jobs matching Utilization Review

Utilization Review Nurse Jobs

Utilization Management Nurse - Surgical Services POE

Position Objective: Conducts concurrent and retrospective chart review for clinical, financial, and resource utilization information. Provides intervention and coordination to decrease avoidable delays and denial of payment. Essential Job Duties: 1. Chart Review : Reviews the medical record by applying utilization review criteria, to assess clinical, financial, and resource utilization; enters clinical review in EPIC; maintains close communication with external reviews, care coordinators, and providers; reconciles and records days authorized in EPIC 2. Denial Management : Monitors and identifies patterns or trends in utilization management; monitors potential and actual denials and collaborates with care coordinator for any follow up necessary; documents actions taken to avoid denial; assists Care Coordinator in communicating with the patient denied hospital days with work toward resolution and discharge. 3. Care Coordination: Collaborates with the Care Coordinator to achieve optimal and efficient patient outcomes while decreasing length of stay, avoidable delays and denied days; utilizes Physician Advisor and administrative personnel for unresolved issues; identifies opportunities for expedited appeals and collaborates with the care coordinator and Physician Advisor to resolve payer issues. 4. Process improvement initiatives Participates in nursing unit and department clinical outcome projects as well as process improvement initiatives of care management. Educational/Experience Requirements: Bachelor’s of Science in Nursing or Associate’s degree in Nursing with equivalent experience. BSN must be achieved within 5 years of start date in the role. Three years of clinical nursing in an acute care hospital setting. Required License/Certifications: Current RN license from Maryland Board of Nursing. Working Conditions, Equipment, Physical Demands: There is a reasonable expectation that employees in this position will be exposed to blood-borne pathogens. Physical Demands - The physical demands and work environment that have been described are representative of those an employee encounters while performing the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions in accordance with the Americans with Disabilities Act. The above job description is an overview of the functions and requirements for this position. This document is not intended to be an exhaustive list encompassing every duty and requirement of this position; your supervisor may assign other duties as deemed necessary. Pay Range $34 — $55 USD Luminis Health Benefits Overview: • Medical, Dental, and Vision Insurance • Retirement Plan (with employer match for employees who work more than 1000 hours in a calendar year) • Paid Time Off • Tuition Assistance Benefits • Employee Referral Bonus Program • Paid Holidays, Disability, and Life/AD&D for full-time employees • Wellness Programs • Employee Assistance Programs and more *Benefit offerings based on employment status Opt-in for text notifications! Luminis Health's two-way SMS texting platform lets you receive notifications and messages from our Talent Acquisition team directly on your phone. To enable this feature, select "yes" when asked to "opt-in to receive text messages" and to "Receive updates from a recruiter about this job via SMS" when completing your application. Once you are opted in, you can easily opt-out at any time. Standard text messaging rates may apply based on the candidate's mobile carrier plan. Luminis Health is not responsible for any charges incurred by the recipient. Candidates are encouraged to review their mobile carrier's plan for applicable text messaging rates and usage charges.

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

Denver Health Lincoln Park, CO

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

Utilization Review

Full-time

22 hours ago

RN Utilization Review Nurse

MedStar Health Northwest Washington, DC

About this Job: General Summary of Position Conducts admission concurrent and retrospective case reviews to ensure appropriate admit status and level of care by utilizing the nationally approved guidelines. Collaborates with medical staff and ancillary hospital disciplines to ensure high-quality patient care in the most efficient way. This position is remote but must be willing to travel to Washington DC area for regular meetings. Ideal candidate living in the DC, MD or VA area is required. Primary Duties and Responsibilities Conducts admission concurrent and retrospective case reviews to meet hospital objectives of high-quality patient care in the most efficient way Strives to meet the department goals adheres to organizational policies procedures and quality standards. Complies with rules and regulations set forth by the governmental and accrediting agencies. Collaborates with medical staff physician advisor social workers and other ancillary hospital disciplines to meet patients' health care needs in the most cost-effective way. Performs patients' medical record reviews document pertinent information and communicate with third party payors in a timely fashion to ensure proper hospital reimbursement and eliminate unnecessary denials. Implements strategies to avoid potential denials by communicating with all the key stakeholders including attending physician. If necessary non-coverage ABN MOON letters and other appropriate documents as per organizational governmental and accrediting organizations policies and regulations. Actively participates in IDRs Length of Stay and other meetings as per hospital policies. Identifies potential risks pertaining to patients' care and communicates with appropriate hospital discipline including risk management quality safety and infection control. Serves as a resource to the health care team by educating the health care team through in-services staff meetings and formal educational settings in areas of utilization management. Demonstrate current knowledge of State and Federal regulatory requirements as it pertains to the utilization review process. Identifies dynamics of neglect/abuse and reports to the appropriate in-house departments and governmental agencies. Minimal Qualifications Education Associate's degree in Nursing required Bachelor's degree in Nursing preferred Experience 3 or more years' Experience in an acute care setting. required Minimum of 2 years' experience in case management insurance utilization review required Licenses and Certifications RN - Registered Nurse - State Licensure and/or Compact State Licensure in the District of Columbia or the State of Maryland depending on work location required CCM - Certified Case Manager preferred Knowledge Skills and Abilities Excellent problem-solving skills and ability to exercise independent judgment. Business acumen and leadership skills. Strong verbal and written communication skills with ability to effectively interact with all levels of management internal departments and external agencies. Working knowledge of various computer software applications. This position has a hiring range of : USD $89,065.00 - USD $162,801.00 /Yr.

RN Quality Review Manager- Registered Nurse

Personal Touch Home Aides of New York New York, NY

$90,000 - $105,000 / year

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

Utilization Review

Telehealth

5 days ago

Fertility Utilization Management RN - Remote

UnitedHealthcare Des Moines, IA

$60,200 - $107,400 / year

RN Central Utilization Review Nurse

UHS Temecula, CA

Responsibilities Join the Southwest Healthcare Team! About Us: Creating Health and Harmony, Southwest Healthcare is a comprehensive network of care with convenient hospital and ambulatory care/outpatient locations here to serve the Southern California community. With over 6,000 passionate providers and healthcare employees, our shared goal is to provide convenient access to a wide range of healthcare services in a way that benefits you, your family, and the entire community. Southwest Healthcare is comprised of five acute care hospitals and several non-hospital access points, including: Corona Regional Medical Center, Palmdale Regional Medical Center, Southwest Healthcare Rancho Springs Hospital, Southwest Healthcare Inland Valley Hospital and Temecula Valley Hospital, Temecula Valley Day Surgery, A+ Urgent Care Centers, and Riverside Medical Clinics. For more information, please visit our website at www.swhealthcaresystem.com . Job Summary: The Southwest Healthcare Regional office in Temecula, CA is seeking a Full-Time RN Central Utilization Review Nurse who will be responsible for carrying out utilization management functions by planning, coordinating, and managing patient needs during hospitalization and throughout the continuum of care. Duties include but not limited to: Conducts admission and continued stay reviews per guidelines to ensure medical necessity of level of care and hospitalization for multiple entities. Reviews medical record for presence of accurate placement orders reconciles variances with patient providers. Works collaboratively with attending providers, specialty providers, and physician advisors to ensure application of evidence-based guidelines for determining appropriate status. Collaborates with Patient Access team to ensure correct payer source for hospitalization and communication. Ensures compliance of utilization review practices as required by payers, external regulatory agencies, and organization. Hybrid schedule may be considered after 90 days of employment. Must be available to work weekends and holidays. Benefit Highlights: Challenging and rewarding work environment. Competitive Compensation & Generous Paid Time Off. Excellent Medical, Dental, Vision and Prescription Drug Plans. 401(K) with company match and discounted stock plan. SoFi Student Loan Refinancing Program. Tuition, CEU, Certification, Licenses Reimbursement program. Career development opportunities within UHS and its 300+ Subsidiaries! More information is available on our Benefits Guest Website: UHS Guest Benefits Qualifications Experience/Training/Experience: Associates degree in Nursing or Graduate of a Vocational Nursing school required. Two (2) years of clinical experience in an acute care hospital setting with (1) year in an inpatient or outpatient case management setting required. Certifications/Licenses: Current license as a RN in the State of California required. Other Skills and Abilities: Demonstrates knowledge and ensures compliance with the Nurse Practice Act, The Joint Commission and Title 22 standards and guidelines. Demonstrates compliance with hospital policies and procedures at all times. Demonstrates strong leadership, organization, communication and interpersonal skills. Demonstrates ability to relate to clinical personnel and medical staff, as well as ability to interact well with the public. Must have knowledge of PC and applications. Capable of resolving escalated issues arising from operations and requiring coordination with other Knowledgeable in Interqual guidelines. About Universal Health Services Headquartered in King of Prussia, PA, Universal Health Services, Inc. (NYSE: UHS) is one of the nation’s largest and most respected providers of hospital and healthcare services. Since our founding in 1979, UHS has grown steadily into a premier Fortune 500® corporation perennially recognized by multiple esteemed national rating entities. Through its subsidiaries, UHS operates inpatient acute care facilities, inpatient behavioral health facilities, outpatient and other facilities, nationwide virtual behavioral health services, an insurance offering, a physician network and various related services with physical locations in the U.S., Puerto Rico, Ireland and United Kingdom. www.uhs.com . From Fortune , ©2025 , 2026 Fortune Media IP Limited. All rights reserved. Used under license. EEO Statement: All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws. We believe that diversity and inclusion among our teammates is critical to our success. Avoid and Report Recruitment Scams: We are aware of a scam whereby imposters are posing as Recruiters from UHS, and our subsidiary hospitals and facilities. Beware of anyone requesting financial or personal information. At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skill set and experience with the best possible career path at UHS and our subsidiaries. During the recruitment process, no recruiter or employee will request financial or personal information (e.g., Social Security Number, credit card or bank information, etc.) from you via email. Our recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc. If you suspect a fraudulent job posting or job-related email mentioning UHS or its subsidiaries, we encourage you to report such concerns to appropriate law enforcement. We encourage you to refer to legitimate UHS and UHS subsidiary career websites to verify job opportunities and not rely on unsolicited calls from recruiters.

