatively with clients of diverse functional abilities, social, economic, and cultural backgrounds to support both client autonomy and client safety. Leadership skills to delegate and provide direction/guidance to staff and hold others accountable. Able to learn and work in a variety of computer programs, including EPIC, Allscripts, InterQual, and Microsoft Outlook. Work shift: 0800-1630 Days worked per week: 5 Hours worked per day: 8 work schedule: Tuesday-Saturday (week 1) Wednesday-Saturday (week 2) Work Shift: 08.0 - 08:00 - 16:30 No Waive (United States of America) Pay Range: $89.23 - $121.58 Hourly Offer amounts are based on demonstrated/relevant experience and/or licensure. Pay will be adjusted to the local market if hired outside of the Bay Area. Note: Positions at JMH which are exempt (not eligible for overtime) under the level of Manager are listed as hourly for compensation purposes on this posting. The work shift will contain the word ‘exempt’ on it. Scheduled Weekly Hours: 36
Job Description: The role of the inpatient case manager is one of patient advocate of appropriate utilization of resources. The inpatient case manager applies the process of assessment, planning, implementation, monitoring, evaluation and coordination of care to meet the patient’s health care needs through hospitalization and transition back to the community and does this in coordination with the interdisciplinary health team. The RN Case Manager is expected to function within the full scope of the nursing practice with specialized focus on care coordination, compliance, transition management, education, and utilization management. Education: Bachelor's Degree Accredited School of Nursing Required Experience: 3 years Nursing - Medical/Surgical Preferred or 3 years Nursing - Critical Care Preferred 2 years Care Coordination - Case Management Preferred or Equivalent Work Experience Certifications/Licensures: RN Registered Nursing - California Board of Nursing Required BLS Basic Life Support - American Heart Association Required ACM Accredited Case Manager - ACMA American Case Management Association or CCM Certified Case Manager - CCMC Commission for Case Manager Certification Strongly Preferred Skills: Strong written and verbal communication skills. Effectively motivates teams. Strong knowledge of Medicare and Medi-Cal guidelines and benefit resources as applicable to hospitalization and transition planning. Working know ledge of common diagnoses and procedures and the impact this w ill have to patients/families and their ability to manage their care outside of the hospital. Specialized know ledge may be required for certain areas of practice. Knowledge of individual and family development over the life span, and the influences of cultural and spiritual values in health care. General knowledge of commercial coverage plans and usually covered benefits. Strong understanding of various reimbursement models and impact to care delivery, patient management and reimbursements such as ACOs, DRGs, Full Risk, etc. Strong understanding of the criteria, rules and regulations around Inpatient, Observation and Outpatient levels of patient management. Strong know ledge of geriatrics and the impact to health and function in the aged as w ell as a working know ledge of chronic/progressive disease states such as CHF, COPD, Diabetes and End Stage Renal Disease, etc. Clear understanding of the role of the inpatient Social Worker and Palliative Care Resources. Ability to plan, organize, manage time and prioritize work in collaboration with others. Ability to work independently and as a part of a multidisciplinary team. Effective problem solving and conflict resolution skills. Ability to work respectfully and creatively with clients of diverse functional abilities, social, economic, and cultural backgrounds to support both client autonomy and client safety. Leadership skills to delegate and provide direction/guidance to staff and hold others accountable. Able to learn and work in a variety of computer programs, including EPIC, Allscripts, InterQual, and Microsoft Outlook. Work shift: 0800-1630 Days worked per week: 5 Hours worked per day: 8 work schedule: Sunday to Wednesday (week 1) Sunday-Thursday (week2) Work Shift: 08.0 - 08:00 - 16:30 No Waive (United States of America) Pay Range: $89.23 - $121.58 Hourly Offer amounts are based on demonstrated/relevant experience and/or licensure. Pay will be adjusted to the local market if hired outside of the Bay Area. Note: Positions at JMH which are exempt (not eligible for overtime) under the level of Manager are listed as hourly for compensation purposes on this posting. The work shift will contain the word ‘exempt’ on it. Scheduled Weekly Hours: 36