PRN Utilization Management Nurse Practitioner (NP)

NaphCare, Inc. Hoover, AL

Overview NaphCare is hiring a PRN, Utilization Management - Nurse Practitioner NP to join our team of medical professionals at the Corporate office in Birmingham , AL. As a Utilization Management - Nurse Practitioner NP , you will review clinical charts to evaluate the medical necessity and appropriateness of off-site specialty visits and also perform case management for hospitalized patients. This is a unique position where you can make a difference to this diverse population of patients with complex medical needs. Responsibilities Responsibilities for Utilization Management Nurse Practitioner (NP): Understanding of the principles and concepts of medical quality assurance and utilization review. Develop, implement, and administer the quality assurance and utilization review processes. Monitor and report on the quality of all facets of the medical care provided to patients. Perform utilization and concurrent review of patient cases. Conduct detailed clinical chart assessments. Gather clinical information to assess and expedite care needs. Determine need, if any, for intervention, and discuss with physicians. Reviews requests from providers regarding the medical necessity of requested services for patients. Reviews and audits patients' medical records as indicated to determine medical necessity. Utilizes nationally recognized criteria to determine the medical necessity of requested services. Refers provider requests to the Medical Director or designee when the medical necessity of requested services does not meet recognized criteria. Qualifications Qualifications for Utilization Management Nurse Practitioner (NP): A current and unrestricted Nurse Practitioner license in Arizona A valid CPR card (AHA required) A minimum of 3-years experience in an acute care setting and 2 years' experience in utilization review and/or case management. Familiarity with Milliman or Interqual Care Guidelines is preferred Excellent communication and interpersonal skills Attention to detail and decision-making skills are essential Why Join NaphCare? NaphCare is one of the largest providers of healthcare services to correctional facilities throughout the US, and we are growing. If you have never considered a career in correctional healthcare, now may be the time! In addition to competitive salaries and generous employee benefits, we have opportunities for new graduates and experienced medical professionals, promote educational growth, and strongly support career advancement within the company. NaphCare Benefits for Full-Time Employees Include: Health, dental & vision insurance that starts day one! Prescriptions free of charge through our health plan, beginning day one Lowest Cost Benefits! Employee Assistance Program (EAP) services 401K and Roth with company contribution that starts day one! Tuition Assistance Referral bonuses Term life insurance at no cost to the employee Generous paid time off & paid holidays Free continuing education and CMEs If you would like to speak with me to learn more about this position and NaphCare, apply directly to the position to initiate the application process , and I’ll be in touch. Equal Opportunity Employer: disability/veteran Follow Us: Instagram | Facebook | LinkedIn | Advancing Correctional Healthcare | NaphCare

Utilization Management Nurse Practitioner (NP)

NaphCare, Inc. Hoover, AL

Overview NaphCare is hiring a Full Time, Utilization Management - Nurse Practitioner NP to join our team of medical professionals at the Corporate office in Birmingham , AL. As a Utilization Management - Nurse Practitioner NP , you will review clinical charts to evaluate the medical necessity and appropriateness of off-site specialty visits and also perform case management for hospitalized patients. This is a unique position where you can make a difference to this diverse population of patients with complex medical needs. Responsibilities Responsibilities for Utilization Management Nurse Practitioner (NP): Understanding of the principles and concepts of medical quality assurance and utilization review. Develop, implement, and administer the quality assurance and utilization review processes. Monitor and report on the quality of all facets of the medical care provided to patients. Perform utilization and concurrent review of patient cases. Conduct detailed clinical chart assessments. Gather clinical information to assess and expedite care needs. Determine need, if any, for intervention, and discuss with physicians. Reviews requests from providers regarding the medical necessity of requested services for patients. Reviews and audits patients' medical records as indicated to determine medical necessity. Utilizes nationally recognized criteria to determine the medical necessity of requested services. Refers provider requests to the Medical Director or designee when the medical necessity of requested services does not meet recognized criteria. Qualifications Qualifications for Utilization Management Nurse Practitioner (NP): A current and unrestricted Nurse Practitioner license in Arizona A valid CPR card (AHA required) A minimum of 3-years experience in an acute care setting and 2 years' experience in utilization review and/or case management. Familiarity with Milliman or Interqual Care Guidelines is preferred Excellent communication and interpersonal skills Attention to detail and decision-making skills are essential Why Join NaphCare? NaphCare is one of the largest providers of healthcare services to correctional facilities throughout the US, and we are growing. If you have never considered a career in correctional healthcare, now may be the time! In addition to competitive salaries and generous employee benefits, we have opportunities for new graduates and experienced medical professionals, promote educational growth, and strongly support career advancement within the company. NaphCare Benefits for Full-Time Employees Include: Health, dental & vision insurance that starts day one! Prescriptions free of charge through our health plan, beginning day one Lowest Cost Benefits! Employee Assistance Program (EAP) services 401K and Roth with company contribution that starts day one! Tuition Assistance Referral bonuses Term life insurance at no cost to the employee Generous paid time off & paid holidays Free continuing education and CMEs If you would like to speak with me to learn more about this position and NaphCare, apply directly to the position to initiate the application process , and I’ll be in touch. Equal Opportunity Employer: disability/veteran Follow Us: Instagram | Facebook | LinkedIn | Advancing Correctional Healthcare | NaphCare

Utilization Review

Telehealth

6 days ago

Preservice Review RN - Remote in HI

UnitedHealthcare Honolulu, HI

$29 - $52 / hour

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us in making healthcare work better for everyone through people-led, responsible AI while Caring. Connecting. Growing together. General Job Profile: Generally work is self-directed and not prescribed Works with less structured, more complex issues Serves as a resource to others If you are located in Hawaii, you will have the flexibility to work remotely* as you take on some tough challenges. Primary Responsibilities: Assesses and interprets customer needs and requirements Identifies solutions to non-standard requests and problems Solves moderately complex problems and/or conducts moderately complex analyses Works with minimal guidance; seeks guidance on only the most complex tasks Translates concepts into practice Provides explanations and information to others on difficult issues Coaches, provides feedback, and guides others Acts as a resource for others with less experience Functional Competencies: CPS_Conduct Non-Clinical Research to Support Determinations Determine that the case is assigned to the appropriate team for review (e.g., Medicare, Medicaid, Commercial) -Validate that cases/requests for services require additional research Identify and utilize appropriate resources to conduct non-clinical research (e.g., benefit documents, evidence of coverage, state/federal mandates, online resources) Prioritize cases based on appropriate criteria (e.g., date of service, urgent, expedited) Ensure compliance with applicable federal/state requirements and mandates (e.g., turnaround times, medical necessity) CPS_Review Existing Clinical Documentation Review/interpret clinical/medical records submitted from provider (e.g., office records, test results, prior operative reports) -Identify missing information from clinical/medical documentation, and request additional medical or clinical documentation as needed (e.g., LOI process, phone/fax) Review and validate diagnostic/procedure/service codes to ensure their relevance and accuracy, as applicable (e.g., PNL list, EPAL list, state grid, LCDs, NCDs) Identify and validate usage of non-standard codes, as necessary (e.g., generic codes) Apply understanding of medical terminology and disease processes to interpret medical/clinical records Make determinations per relevant protocols, as appropriate (e.g., approval, denial process, conduct further clinical or non-clinical research) Review care coordinator assessments and clinical notes, as appropriate CPS_Conduct Clinical Research to Support Determinations Identify relevant information needed to make medical or clinical determinations Identify and utilize medically-accepted resources and systems to conduct clinical research (e.g., clinical notes, MCG, medical policies, Coverage Determination Guidelines [CDG], National Comprehensive Cancer Network [NCCN], state/federal mandates) -Review/interpret other sources of clinical/medical information to support clinical or medical determinations (e.g., previous diagnoses, authorizations/denials, case management documentation) Obtain information from patients, providers and/or care coordinators as needed to verify services rendered and/or recommend additional options (e.g., Organization Determination Appeals and Grievance [ODAG], steerage calls) Apply knowledge of applicable state/federal mandates, benefit language, medical/ reimbursement policies and consideration of relevant clinical information to support determinations Collaborate with applicable internal stakeholders as needed to drive the clinical coverage review process (e.g., Medical Directors and their staff, Optum, UHC, Account Management) CPS_Make Final Determinations Based on Clinical and Departmental Guidelines Demonstrate understanding of business implications of clinical decisions to drive high quality of care Understand and adhere to applicable legal/regulatory requirements (e.g., federal/state requirements, DOI, HIPAA, CHAP, CMS, NCQA/URAC accreditation) Ask critical questions to ensure member- and customer-centric approach to work Identify and consider appropriate options to mitigate issues related to quality, safety or risk, and escalate to ensure optimal outcomes, as needed Utilize evidence-based guidelines (e.g., medical necessity guidelines, practice standards, industry standards, best practices, and contractual requirements) to make clinical decisions, improve clinical outcomes and achieve business results Identify and implement innovative approaches to the practice of nursing, in order to achieve or enhance quality outcomes Use appropriate business metrics to optimize decisions and clinical outcomes Prioritize work based on business algorithms and established work processes (e.g., assessments, case/claim loads, previous hospitalizations, acuity, morbidity rates, quality of care follow up) CPS_Achieve and Maintain Established Productivity and Quality Goals Meet/exceed established productivity goals Adhere to relevant quality audit standards in performing reviews, making determinations and documenting recommendations -Manage/prioritize workload and adjust priorities to meet quality and productivity goals CPS_Drive Effective Clinical Decisions Within a Business Environment Ask critical questions to ensure member/customer centric approach to work Identify and consider appropriate options to mitigate issues related to quality, safety or affordability when they are identified, and escalate to ensure optimal outcomes, as needed Utilize evidence-based guidelines (e.g., medical necessity guidelines, practice standards, industry standards, best practices, and contractual requirements) to make clinical decisions, improve clinical outcomes and achieve business results Identify and implement innovative approaches to the nursing role, in order to achieve or enhance quality outcomes and/or financial performance Understand and operate effectively/efficiently within legal/regulatory requirements (e.g., HIPAA, healthcare reform, URAC/NCQA/ERISA/state accreditation) You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications: Valid RN license in Hawaii Residence in Hawaii 3+ years of RN experience in an acute setting Advanced computer proficiency (Microsoft Word, Outlook, and Internet) Saturday availability Preferred Qualification: 3+ years of experience as an RN in utilization management *All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $29 - $52 per hour based on full-time employment. We comply with all minimum wage laws as applicable. At UnitedHealth Group, our mission is to help people live healthier lives and help make the health system work better for everyone. Together, we are shaping the future of healthcare by harnessing technology and innovation to make care simpler to navigate, more affordable and more connected for the people we serve. We are committed to creating an inclusive workplace where everyone feels welcomed, valued, heard and respected, empowering people to bring their authentic selves to work and strengthening our collective impact through diverse talents, backgrounds, experiences and perspectives. UnitedHealth Group and its affiliated brands are an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations. UnitedHealth Group and its affiliated brands are a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

Utilization Review

Full-time

6 days ago

Utilization Review Nurse RN

Health & Hospital Corporation Indianapolis, IN

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

Utilization Review

Full-time

5 days ago

Utilization Management Case Manager

Cottage Health Santa Barbara, CA

$60 - $92 / hour

Job Description Santa Barbara Cottage Hospital seeks a Utilization Management Case Manager for their SBCH Care Management department responsible for the utilization management, quality assurance, and discharge planning activities for assigned services/areas/patients within Cottage Health. Case management activities will result in quality outcomes, optimal care/cost management of services and/or procedures, a high level of customer satisfaction and contribution to an overall value-oriented experience of stakeholders and persons served. Qualifications QUALIFICATIONS: All job qualifications listed indicate the minimum level necessary to perform this job proficiently. Education: Minimum: Associate's Degree in Nursing (ADN). Preferred: Bachelor's Degree in Nursing (BSN). Certifications, Licenses, Registrations: Minimum: Current California Nursing license in good standing. Preferred: Certification in Case Management. Years of Related Work Experience: Minimum: 2 years direct patient care experience in an acute care setting. Other patient care experience may be considered. Preferred: Previous experience as a case manager in an acute care setting. About Us Cottage Health is a leading acute care hospital system, located on the central coast of California, widely known for our superior patient care, innovation, medical research and education. Our health system operates primarily in Santa Barbara, CA, since 1888, and consists of three acute care hospitals, a Rehabilitation Hospital, multiple clinics and a multi-site Urgent Care system. Our mission is to serve the central coast communities with excellence, integrity, and compassion. Every day we touch thousands of lives in many different ways, resolute in our mission to put patients first. We take pride in helping our patients get back to living their lives - in the places they love. Pay for non-physician positions is determined based on related years of experience and internal equity. Eligible employees may also receive additional forms of compensation, including shift differentials, on-call pay, incentive pay, and bonus opportunities, where applicable. Manager and above positions may participate in Cottage Health’s annual management incentive program. Physician compensation is determined based upon specialty and may include bonus potential. For more information on our comprehensive Total Rewards offerings, please visit https://cottagehealth.org/careers/total-rewards . If you're already a Cottage Health employee, please apply on this link only.