Job Description: The role of the inpatient case manager is one of patient advocate of appropriate utilization of resources. The inpatient case manager applies the process of assessment, planning, implementation, monitoring, evaluation and coordination of care to meet the patient’s health care needs through hospitalization and transition back to the community and does this in coordination with the interdisciplinary health team. The RN Case Manager is expected to function within the full scope of the nursing practice with specialized focus on care coordination, compliance, transition management, education, and utilization management. Education: Bachelor's Degree Accredited School of Nursing Required Experience: 3 years Nursing - Medical/Surgical Preferred or 3 years Nursing - Critical Care Preferred 2 years Care Coordination - Case Management Preferred or Equivalent Work Experience Certifications/Licensures: RN Registered Nursing - California Board of Nursing Required BLS Basic Life Support - American Heart Association Required ACM Accredited Case Manager - ACMA American Case Management Association or CCM Certified Case Manager - CCMC Commission for Case Manager Certification Strongly Preferred Skills: Strong written and verbal communication skills. Effectively motivates teams. Strong knowledge of Medicare and Medi-Cal guidelines and benefit resources as applicable to hospitalization and transition planning. Working know ledge of common diagnoses and procedures and the impact this w ill have to patients/families and their ability to manage their care outside of the hospital. Specialized know ledge may be required for certain areas of practice. Knowledge of individual and family development over the life span, and the influences of cultural and spiritual values in health care. General knowledge of commercial coverage plans and usually covered benefits. Strong understanding of various reimbursement models and impact to care delivery, patient management and reimbursements such as ACOs, DRGs, Full Risk, etc. Strong understanding of the criteria, rules and regulations around Inpatient, Observation and Outpatient levels of patient management. Strong know ledge of geriatrics and the impact to health and function in the aged as w ell as a working know ledge of chronic/progressive disease states such as CHF, COPD, Diabetes and End Stage Renal Disease, etc. Clear understanding of the role of the inpatient Social Worker and Palliative Care Resources. Ability to plan, organize, manage time and prioritize work in collaboration with others. Ability to work independently and as a part of a multidisciplinary team. Effective problem solving and conflict resolution skills. Ability to work respectfully and creatively with clients of diverse functional abilities, social, economic, and cultural backgrounds to support both client autonomy and client safety. Leadership skills to delegate and provide direction/guidance to staff and hold others accountable. Able to learn and work in a variety of computer programs, including EPIC, Allscripts, InterQual, and Microsoft Outlook. Work shift: 0800-1630 Days worked per week: 5 Hours worked per day: 8 work schedule: Tuesday-Saturday (week 1) Wednesday-Saturday (week 2) Work Shift: 08.0 - 08:00 - 16:30 No Waive (United States of America) Pay Range: $89.23 - $121.58 Hourly Offer amounts are based on demonstrated/relevant experience and/or licensure. Pay will be adjusted to the local market if hired outside of the Bay Area. Note: Positions at JMH which are exempt (not eligible for overtime) under the level of Manager are listed as hourly for compensation purposes on this posting. The work shift will contain the word ‘exempt’ on it. Scheduled Weekly Hours: 36
Utilizing InterQual and other appropriate criteria, responsible for reviewing all admissions and continued stay of patients in conformance with the established criteria set forth in the hospital's utilization management and quality assurance plan. Will determine the medical necessity for admission and continued stays for patients within department's scope of service and to meet the hospital's objectives for assuring a high quality of patient care as well as assuring the effective and efficient utilization of available health services. Identifies appropriate level of care for inpatients and outpatients requiring overnight care. Education Other Graduate Of An Accredited School Of Nursing Required Bachelor's Degree BSN Required Experience 2 years experience in clinical nursing preferably in acute care Preferred General Experience in utilization review, case management, PreCertification, or discharge planning Preferred General Experience and knowledge of Medicare, Medicaid, and commercial insurance guidelines Preferred General Experience and knowledge of MCG and InterQual criteria tools Preferred Licenses PA Registered Nurse License Required or Multi State Compact RN License Required Schedule: M-F 8:00am-4:30pm with every third weekend requirement
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours. Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function. Typical office working environment with productivity and quality expectations. Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor. Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment. Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding. Effective communication skills, both verbal and written Required Qualifications - 2+ years of experience as a Registered Nurse in adult acute care/critical care setting - Must have active current and unrestricted RN licensure in state of residence - Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours Preferred Qualifications - 2+ years of clinical experience required in med surg or specialty area - Managed Care experience preferred, especially Utilization Management - Preference for those residing in EST zones Education Associates Degree required BSN preferred Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $29.10 - $62.32 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan . No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 04/30/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours. Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function. Typical office working environment with productivity and quality expectations. Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor. Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment. Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding. Effective communication skills, both verbal and written Required Qualifications - 2+ years of experience as a Registered Nurse in adult acute care/critical care setting - Must have active current and unrestricted RN licensure in state of residence - Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours Preferred Qualifications - 2+ years of clinical experience required in med surg or specialty area - Managed Care experience preferred, especially Utilization Management - Preference for those residing in CST zones Education Associates Degree required BSN preferred Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $26.01 - $56.14 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan . No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 04/30/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
Job Summary: Clinical Care Reviewer II is responsible for processing medical necessity reviews for appropriateness of authorization for health care services, assisting with discharge planning activities (i.e. DME, home health services) and care coordination for members, as well as monitoring the delivery of healthcare services. Essential Functions: Complete prospective, concurrent and retrospective review such as acute inpatient admissions, post-acute admissions, elective inpatient admissions, outpatient procedures, homecare services and durable medical equipment Identify, document, communicate, and coordinate care, engaging collaborative care partners to facilitate transitions to an appropriate level of care Engage with medical director when additional clinical expertise if needed Maintain knowledge of state and federal regulations governing CareSource, State Contracts and Provider Agreements, benefits, and accreditation standards Identify and refer quality issues to Quality Improvement Identify and refer appropriate members for Care Management Provide guidance to non-clinical staff Provide guidance and support to LPN clinical staff as appropriate Attend medical advisement and State Hearing meetings, as requested Assist Team Leader with special projects or research, as requested Perform any other job related duties as requested. Education and Experience: Associates of Science (A.S) Completion of an accredited registered nursing (RN) degree program required Three (3) years clinical experience required Med/surgical, emergency acute clinical care or home health experience preferred Utilization Management/Utilization Review experience preferred Medicaid/Medicare/Commercial experience preferred Competencies, Knowledge and Skills: Proficient data entry skills and ability to navigate clinical platforms successfully Working knowledge of Microsoft Outlook, Word, and Excel Effective oral and written communication skills Ability to work independently and within a team environment Attention to detail Proper grammar usage and phone etiquette Time management and prioritization skills Customer service oriented Decision making/problem solving skills Strong organizational skills Change resiliency Licensure and Certification: Current, unrestricted Registered Nurse (RN) Licensure in state(s) of practice required MCG Certification or must be obtained within six (6) months of hire required Working Conditions: General office environment; may be required to sit or stand for extended periods of time Travel is not typically required Compensation Range: $62,700.00 - $100,400.00 CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package. Compensation Type (hourly/salary): Hourly Organization Level Competencies Fostering a Collaborative Workplace Culture Cultivate Partnerships Develop Self and Others Drive Execution Influence Others Pursue Personal Excellence Understand the Business This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds. #LI-JM1
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. Kentucky Medicaid M-F 8-5 EST SUD experience Position Purpose: Performs a clinical review and assesses care related to mental health and substance abuse. Monitors and determines if level of care and services related to mental health and substance abuse are medically appropriate. Evaluates member’s treatment for mental health and substance abuse before, during, and after services to ensure level of care and services are medically appropriate Performs prior authorization reviews related to mental health and substance abuse to determine medical appropriateness in accordance with regulatory guidelines and criteria Performs concurrent review of behavioral health (BH) inpatient to determine overall health of member, treatment needs, and discharge planning Analyzes BH member data to improve quality and appropriate utilization of services Provides education to providers members and their families regrading BH utilization process Interacts with BH healthcare providers as appropriate to discuss level of care and/or services Engages with medical directors and leadership to improve the quality and efficiency of care Formulates and presents cases in staffing and integrated rounds Performs other duties as assigned. Complies with all policies and standards. Kentucky Medicaid M-F 8-5 EST SUD experience Education/Experience: Requires Graduate of an Accredited School Nursing or Bachelor's degree and 2 – 4 years of related experience. License to practice independently, and/or have obtained the state required licensure as outlined by the applicable state required. Master’s degree for behavioral health clinicians required. Clinical knowledge and ability to review and/or assess treatment plans related to mental health and substance abuse preferred. Knowledge of mental health and substance abuse utilization review process preferred. Experience working with providers and healthcare teams to review care services related to mental health and substance abuse preferred. License/Certification: LCSW- License Clinical Social Worker required or LMHC-Licensed Mental Health Counselor required or LPC-Licensed Professional Counselor required or Licensed Marital and Family Therapist (LMFT) required or Licensed Mental Health Professional (LMHP) required or RN - Registered Nurse - State Licensure and/or Compact State Licensure required For Fidelis Care only: LMSW, LCSW, LMHC, LPC, LMFT, LMHP or RN required Pay Range: $27.02 - $48.55 per hour 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
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary This is a fulltime remote Utilization Management Nurse Consultant opportunity. Utilization management is a 24/7 operation. Work schedules may include weekends and holidays and evening rotations. Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function. Typical office working environment with productivity and quality expectations. Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor. Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment. Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding. Effective communication skills, both verbal and written Required Qualifications Must have active current and unrestricted RN licensure in state of residence 3+ years of experience as a Registered Nurse 1+ years of clinical experience in acute or post-acute setting Candidates must be able to work Monday - Friday 8:00am-5:00pm EST with late night rotation 10:30 - 7pm EST. Work schedules include weekends, holidays and evening rotations Preferred Qualifications Experience working in ER, Med/Surg, and/or Critical care setting Managed Care experience Utilization review experience Experience working with MS office applications such as Teams, Outlook, Excel, and Word Education Minimum of an Associate's Degree in Nursing BSN preferred Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $29.10 - $62.32 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan . No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 04/18/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
Overview Audit Documentation. Ensure Compliance. Improve Quality Standards. As a Clinical Review Specialist, you will be responsible for completing chart audits and other functions that monitor, improve, and enforce compliance and Quality Assurance standards. You’ll collaborate with local and corporate teams to identify training needs, guide process improvements, and ensure adherence to federal and state regulations—all while supporting exceptional hospice care delivery. As a Clinical Review Specialist, You Will: Conduct proactive, recurring audits to support company infrastructure. Review and analyze documentation in HomeCareHomeBase (HCHB), making recommendations to improve accuracy and compliance. Quantify documentation quality and guide local management in targeted improvement strategies. Adhere to quality assurance, compliance, and departmental plans. Identify skill gaps among hospice agency staff and work with management to arrange appropriate training. Prepare reports and data analysis to support quality improvement initiatives. Assist in HCHB adjustments to prevent recurring deficiencies. Stay current on hospice best practices and recommend beneficial training resources. Support orientation and ongoing education of staff and committees on quality assurance and care standards. Participate in defining factors that influence care quality for hospice patients. Coordinate management calls to review patient chart findings and improvement recommendations. Compile local documentation outcome data and use company-wide insights to enhance QA. Meet or exceed department chart audit productivity expectations. This is a work from home position. To support operational needs and business hours, candidates should reside in one of these states: Alabama, Arkansas, Florida, Georgia, Indiana, Kansas, Michigan, Missouri, North Carolina, Pennsylvania, South Carolina, Tennessee, Texas or Virginia. About You Qualifications – What You’ll Bring: Registered Nurse (RN) currently licensed in the state of residence. Minimum of three years’ Hospice and Home Care experience, including at least one year in clinical record review and QAPI. Experience participating in state surveys. Valid driver’s license and insurance coverage. Strong understanding of documentation requirements to support medical necessity for hospice care. Knowledge of hospice federal and state regulations. Ability to manage confidential information with discretion. Initiative in researching and resolving documentation issues. Skilled at gathering and processing time-sensitive data from multiple sources. Flexible, responsive, and able to adapt to changing priorities in a fast-paced environment. Preferred Experience (Not Required) BSN or equivalent degree