Utilization Review

Full-time

5 days ago

Utilization Management Case Manager

Cottage Health Santa Barbara, CA

$60 - $92 / hour

Medical Review Nurse (RN or LPN)

Molina Healthcare Harbor View Business Park, AZ

$29.05 - $56.64 / hour

Job Description Job Summary Utilizing clinical knowledge and experience, responsible for review of documentation to ensure medical necessity and appropriate level of care utilizing MCG/InterQual, state/federal guidelines, billing and coding regulations, and Molina policies; validates the medical record and claim submitted support correct coding to ensure appropriate reimbursement to providers. Job Duties • Facilitates medical review of prospective, retrospective, and concurrent review of appeals for denied prior authorizations. Includes standard and expedited cases, inpatient, outpatient, and pharmaceutical authorization appeals. • Facilitates clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases in which an appeal has been made, or is likely to be made, to ensure medical necessity and appropriate/accurate billing and claims processing. • Reevaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of relevant and applicable state and federal regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of services provided, length of stay, level of care, and inpatient readmissions. • Validates member medical records and claims submitted/correct coding, to ensure appropriate reimbursement to providers. • Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) issues. • Identifies and reports quality of care issues. • Assists with complex claim review including diagnosis-related group (DRG) validation, itemized bill review, appropriate level of care, inpatient readmission, and any opportunities identified by the payment integrity analytical team; makes decisions and recommendations pertinent to clinical experience. • Prepares and presents cases representing Molina, along with the chief medical officer (CMO), for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings. • Reviews medically appropriate clinical guidelines and other appropriate criteria with medical directors on denial decisions. • Supplies criteria supporting all recommendations for denial or modification of payment decisions. • Serves as a clinical resource for utilization management, CMOs, physicians and member/provider inquiries/appeals. • Provides training and support to clinical peers. • Identifies and refers members with special needs to the appropriate Molina program per applicable policies/protocols. Job Qualifications REQUIRED QUALIFICATIONS: • At least 2 years clinical nursing experience, including at least 1 year of utilization review (prospective, retrospective and concurrent clinical review), medical claims review, long-term services and supports (LTSS), claims auditing, medical necessity review and/or coding experience, or equivalent combination of relevant education and experience. • Registered Nurse (RN). License must be active and unrestricted in state of practice. Compact license is acceptable where states allow. • Experience demonstrating knowledge of ICD-10, Current Procedural Technology (CPT) coding and • Healthcare Common Procedure Coding (HCPC). • Experience working within applicable state, federal, and third-party regulations. • Analytic, problem-solving, and decision-making skills. • Organizational and time-management skills. • Attention to detail. • Critical-thinking and active listening skills. • Common look proficiency. • Effective verbal and written communication skills. • Microsoft Office suite and applicable software program(s) proficiency. PREFERRED QUALIFICATIONS: • Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ), or other health care certifications. • Nursing experience in critical care, emergency medicine, medical/surgical or pediatrics. • Experience with Medicare guidelines 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: $29.05 - $56.64 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Utilization Review

1 week ago

Case Manager - Utilization Review RN

Community First Medical Center Chicago, IL

$43.47 - $53 / hour

Description Under the general direction of the Director of Behavioral Health, the Case Manager – Utilization Review RN provides clinically based case management and utilization review services to support the delivery of high-quality, cost-effective patient care. The RN is responsible for concurrent utilization review, medical necessity determination, denial prevention, discharge planning, care coordination, and resource management across the continuum of care. The Case Manager – Utilization Review RN collaborates with physicians, interdisciplinary team members, physician advisors, social workers, revenue cycle staff, and third-party payers to ensure appropriate utilization of hospital resources, regulatory compliance, optimal reimbursement, and safe patient transitions. Community First Medical Center offers benefits to all its full-time and part-time employees : United Healthcare Medical PPO/HMO/HSA Plans, premiums as low as $50.00/full time, $85.00/Part Time Met Life Dental and Vision Paid Time Off (PTO) with annual accruals up to 168 hrs./year Six paid holidays Company Paid Life insurance and Short-term Disability 401(k) after 90 days Continuing Education reimbursement and 2 days paid off separate from PTO Free Parking Garage Internal Growth Opportunities Requirements To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. QUALIFICATIONS Education Associate Degree in Nursing required. Bachelor of Science in Nursing (BSN) preferred. Experience Minimum three (3) years of acute care nursing experience required. Minimum two (2) years of Case Management and/or Utilization Review experience preferred. Experience with discharge planning, utilization review, denial management, and payer authorization preferred. Licensure Current Illinois Registered Nurse license required. ACM, CCM, or CMAC certification preferred. KNOWLEDGE, SKILLS & ABILITIES Knowledge of Medicare, Medicaid, and commercial insurance regulations. Working knowledge of InterQual and/or MCG criteria. Behavioral Health background knowledge Access to Behavioral Health Networks Understanding of utilization management and care coordination principles. Knowledge of discharge planning and post-acute care resources. Strong analytical and critical thinking skills. Excellent verbal and written communication skills. Ability to prioritize multiple complex patient cases. Ability to build collaborative relationships with physicians and interdisciplinary teams. Computer proficiency and electronic medical record experience. PERFORMANCE EXPECTATIONS Success in this role is measured by: Appropriate admission status determination Denial prevention and appeal success Timely discharge planning Reduction in avoidable days Average Length of Stay management Readmission reduction Documentation compliance Regulatory compliance Patient throughput Patient and physician satisfaction

Claims Review Nurse, LVN (Remote)

Inland Empire Health Plan Rancho Cucamonga, CA

$63,897.60 - $83,075.20 / year

Overview: What you can expect! Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience! Reporting to the Supervisor, Integrated Transitional Care, the Claims Review Nurse, LVN is responsible for conducting timely medical reviews of IEHP facility and professional claims and appeals. The Claims Review Nurse, LVN identifies process improvements in the UM/Claims interface and makes recommendations to improve the claim authorization process and business rules between Claims and UM teams. The Claims Review Nurse, LVN exercises independent judgment in conducting claims reviews and supports key clinical determinations in alignment with guidance from the Supervisor, Integrated Transitional Care. Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation. Additional Benefits: Perks IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more. Competitive salary State of the art fitness center on-site Medical Insurance with Dental and Vision Life, short-term, and long-term disability options Career advancement opportunities and professional development Wellness programs that promote a healthy work-life balance Flexible Spending Account – Health Care/Childcare CalPERS retirement 457(b) option with a contribution match Paid life insurance for employees Pet care insurance Key Responsibilities: Audit medical necessity claims in accordance with departmental policies and procedures Act as the key clinical interface between the Claims and Medical Services departments Attend UM and Claims team meetings Review inpatient and outpatient claims that require authorization, appeals and other disputed claims in a timely manner to meet regulatory requirements Obtain the appropriate clinical information necessary to make authorization decisions for unauthorized claims Identify potential denied services/admissions/days and present to the Medical Director, both Plan and Direct, for appropriate decision/direction Review medical records to determine if charges and/or services are appropriate (e.g., reviewing CPT/HCPCS codes, up-coding practices, and similar items) Analyze level of care on in-patient reviews. Track trends in billing patterns by provider and report to leadership practices that may need further investigation Develop and sustain positive working relationships, collaborating with physicians, nurses, ancillary personnel and all others as appropriate to promote open communication channels, obtain/disseminate information, and enhance customer relations Inform appropriate staff for coordination and negotiation of financial arrangements for non-contracted and/or fee-for-service providers and facilities Provide reports as necessary Adapt to changes or unusual circumstances to promote cooperation and minimize disruption of working environment Perform any other duties as required to ensure Health Plan operations and department business needs are successful Qualifications: Education & Experience A minimum of one (1) year of relevant work experience Recent experience with inpatient and outpatient utilization and case management required Experience in auditing claims Experience in reviewing inpatient medical records and claims preferred Experience in managed care, MediCal, Medicare preferred High school diploma or GED Associate’s degree in health care or a related field from an accredited institution Possession of an active, unrestricted, and unencumbered Vocational Nurse (LVN) license issued by the California Board of Vocational Nursing and Psychiatric Technicians required Key Qualifications Knowledge and understanding of: CPT, ICD-10, HCPCS and hospital revenue codes Nationally recognized clinical criteria (e.g., InterQual, Milliman, Apollo) Medi-Cal, Medicare and other state/federal Program & Regulations Foundations of nursing practice and clinical pathways across inpatient, outpatient, and post‑acute settings Health plan policies, prior authorization protocols, appeals processes, and denial management Proficient in computer applications such as Word and Excel Skilled in Data Entry Skilled clinical review and judgement Data analysis and trend identification skills Communication skills (both written and verbal) Proven ability to: Exercise sound clinical judgement with minimal supervision Escalate appropriately to Medical Director for complex determinations Build trust and collaboration with physicians, nurses, ancillary staff, and claims personnel Navigates diverse perspectives Adjust to policy updates, workflow changes, and unusual circumstances while maintaining service quality Handle PHI with strict adherence to privacy and security standards; maintains ethical audit practices Possess a strong attention to detail with the ability to multi-task Start your journey towards a thriving future with IEHP and apply TODAY ! Work Model Location: Telecommute (All IEHP positions approved for telecommute work locations may periodically be required to report to IEHP’s main campus for mandatory in-person meetings or for other business needs as determined by IEHP leadership) Pay Range: USD $63,897.60 - USD $83,075.20 /Yr.

Quality Review Nurse - Med Surg/DOU - Full Time - Days 8hr FPH

Emanate Health Glendora, CA

$54.63 - $84.67 / hour

Current Emanate Health Employees - Please log into your Workday account to apply Everyone at Emanate Health plays a vital role in the care we deliver. No matter what department you belong to, the work you do at Emanate Health affects lives. When you join Emanate Health, you become part of a team that works together to strengthen our communities and grow as individuals. On Glassdoor's list of "Best Places to Work" in 2021, Emanate Health was named the #1 ranked health care system in the United States, and the #19 ranked company in the country. Job Summary Provides expertise to the organization in the form of quality management review and performance improvement knowledge. Supports the hospital units and staff in preparation for surveys, clinical documentation review, regulatory needs and rounding on patients with discharge calls. Assists in the review process and peer education/correction. Psych - Provides expertise to the organization in the form of quality management review and performance improvement knowledge. Supports the Psychiatric unit and staff in preparation for surveys, clinical documentation review, regulatory needs and rounding on patients with discharge calls. Assists in the review process and peer education/correction. Job Requirements Minimum Education Requirement : BSN preferred. Minimum Experience Requirement : Minimum of three years of acute care experience. Excellent customer service skills required. Experience in Telemetry, DOU, or Neuroscience preferred Experience in MedSurg, Telemetry, Orthopedics, or Oncology preferred Minimum License Requirement : California RN license and BLS required. ACLS required within 90 days of hire or transfer. NIHSS Stroke Certification required within 90 days of hire or transfer. Delivering world-class health care one patient at a time. Pay Range: $54.63 - $84.67

Utilization Review

Full-time

1 week ago

Utilization Management Case Manager

Havenwyck Hospital Lake Angelus, MI

Responsibilities HAVENWYCK HOSPITAL (a UHS facility) Havenwyck Hospital is a Joint Commission-accredited and licensed psychiatric hospital, overlooking Lake Galloway in Auburn Hills, Michigan. We specialize in providing comprehensive, compassionate behavioral health services to children, adolescents and adults. It is the ultimate goal of our dedicated staff to build strength, confidence and knowledge within each patient, in hopes that they may continue learning and understanding their needs and practicing self-care for the rest of their lives. If you would like to learn more about this position before applying, please contact Havenwyck Hospital at 248-373-9200. POSITION SUMMARY: The Utilization Management Case Manager has a responsibility for organizing and conducting the manager care process. These duties shall be directed toward supporting the hospital's mission in the pursuit of excellence in care/service and will include (but not limited to ): conducting timely admission and continues stay record reviews with external payers, utilizing approved criteria to make determinations of medical necessity and level of care planning, verifying active treatment by completing internal audit reviews within approved time frames, assisting the treatment team when indicated in the discharge planning process, and acting as liaison with MD/Clinical Treatment Team and external agencies. Report authorizations, denials, and documentation concerns, as well as collaborate effectively across departments to minimize denials/facilitate optimal use of hospital resources. DUTIES AND RESPONSIBILITIES: Through clinical skills (experience and knowledge), reports to external insurance and review entities an accurate presentation of the medical management of a patient's illness, length of stay and care alternatives available within the confines on the client's benefits and financial resources. Communicates with the Treatment Team (physicians, nursing staff, social workers, etc.) as necessary to advocate for the patient's clinical treatment within the confines on the client's benefits and financial resources. Using clinical skills (experience and knowledge) assists the team in ensuring the completeness and accuracy of the medical records. Performs other related duties as assigned. BENEFIT HIGHLIGHTS: Challenging and rewarding work environment Competitive Compensation & Generous Paid Time Off Excellent Medical, Dental, Vision and Prescription Drug Plan 401(K) with company match and discounted stock plan Career development opportunities within UHS and its 300+ Subsidiaries Free Basic Life Insurance Tuition Reimbursement SoFi Student Loan Refinancing Program Student Loan Repayment Program - for some degrees and criteria What do our current employees value at Havenwyck Hospital and UHS? An environment that puts patient care first. One of the most rewarding aspects of this job is providing excellent care, comfort, and security to the patients and families you treat, at their most vulnerable times. Supportive and responsive leadership. You are never alone, as you are part of a large network of peer co-workers that routinely exchange ideas and review current topics within the industry. Having the opportunity to grow, learn, and advance in your career. There are very robust continuing education options and opportunities for skills diversification and career advancement with UHS. About Universal Health Services One of the nation’s largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (UHS) has built an impressive record of achievement and performance. Growing steadily since its inception into an esteemed Fortune 500® corporation, annual revenues during 2025 were $17.4 billion. In 2026, UHS was again recognized as one of Fortune World’s Most Admired Companies™ and in 2025, was listed in Forbes ranking of America’s Largest Public Companies. Headquartered in King of Prussia, PA, UHS has approximately 101,500 employees and continues to grow through its subsidiaries. Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory care access points, an insurance offering, a physician network and various related services located in 40 U.S. states, Washington, D.C., Puerto Rico and the United Kingdom. For additional information visit www.uhs.com . Qualifications QUALITICATIONS: Bachelor Degree in social work, psychology, counseling or nursing required. Master's degree in social work, psychology, or counseling preferred. Limited or fully licensed (LBSW, RN, LLMSW, LLP, TLLP, LPC, LMFT, etc.). A minimum of 2 years of post-graduate related experience in psychiatric or substance abuse treatment required. Hospital utilization review/utilization management experience preferred. Familiarity with manager health care process, medical terminology, experience in case management, discharge planning, and/or utilization review preferred. EEO Statement All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws. We believe that diversity and inclusion among our teammates is critical to our success. Avoid and Report Recruitment Scams We are aware of a scam whereby imposters are posing as Recruiters from UHS, and our subsidiary hospitals and facilities. Beware of anyone requesting financial or personal information. At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skill set and experience with the best possible career path at UHS and our subsidiaries. During the recruitment process, no recruiter or employee will request financial or personal information (e.g., Social Security Number, credit card or bank information, etc.) from you via email. Our recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc. If you suspect a fraudulent job posting or job-related email mentioning UHS or its subsidiaries, we encourage you to report such concerns to appropriate law enforcement. We encourage you to refer to legitimate UHS and UHS subsidiary career websites to verify job opportunities and not rely on unsolicited calls from recruiters.