Previous experience with HomeCare HomeBase (HCHB) documentation systems. Prior quality assurance leadership experience in a hospice setting. We Offer Benefits for All Hospice Associates (Full-Time & Per Diem): Competitive Pay 401(k) with Company Match Career Advancement Opportunities National & Local Recognition Programs Teammate Assistance Fund Additional Full-Time Benefits: Medical, Dental, Vision Insurance Mileage Reimbursement or Fleet Vehicle Program Generous Paid Time Off + 7 Paid Holidays Wellness Programs (Telemedicine, Diabetes Management, Joint & Spine Concierge Care) Education Support & Tuition Assistance Free Continuing Education Units (CEUs) Company-paid Life & Long-Term Disability Insurance Voluntary Benefits (Pet, Critical Illness, Accident, LTC) Apply today and help support compassionate care that makes every moment count. Legalese This is a safety-sensitive position Employee must meet minimum requirements to be eligible for benefits Where applicable, employee must meet state specific requirements We are proud to be an EEO employer We maintain a drug-free workplace ReqID: 2026-134461 Category: Branch Admin and Clerical Position Type: Full-Time Company: Gentiva
Overview Audit Documentation. Ensure Compliance. Improve Quality Standards. As a Clinical Review Specialist, you will be responsible for completing chart audits and other functions that monitor, improve, and enforce compliance and Quality Assurance standards. You’ll collaborate with local and corporate teams to identify training needs, guide process improvements, and ensure adherence to federal and state regulations—all while supporting exceptional hospice care delivery. As a Clinical Review Specialist, You Will: Conduct proactive, recurring audits to support company infrastructure. Review and analyze documentation in HomeCareHomeBase (HCHB), making recommendations to improve accuracy and compliance. Quantify documentation quality and guide local management in targeted improvement strategies. Adhere to quality assurance, compliance, and departmental plans. Identify skill gaps among hospice agency staff and work with management to arrange appropriate training. Prepare reports and data analysis to support quality improvement initiatives. Assist in HCHB adjustments to prevent recurring deficiencies. Stay current on hospice best practices and recommend beneficial training resources. Support orientation and ongoing education of staff and committees on quality assurance and care standards. Participate in defining factors that influence care quality for hospice patients. Coordinate management calls to review patient chart findings and improvement recommendations. Compile local documentation outcome data and use company-wide insights to enhance QA. Meet or exceed department chart audit productivity expectations. This is a work from home position. To support operational needs and business hours, candidates should reside in one of these states: Alabama, Arkansas, Florida, Georgia, Indiana, Kansas, Michigan, Missouri, North Carolina, Pennsylvania, South Carolina, Tennessee, Texas or Virginia. About You Qualifications – What You’ll Bring: Registered Nurse (RN) currently licensed in the state of residence. Minimum of three years’ Hospice and Home Care experience, including at least one year in clinical record review and QAPI. Experience participating in state surveys. Valid driver’s license and insurance coverage. Strong understanding of documentation requirements to support medical necessity for hospice care. Knowledge of hospice federal and state regulations. Ability to manage confidential information with discretion. Initiative in researching and resolving documentation issues. Skilled at gathering and processing time-sensitive data from multiple sources. Flexible, responsive, and able to adapt to changing priorities in a fast-paced environment. Preferred Experience (Not Required) BSN or equivalent degree Previous experience with HomeCare HomeBase (HCHB) documentation systems. Prior quality assurance leadership experience in a hospice setting. We Offer Benefits for All Hospice Associates (Full-Time & Per Diem): Competitive Pay 401(k) with Company Match Career Advancement Opportunities National & Local Recognition Programs Teammate Assistance Fund Additional Full-Time Benefits: Medical, Dental, Vision Insurance Mileage Reimbursement or Fleet Vehicle Program Generous Paid Time Off + 7 Paid Holidays Wellness Programs (Telemedicine, Diabetes Management, Joint & Spine Concierge Care) Education Support & Tuition Assistance Free Continuing Education Units (CEUs) Company-paid Life & Long-Term Disability Insurance Voluntary Benefits (Pet, Critical Illness, Accident, LTC) Apply today and help support compassionate care that makes every moment count. Legalese This is a safety-sensitive position Employee must meet minimum requirements to be eligible for benefits Where applicable, employee must meet state specific requirements We are proud to be an EEO employer We maintain a drug-free workplace ReqID: 2026-134461 Category: Branch Admin and Clerical Position Type: Full-Time Company: Gentiva