Utilization Review

1 week ago

Quality Review Specialist-RN

Lexington Medical Center West Columbia, SC

Quality Management - Acute Full TimeDay Shift 8-430 Lexington Health is a comprehensive network of care that includes six community medical and urgent care centers, nearly 80 physician practices, more than 9,000 health care professionals and Lexington Medical Center, a 607-bed teaching hospital in West Columbia, South Carolina. It was selected by Modern Healthcare as one of the Best Places to Work in Healthcare and was first in the state to achieve Magnet with Distinction status for excellence in nursing care. Consistently ranked as best in the Columbia Metro area by U.S. News & World Report, Lexington Health delivers more than 4,000 babies each year, performs more than 34,000 surgeries annually and is the region's third largest employer. Lexington Health also includes an accredited Cancer Center of Excellence, the state’s first HeartCARE Center, the largest skilled nursing facility in the Carolinas, and an Alzheimer’s care center. Its postgraduate medical education programs include family medicine and transitional year residencies, as well as an informatics fellowship.Job Summary The Quality Review Specialist-RN provides consultative services regarding quality assessment and trends to medical staff and to hospital ancillary department personnel. In this role, the employee will perform comprehensive retrospective reviews in a timely manner utilizing criteria developed and approved by the medical staff, hospital, and regulatory agents. Minimum Qualifications Minimum Education: High School Diploma or Equivalent Minimum Years of Experience: 4 Years of clinical or hospital experience; 2 Years of experience in quality or utilization review. Substitutable Education & Experience (Optional): None. Required Certifications/Licensure: Registered Nurse (RN) Required Training: None. Essential Functions Utilizes in-depth knowledge of clinical workflows, policies and procedures, patient care / clinical business processes, regulatory requirements, and best practices to: Risk Management- Perform daily review of new occurrence reports. Identify occurrences that require additional follow-up and reports these to the Director or designee in a timely manner. Ensure that occurrences are categorized correctly and all fields completed and correct. Verifies data accuracy with medical record if necessary. Ensure that occurrence reports are forwarded to all appropriate persons. Access other sources of data as needed for investigation and follow up. Serves as System Administrator for the occurrence reporting system. Primary liaison between Risk Management, Information Services, and system users. Manages access to the occurrence reporting system. Adds new locations and new users and provides new-user training. Assigns passwords. Removes users as needed. Provides new user training and ongoing user support, paying keen attention to user needs and opportunities to offer solutions and modify processes to improve efficiencies. Coordinates with vendor and Information Services to troubleshoot system as needed. Center for Best Practice & PN Quality- Assists with development, implementation, and evaluation of the hospital’s overall quality improvement program. Assist with coordination, preparation, and maintenance of performance improvement assessment and improvement activities. Responsible for data integrity and follows well defined processes for maintaining data integrity as well as manage assigned database. Assists in evaluation, analysis, maintenance and development of system functionality of the EHR to meet clinical objectives including participating in project plan development/tracking and workflow analysis. Duties & Responsibilities Provides accurate and timely routine statistical analyses and reports to designated parties. Identifies need for new reports and develops and creates reports. Generates user-friendly reports from other databases. Evaluates and analyzes data for trends, identifies areas of concern, and uses data display techniques to provide reports for various meetings and hospital committees. Prepares materials for meetings and assists with maintenance of performance improvement project records. Represents department on committees / teams as assigned. Participates and supports department goals, objectives and timelines, working with a sense of urgency and accuracy to ensure effective implementation. Successfully engages in multiple initiatives simultaneously and demonstrates flexibility in role and a willingness to help others. Attains an annual minimum of 12 hours of continuing education in topics related to role. May prepare materials for meetings and assists with maintenance of performance improvement project records. May represent department on committees / teams as assigned. Risk Management: Resolves problems and recommends solutions through research, inquiry, and data analysis, maintaining support call logs and tracking of issues. Compiles and maintains accurate statistics pertaining to occurrence data. Participates in and contributes to patient safety / risk reduction activities, including: Participates in and contributes to investigations of serious unanticipated events and "close-calls". Participates in and contributes to development, implementation and evaluation of corrective action plans. Supports a culture of safety by encouraging staff to speak up and report safety and quality issues. Center for Best Practice & PN Quality: Identifies opportunities for improvement and coordinates/participates in the development and implementation of action plans to make improvements- recommends changes to systems/processes that do not contribute to desired outcomes. Works collaboratively and communicates effectively with administration, IS, and clinical care teams through participation in the planning, development, and evaluation and maintenance of the Clinical Information system. Audits database contents for accuracy and validity. Acts as a resource person in quality assessment activities with hospital departments and committees. Works directly with hospital personnel to provide assistance and guidance in establishing criteria, reviewing medical records, etc. Requires efficient use of numerous software products (Word, Excel, PowerPoint, Outlook, etc.) Performs all other duties as assigned. We are committed to offering quality, cost-effective benefits choices for our benefit eligible employees and their families: Day ONE medical, dental and life insurance benefits Health care and dependent care flexible spending accounts (FSAs) Employees are eligible for enrollment into the 403(b) match plan day one. LHI matches dollar for dollar up to 6%. Employer paid life insurance – equal to 1x salary Employee may elect supplemental life insurance with low cost premiums up to 3x salary Adoption assistance LHI provides its full-time employees employer paid short-term disability and long-term disability coverage after 90 days of eligible employment Tuition reimbursement Student loan forgiveness Equal Opportunity EmployerIt is the policy of Lexington Health to provide equal opportunity of employment for all individuals, and to remain compliant with applicable state and federal laws and regulations. Lexington Health strives to provide a discrimination-free environment, and to recruit, select, on-board, and employ all employees without regard to race, color, religion, sex, age, disability, national origin, veteran status, or pregnancy, childbirth, or related medical conditions, including but not limited to, lactation. Lexington Health endeavors to upgrade and promote employees from within the hospital where possible and consistent with the employee’s desires and abilities and the hospital’s needs.

Quality Review Nurse - Med Surg/DOU - Full Time - Days 8hr FPH

Emanate Health Glendora, CA

$54.63 - $84.67 / hour

Supervisor, Utilization Management RN (Outpatient)

L.A. Care Health Plan Westlake, CA

$102,183 - $163,492 / year

Salary Range: $102,183.00 (Min.) - $132,838.00 (Mid.) - $163,492.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job Summary The Supervisor of Utilization Management (UM) RN is responsible for executing the day-to-day operations of the UM department, and monitoring the Care Management (CM) staff’s responsibilities and activities. This includes, but not limited to, ensuring proper staffing and coverage; monitoring and evaluating departmental operations to ensure optimal efficiency, productivity, and effectiveness; documenting and appropriately addressing excellence or deviations in work, departmental, and organizational expectations; and conducting intermittent and annual performance evaluations. This role assists in triaging identified issues/problems and forming resolution within the scope of work/licensure. The Supervisor is a subject matter expert (SME) in Care/Case/Utilization Management and supporting regulations, policies, protocols, and procedures. This position serves as a formal and informal instructor, and escalates issues/concerns to the appropriate person when outside of their scope. This position is responsible in assisting with and development and maintenance of a successful and cohesive unit, with high level of productivity and accuracy to achieve the department's overall performance metrics. The Supervisor ensures all functions of the UM department are operating in accordance with the organization's mission, values and strategic goals, which are focused on quality care delivery and continuous improvement; and are provided in a manner that is responsive and sensitive to the needs of L.A. Care's culturally diverse membership. The position supports the UM Manager/Director. This role also assists UM Educator/Manager/Director in identification of training needs including, but not limited to, collaborating in development of programs, training materials, competency checklist, and orientation checklists necessary to meet education and training needs of UM staff. The position supervises all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports. Duties Ensures adequate/appropriate distributions of workforce, assignments and time off requests. Participates in the hiring and termination process providing recommendations with appropriate supporting documentation. Monitors of staff's performance including productivity and compliance with regulatory requirements, compliance with policies. Identifies, communicates and coaches to improve staff performance. Develops tools, job aids, and workflows to optimize the process flow, performance and productivity of the UM team. Completes intermittent and annual staff evaluations. Serves as the primary resource for all business-related questions/issues raised by staff; escalates to appropriate leader/team when necessary. Recommends and implements process improvement measures to achieve department's performance measures outcomes and goals. Plans and oversees UM activities according to model of care, program description and policy and procedures to provide timely, quality care and services to members. Maintains all assigned reporting responsibilities, conducts regular audits to ensure compliance with community, industry and organizational standards including regulatory requirements. Serves as a super-user on electronic programs and systems used by the department. Assists in the development of programs, workflows, tools, training materials, orientation checklists, and competency checklist necessary to meet educational needs. Trains new staff, remediation of seasoned staff and cross training as needed in specified business lines. Serves as a leader and role model as well as technical and informational resource for staff and peers. Duties Continued Fosters a culture that encourages employee contribution to ensure that the department maintains an environment in which quality flourishes. Services as member/resource/liaison to the Interdisciplinary Care Team. Recommends resources to improve performance standards in terms of Utilization Management. Collaborates with peers and colleagues within the organization to address process improvements, member's needs, department and organizational enhancements and communicate development as appropriate. Participates on internal and external committees as delegated or assigned. Serves as a consultant to other departments or organizations as needed. Responsible for the daily workflow and leading the work of assigned staff. This role will mentor, coach, act as a resource and provide feedback on performance of assigned staff. Performs other duties as assigned. Education Required Associate's Degree in NursingEducation Preferred Bachelor's Degree in NursingExperience Required: Minimum of 7 years of acute/clinical care experience. Minimum of 2 years of experience in Case/Care/Utilization Management in an acute care or health plan setting. Minimum of 3 years leading process, program, or staff or supervisory experience. Equivalency: Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement. Skills Required: Knowledge of state, federal and regulatory requirements in Care/Case/Utilization Management. Strong verbal and written communication skills. Computer literacy with proficiency with Microsoft Word, Excel, etc. and ability to learn core departmental computer systems and software. Excellent organizational, time management, and interpersonal skills. Must be detailed-oriented, energetic, and an enthusiastic team player. Must be able to work independently. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California LicenseLicenses/Certifications Preferred Required Training Physical Requirements LightAdditional Information Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. L.A. Care offers a wide range of benefits including Paid Time Off (PTO) Tuition Reimbursement Retirement Plans Medical, Dental and Vision Wellness Program Volunteer Time Off (VTO)

Utilization Review

Full-time

1 week ago

Utilization Review RN, Case Management/UR, Full Time, Day Shift, Job ID # 1876071

Palmetto General Hospital Miami Lakes, FL

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

Utilization Review

Full-time

1 week ago

RN-Utilization Review/ Denials and Appeal Coordinator

Moffitt Cancer Center Tampa, FL

$85,009.60 - $129,584 / year

Working at Moffitt is both a career and a mission: to contribute to the prevention and cure of cancer. As the only National Cancer Institute-designated Comprehensive Cancer Center based in Florida, Moffitt employs some of the best and brightest minds from around the world. Join a dedicated team of nearly 11,000 who are shaping the future we envision. Moffitt has been recognized as a Best and Brightest Company to Work For in the Nation and is continually named one of the Tampa Bay Times’ Top Workplaces. Summary Works with Case Management leadership to establish quality review standards for discharge planning documentation, utilization review, and the applications of clinical criteria (InterQual). Maintains knowledge of regulatory, appeal, and survey standards. Responsible for overseeing the Case management workflow of concurrent denials for government and managed care appeals. Assures all deadlines are met. Works closely with the Physician Advisor and Case Management leadership as needed. As needed, provide guidance, orientation, and training to Case Management staff regarding hospital policy, regulatory standards, and utilization review criteria. Responsible for keeping staff current on governmental mandates and changes. Job Title: Utilization Review Denials and Appeals Coordinator Minimum Education Level: Bachelor's Degree Minimum Field Of Study Minimum Education Notes: Preferred Education Level: Master's Degree Preferred Field of Study: Nursing or Healthcare Administration Preferred Education Notes Licensure Certification Needed: Yes Minimum Licensure: Registered Nurse (RN) Minimum Licensure (Other) Graduate of an accredited school of nursing required. Current Florida RN Licensure Required. Minimum 5 years clinical experience in an acute care setting required. Minimum 1 year case management/utilization review/denial and appeal experience in an acute care setting required. Must be able to work independently with minimal direction, anticipate and organize workflow, prioritize and follow Through On Responsibilities Training Required: Preferred Licensure: Basic Life Support (BLS)Other (If other, please enter details in section to the right)Other (If other, please enter details in section to the right) Preferred Licensure (Other): CCMACM Salary Range $85,009.60 - $129,584.00 Salary ranges posted for this position represent the expected base pay range for the role. Actual compensation may vary based on location and a variety of job-related factors, including experience, skills, education, and internal equity among Team Members in similar positions. We are committed to maintaining fair and equitable pay practices and regularly review compensation to ensure alignment across our workforce. Moffitt Career Site If you have the vision, passion, and dedication to contribute to our mission, then we have a place for you! Equal Employment Opportunity Moffitt Cancer Center is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, or protected veteran or disabled status. We seek candidates whose skills, and personal and professional experience, have prepared them to contribute to our commitment to diversity and excellence. Reasonable Accommodation Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment. Moffitt endeavors to make moffitt.org/careers accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact one of the Human Resources receptionists by phone at 813-745-7899 or by email at HRReceptionists@moffitt.org. This contact information is for accommodation requests only and cannot be used to inquire about the status of applications. Read more information about your EEO rights under the law. Transparency in Coverage Rule

Utilization Review

Full-time

2 weeks ago

Utilization Review Registered Nurse - 40 hours

MaineGeneral Health Augusta, ME

$39 - $68.25 / hour

Job Summary: MaineGeneral Health is seeking an experienced Utilization Review Registered Nurse (RN) to join our collaborative Utilization Review team. If you’re an RN who enjoys using your clinical expertise to support appropriate patient care, navigate medical necessity and reimbursement, and work collaboratively with a multidisciplinary team, we want to hear from you! Our Utilization Review team is a supportive group that works closely together, sharing knowledge and collaborating on clinical and utilization decisions. This position provides an opportunity to use your nursing experience in a role focused on patient care coordination, utilization management, documentation, and reimbursement. Job Description: What You'll Do: Reviews admissions and service requests within assigned unit for prospective, concurrent, and retrospective medical necessity and/or compliance with reimbursement policy criteria. Assists multidisciplinary teams with issues related to medical records/documentation, pre-certifications, reimbursement and claim denials/appeals. Collaborates to assess and coordinate patient's discharge planning needs with members of the healthcare team. Monitors for delays in care and prepares data to reduce length of stay and maximize reimbursement. What You'll Bring: Current Maine Registered Nurse (RN) license or the ability to obtain Maine licensure in a timely manner. Utilization Review or Care Management experience strongly preferred. Strong clinical assessment, critical thinking, and decision-making skills. Excellent communication and collaboration skills. Ability to work independently while contributing effectively as part of a team. Knowledge of medical necessity, reimbursement guidelines, and clinical documentation preferred. Why MaineGeneral? At MaineGeneral Health, you’ll be part of a team that values collaboration, professional growth, and making a difference in the lives of the patients and communities we serve. We offer competitive benefits, including: Medical, dental, and vision insurance Generous paid time off Retirement plan with employer contribution Tuition assistance and professional development opportunities Employee wellness programs And more! Compensation Information: $39.00 - $68.25 The hourly pay range shown represents the base pay range for this position. Individual pay is determined based on factors such as experience, qualifications, skills, and market considerations. In addition to base pay, eligible team members may earn additional compensation through shift, weekend, holiday, on-call, and other applicable differentials. We are proud to offer a competitive total rewards package designed to recognize our caregivers and support them in delivering exceptional care to the communities we serve. Scheduled Weekly Hours: 40 Job Exempt: No Benefits: Supporting all aspects of our employees’ wellness – physical, emotional and financial – is a critical component of being a great place to work. With the wide range of benefits and programs available, employees have the resources they need to be well at every stage of life and plan for the future. Physical Wellness: We offer quality health, dental, and vision benefits and wellness programs and resources to provide employees access to resources for a healthy lifestyle and help manage health care costs. Employees have access to industry-leading leave for new parents. A generous earned time plan is offered to all employees - We believe employees need and deserve time away from work to observe holidays, be with family, go on vacation, or simply take care of themselves. Emotional Wellness: When life gets challenging, employees have access to our Employee Assistance Program for employees and anyone in their household. Financial Wellness: Access the wages you’ve already earned before payday with Payactiv, giving you greater flexibility over your finances. Tuition Reimbursement is available to all employees to further develop skills and career. We offer eligible employees up to 2% of eligible pay in 403(b) company-matching contributions plus another 2% in the 401(a) retirement income plan. Three insurance plans are available to protect your family from the sudden loss of income in the event of your death, terminal illness or serious injury from accident. We offer both short-term and long-term disability insurance to replace a portion of your income if you become disabled and cannot work for a period of time. Career Mobility: Helping our employees develop their skills and grow their careers is critical to how we retain our talent and sustain our business. We do this by offering our teammates a variety of leadership-supported programs and learning and development resources for every stage of their professional development. We know that our employees are our most valuable resource – they’re how we grow our business and care for our community. Equal Opportunity Employer M/F/Vet/Disability Assistive technologies are available. Application assistance for those requesting reasonable accommodation to the career site is available by contacting HR at (207) 861-3440 .