Overview Audit Documentation. Ensure Compliance. Improve Quality Standards. As a Clinical Review Specialist, you will be responsible for completing chart audits and other functions that monitor, improve, and enforce compliance and Quality Assurance standards. You’ll collaborate with local and corporate teams to identify training needs, guide process improvements, and ensure adherence to federal and state regulations—all while supporting exceptional hospice care delivery. As a Clinical Review Specialist, You Will: Conduct proactive, recurring audits to support company infrastructure. Review and analyze documentation in HomeCareHomeBase (HCHB), making recommendations to improve accuracy and compliance. Quantify documentation quality and guide local management in targeted improvement strategies. Adhere to quality assurance, compliance, and departmental plans. Identify skill gaps among hospice agency staff and work with management to arrange appropriate training. Prepare reports and data analysis to support quality improvement initiatives. Assist in HCHB adjustments to prevent recurring deficiencies. Stay current on hospice best practices and recommend beneficial training resources. Support orientation and ongoing education of staff and committees on quality assurance and care standards. Participate in defining factors that influence care quality for hospice patients. Coordinate management calls to review patient chart findings and improvement recommendations. Compile local documentation outcome data and use company-wide insights to enhance QA. Meet or exceed department chart audit productivity expectations. This is a work from home position. To support operational needs and business hours, candidates should reside in one of these states: Alabama, Arkansas, Florida, Georgia, Indiana, Kansas, Michigan, Missouri, North Carolina, Pennsylvania, South Carolina, Tennessee, Texas or Virginia. About You Qualifications – What You’ll Bring: Registered Nurse (RN) currently licensed in the state of residence. Minimum of three years’ Hospice and Home Care experience, including at least one year in clinical record review and QAPI. Experience participating in state surveys. Valid driver’s license and insurance coverage. Strong understanding of documentation requirements to support medical necessity for hospice care. Knowledge of hospice federal and state regulations. Ability to manage confidential information with discretion. Initiative in researching and resolving documentation issues. Skilled at gathering and processing time-sensitive data from multiple sources. Flexible, responsive, and able to adapt to changing priorities in a fast-paced environment. Preferred Experience (Not Required) BSN or equivalent degree Previous experience with HomeCare HomeBase (HCHB) documentation systems. Prior quality assurance leadership experience in a hospice setting. We Offer Benefits for All Hospice Associates (Full-Time & Per Diem): Competitive Pay 401(k) with Company Match Career Advancement Opportunities National & Local Recognition Programs Teammate Assistance Fund Additional Full-Time Benefits: Medical, Dental, Vision Insurance Mileage Reimbursement or Fleet Vehicle Program Generous Paid Time Off + 7 Paid Holidays Wellness Programs (Telemedicine, Diabetes Management, Joint & Spine Concierge Care) Education Support & Tuition Assistance Free Continuing Education Units (CEUs) Company-paid Life & Long-Term Disability Insurance Voluntary Benefits (Pet, Critical Illness, Accident, LTC) Apply today and help support compassionate care that makes every moment count. Legalese This is a safety-sensitive position Employee must meet minimum requirements to be eligible for benefits Where applicable, employee must meet state specific requirements We are proud to be an EEO employer We maintain a drug-free workplace ReqID: 2026-134461 Category: Branch Admin and Clerical Position Type: Full-Time Company: Gentiva
Job Description Spectrum Healthcare Resources has an excellent opportunity for a civilian Utilization Management Registered Nurse at FE Warren Air Force Base in Cheyenne, WY. Full-time opportunity Monday - Friday (0700-1700) No weekends, on-call or holidays required Provide care and resources to military community Full complement of benefits to include health, dental and vision insurance, PTO, 11 Paid Holidays, 401(k) and more Pay range is $39-48/hour Job Requirements: BSN Degree 6 years of clinical nursing experience and 1 year of utilization management experience required Knowledge, skills and computer literacy to interpret and apply medical care criteria, such as InterQual or Milliman Ambulatory Care Guidelines. Experience in performing prospective, concurrent, and retrospective reviews to justify medical necessity for medical care to aid in collection and recovery from multiple insurance carriers. Current RN license in Wyoming Job duties: Monitor specialty care referrals for appropriateness, covered benefit, and authorized surgery/medical procedures, laboratory, radiology, pharmacy, and general hospital procedures and regulations to analyze medical referrals/appointments. Receives and makes patient telephone calls and computer/written correspondence regarding specialty clinic appointments and referrals. Develops and implements a comprehensive Utilization Management plan/program for beneficiaries within MTF’s goals and objectives. Company Overview: At Spectrum, we utilize over thirty-five years of experience providing optimal solutions for federal agencies that are both innovative and cost-effective. We hold ourselves to the highest standard to ensure successful outcomes for the facilities and health care professionals we serve. As a Joint Commission Certified Healthcare Resource, dependability and service are the driving forces of our mission. EOE/Disabled/Veterans Location : Location US-WY-Cheyenne Recruiter : Full Name: First Last Lauren Larkin Direct phone number 571-410-2088 Recruiter : Email Lauren_Larkin@spectrumhealth.com
Job Description Spectrum Healthcare Resources has a potential opportunity for a civilian Utilization Management Registered Nurse at FE Warren Air Force Base in Cheyenne, WY. Full-time opportunity Monday through Friday, 40 hours per week Outpatient setting, providing care to our Active Duty Air Men and Women No on-call responsibilities Full complement of benefits to include health, dental and vision insurance, paid time off, 11 Paid Holidays, 401k and more Job Requirements: The Position will have the following requirements: Degree: Baccalaureate of Science in Nursing Program from an approved National League of Nursing. Education: Graduate from a college or university accredited by Accreditation Commission for Education in Nursing (ACEN), the Commission on Collegiate Nursing Education (CCNE). Experience: Six years of clinical nursing experience is required. One year of previous experience in Utilization Management is required. Full time employment in a nursing field within the last 36 months is mandatory. Knowledge, skills and computer literacy to interpret and apply medical care criteria, such as InterQual or Milliman Ambulatory Care Guidelines. Must possess experience in performing prospective, concurrent, and retrospective reviews to justify medical necessity for medical care to aid in collection and recovery from multiple insurance carriers. Review process includes Direct Care and Purchase Care System referrals, ward rounds for clinical data collection, contacting providers to inform them of dollars lost for missing documentation, and providing documentation for appeals resolution. Must possess experience in performing prospective, concurrent, and retrospective reviews to justify medical necessity for medical care to aid in collection and recovery from multiple insurance carriers. Review process includes Direct Care and Purchase Care System referrals, ward rounds for clinical data collection, contacting providers to inform them of dollars lost for missing documentation, and providing documentation for appeals resolution. The Contractor must have a working knowledge of Ambulatory Procedure Grouping (APGs), Diagnostic Related Grouping (DRGs), International Classification of Diseases-Version 9 (ICD), and Current Procedural Terminology-Version 4 (CPT-4) coding. Licensure: Current, full, active, unrestricted license to practice as a Registered Nurse in Wyoming Job duties include but not limited to: Coordinate patient care in collaboration with a wide array of healthcare professionals. Facilitate the achievement of optimal outcomes in relation to clinical care, quality and cost effectiveness. Monitors specialty care referrals for appropriateness, covered benefit, and authorized surgery/medical procedures, laboratory, radiology, pharmacy, and general hospital procedures and regulations to analyze medical referrals/appointments. If unsure coordinates with TRICARE Regional Office Clinical Liaison Nurse and MTF Liaison to remedy errors or uncertainty. Assist with orientation and training of other Medical Management staff and assist in providing, assessing, and improving a wide variety of customer service relations. Assists Flight Commander to ensure Health Service Inspection standards are met at the operational level. Receives and makes patient telephone calls and computer/written correspondence regarding specialty clinic appointments and referrals. Routinely monitors referral management Composite Health Care System (CHCS) queue to ensure patients are being called that do not utilize the Referral Management Center walk-in service. Company Overview: Spectrum Healthcare Resources (SHR) was established in 1988 to deliver systems and processes designed to meet the unique needs of Military and VA Health Systems. SHR is a leading organization that provides physician and clinical staffing and management services to United States Military Treatment Facilities, VA clinics and other Federal Agencies through various contracting vehicles. A Joint Commission Health Care Staffing Services firm, SHR is the military staffing division of TeamHealth, a Nationwide organization that serves 850 civilian and military hospitals with a team of 9,600 affiliated health care professionals. Spectrum Healthcare Resources is an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status, or any other characteristic protected by law. Location : Location US-WY-Cheyenne Recruiter : Full Name: First Last Betty Fisk Direct phone number 314-744-4130 Recruiter : Email betty_fisk@spectrumhealth.com