Utilization Case Manager (Remote)

University of Miami Health System

Current Employees: If you are a current Staff, Faculty or Temporary employee at the University of Miami, please click here to log in to Workday to use the internal application process. To learn how to apply for a faculty or staff position, please review this tip sheet . UMHC-SCCC - Business Operations has an exciting opportunity for a Full time, Remote, Utilization Case Manager position, The incumbent is to complete ongoing reviews for clinical utilization and identifying the need for continued authorization. The Utilization Case Manager coordinates with the Nurse Case Manager as well as the Healthcare team for optimal patient outcomes, while avoiding potential treatment delays and authorization denials. The Utilization Case Manager is accountable for a designated patient caseload and ensures that all necessary criteria for continued authorization remains in place. At all times the case manager provides communication of progress and or determination to the clinical team and or the patient. CORE JOB FUNCTIONS Adhere and perform timely reviews for services requiring an authorization for continuation of care Follows the authorization process using established criteria as set forth by the payer or clinical guidelines Accurate review of coverage benefits and limitations to determine continued appropriateness of services requested Facilitates interdepartmental communication regarding status of continued authorization in advance of patient’s appointment. Maintains effective communication regarding authorization status and determination to the clinical team and on occasion the patient. Identifies potential delays in treatment by reviewing the treatment plan and proactively communicates with the healthcare team and or patient regarding the potential treatment barrier Maintains knowledge regarding payer reimbursement policies and clinical guidelines. Adheres to University and department level policies and procedures and safeguards University assets. This list of duties and responsibilities is not intended to be all-inclusive and may be expanded to include other duties or responsibilities as necessary. CORE QUALIFICATIONS Bachelor’s degree in relevant field; or equivalent Minimum of 2 years of relevant experience The University of Miami offers competitive salaries and a comprehensive benefits package including medical, dental, tuition remission and more. UHealth-University of Miami Health System, South Florida's only university-based health system, provides leading-edge patient care powered by the ground breaking research and medical education at the Miller School of Medicine. As an academic medical center, we are proud to serve South Florida, Latin America and the Caribbean. Our physicians represent more than 100 specialties and sub-specialties, and have more than one million patient encounters each year. Our tradition of excellence has earned worldwide recognition for outstanding teaching, research and patient care. We're the challenge you've been looking for. The University of Miami is an Equal Opportunity Employer. Applicants and employees are protected from discrimination based on certain categories protected by Federal law. Job Status: Full time Employee Type: Staff

Utilization Review

Full-time

2 weeks ago

Utilization Review Nurse

Albany Medical Center Albany, NY

$77,075 - $119,466 / year

Department/Unit: Care Management/Social Work Work Shift: Day (United States of America) Salary Range: $77,075.00 - $119,466.00 Responsible for Utilization Management, Quality Screening and Delay Management for assigned patients. Qualifications and Ideal Characteristics 1. Registered nurse with a New York State current license. 2. Associate's degree required. Bachelor's degree preferred. 3. Minimum of three years clinical experience in an assigned service. 4. Recent experience in case management, utilization management and/or discharge planning/home care in a high volume, acute care hospital preferred. PRI and Case Management certification preferred. 5. Assertive and creative in problem solving, critical thinking skills, systems planning and patient care management. 6. Self-directed with the ability to adapt in a changing environment. 7. Basic knowledge of computer systems with skills applicable to utilization review process. 8. Excellent written and verbal communication skills. 9. Working knowledge of MCG criteria and ability to implement and utilize. 10. Understanding of Inpatient versus Outpatient surgery and ICD10-Coding (preferred) and Observation status qualifications. 11. Ability to work independently and demonstrate organizational and time management skills. 12. Strong analytic, data management and PC skills. 13. Working knowledge of Medicare regulatory requirements, Managed Care Plans Principal Position Responsibilities A. Mission, Core Values and Service Excellence 1. Contributes to the creation of a compassionate and caring environment for patients, families, and colleagues through displays of kindness and active listening. Recognizes and appreciates that each employee’s work is valuable and contributes to the success of the Mission. 2. Demonstrates excellence in daily work. Willing to actively participate in performance and quality improvement activities and to work towards enhancing customer/patient satisfaction. 3. Exhibits positive service excellence skills to patients, visitors, and coworkers by greeting others in a friendly manner, keeping customers/patients/colleagues informed about progress, delays, and changes. 4. Demonstrates effective teamwork by interacting in a positive manner with colleagues and creating a collaborative work environment. Initiates open communication, conveys positive intent, offers assistance. 5. Contributes to a safe and secure environment for patients, visitors, colleagues by following established procedures and protocols. 6. Demonstrates stewardship by thoughtful and responsible use of resources including maintaining a clean and hospitable environment, starting work on time, displaying a consciousness regarding costs, supplies and department finances. 7. Demonstrates respect for individual differences of each person by acknowledging the essence of each person, appreciating, and responding to unique, spiritual, personal, and cultural backgrounds of patients, families, and colleagues. B. Utilization Management 1. Completes Utilization Management and Quality Screening for assigned patients. 2. Applies MCG criteria to monitor appropriateness of admissions and continued stays, and documents findings based on Departmental standards. 3. While performing utilization review identifies areas for clinical documentation improvement and contacts appropriate department. 4. Identifies at-risk populations using approved screening tool and follows established reporting procedures. 5. Monitors LOS and ancillary resource use on an ongoing basis. Takes actions to achieve continuous improvement in both areas. 6. Refers cases and issues to Medical Director and Triad Team in compliance with Department procedures and follows up as indicated. 7. Communicates covered day reimbursement certification for assigned patients. Discusses payor criteria and issues and a case-by-case basis with clinical staff and follows up to resolve problems with payors as needed. 8. Uses quality screens to identify potential issues and forwards information to the Quality Department. 9. Demonstrates proper use of MCG and documentation requirements through case review and inter-rater reliability studies. 10. Delay Management 11. Facilitates removal of delays and documents delays when they exist. Reports internal and external delays to the Triad Team. 12. Collaborates with the health care team and appropriate department in the management of care across the continuum of care by assuring communication with Triad Team and health care team. 13. Maintains complete confidentiality of patient information, in addition to hospital and individual physician practice pattern data. Provides information and inservices as necessary to physicians and ancillary staff. Primary Age Groups Served ___ Infant (0-12 months) ___ Preschool (1-4 yrs) ___ School age (5-12 yrs) ___ Adolescent (13-17 yrs) ___ Adult (18-64 yrs) ___ Older Adult (65 + yrs) Physical Demands : The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to stand, walk, use hands to probe, handle, or feel objects, tools, or controls, reach with hands and arms, and speak and hear. The employee is occasionally required to sit and stoop, kneel, or crouch. The employee must regularly lift and/or move up to 50 pounds. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception, and the ability to adjust focus. Work Environment : The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. While performing the duties of this job, the employee may be subject to infectious materials and chemicals (see unit specific MSDS information). The noise level in the work environment is usually moderate. This job requires as an essential function that the majority of the time the employee be physically on-site as the work cannot be done from a remote location. Other Requirements : All job requirements listed indicate the minimum level of knowledge, skills, and/or ability deemed necessary to perform the job proficiently. This job description is not to be construed as an exhaustive statement of duties, responsibilities, or requirements. Employees will be required to perform any other job-related instructions given by their supervisor subject to reasonable accommodations. Thank you for your interest in Albany Med Health System! Albany Med Health System is an equal opportunity employer. This role may require access to information considered sensitive to Albany Med Health System, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that: Access to information is based on a “need to know” and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Med Health System policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification.

Utilization Review Nurse Jobs Overview

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.

If you’re in search of utilization review nurse jobs or other non-bedside nurse jobs, you’ve come to the right place. Start looking for full-time, part-time, remote, contract, temporary, or per diem positions on Credenza today. Some of the more in-demand roles include:

Utilization Review Nurse Job Locations

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)
Health Care Quality and Management (HCQM)
Certified Case Manager (CCM)
Accredited Case Manager (ACM)

Utilization Review Nurse Resume and Cover Letter

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.

Utilization Review Nurse Salary

The average annual salary for a UR nurse is around $92,000 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 Credenza.

Ready to Find Utilization Review Nurse Jobs?

Check out all the positions available right now. Want additional options? Credenza can match you with even more nursing jobs that interest you.