Job Summary: Works collaboratively with an MD to coordinate and screen for the appropriateness of admissions and Continued stays. Makes recommendations to the physicians for alternate levels of care when the patient does not meet the medical necessity for Inpatient hospitalization. Interacts with the family, patient and other disciplines to coordinate a safe and acceptable discharge plan. Functions as an indirect caregiver, patient advocate and manages patients in the most cost effective way without compromising quality. Transfers stable non-members to planned Health care facilities. Responsible for complying with AB 1203, Post Stabilization notification. Complies with other duties as described. Must be able to work collaboratively with the Multidisciplinary team, multitask and in a fast pace environment. Essential Responsibilities: Plans, develops, assesses and evaluates care provided to members. Collaborates with physicians, other members of the multidisciplinary health care team and patient/family in the development, implementation and documentation of appropriate, individualized plans of care to ensure continuity, quality and appropriate resource use. Recommends alternative levels of care and ensures compliance with federal, state and local requirements. Assesses high risk patients in need of post-hospital care planning. Develops and coordinates the implementation of a discharge plan to meet patients identified needs; communicates the plan to physicians, patient, family/caregivers, staff and appropriate community agencies. Reviews, monitors, evaluates and coordinates the patients hospital stay to assure that all appropriate and essential services are delivered timely and efficiently. Participates in the Bed Huddles and carries out recommendations congruent with the patients needs. Coordinates the interdisciplinary approach to providing continuity of care, including Utilization management, Transfer coordination, Discharge planning, and obtaining all authorizations/approvals as needed for outside services for patients/families. Conducts daily clinical reviews for utilization/quality management activities based on guidelines/standards for patients in a variety of settings, including outpatient, emergency room, inpatient and non-KFH facilities. Acts as a liaison between in-patient facility and referral facilities/agencies and provides case management to patients referred. Refers patients to community resources to meet post hospital needs. Coordinates transfer of patients to appropriate facilities; maintains and provides required documentation. Adheres to internal and external regulatory and accreditation requirements and compliance guidelines including but not limited to: TJC, DHS, HCFA, CMS, DMHC, NCQA and DOL. Educates members of the healthcare team concerning their roles and responsibilities in the discharge planning process and appropriate use of resources. Provides patients with education to assist with their discharge and help them cope with psychological problems related to acute and chronic illness. Per established protocols, reports any incidence of unusual occurrences related to quality, risk and/or patient safety which are identified during case review or other activities. Reviews, analyses and identifies utilization patterns and trends, problems or inappropriate utilization of resources and participates in the collection and analysis of data for special studies, projects, planning, or for routine utilization monitoring activities. Coordinates, participates and or facilitates care planning rounds and patient family conferences as needed. Participates in committees, teams or other work projects/duties as assigned.
As a utilization review (UR) nurse, you help ensure that patients are receiving the appropriate level of care while being mindful of expenditures to your employer, whether you work for a hospital, managed care facility, or insurance company.
Wondering where you might work in this role? The federal government requires that organizations participating in Medicare and Medicaid conduct utilization reviews. This means that you’ll find a variety of workplace options for UR nurse jobs.
Education and Certifications for Utilization Review Nursing Jobs
Before you can work in utilization review, you must complete a nursing program from an approved institution. Once you pass the NCLEX and receive your license, you’ll want to gain clinical experience in direct patient care. Registered nurses may also want to pursue experience as an RN case manager.
While likely not required for most jobs, specialty certification can increase both your knowledge and also your leverage when it comes time to look for a new utilization review nurse job. Certifications include:
Health Utilization Management Certification (HUMC)
Put some effort into customizing your utilization review nurse resume to each job posting. For instance, if an employer is seeking a candidate “proficient in insurance prior authorizations and medical necessity criteria for different payers,” include that phrase in your resume. This helps demonstrate that your skills are a good fit for the job.
In your UR nurse cover letter, explain a bit about what drew you to this particular position. Remember, you don’t want just any old job — you want this job. To reinforce this sentiment as you apply to UR nurse jobs, search the employer’s website for their mission statement and see where your values overlap.
Interviewing for a Utilization Review Nurse Job
A job interview has the potential to determine whether or not you’ll get a job offer. Need some pointers? Review our nursing interview tips in advance to help you formulate smart answers to common questions and boost your confidence.
Learn how to answer interview questions about your strengths as a nurse:
Utilization Review Nurse Salary
The average annual salary for a UR nurse is around $91,600 for a registered nurse. Your location, level of education and experience, and employer can impact this number. For a more accurate picture of utilization review nurse jobs’ salary estimates in your area, explore the current UR nursing jobs on IntelyCare.
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