Utilization Review Nurse Jobs

LPN Utilization Review Full-time
CVS Health

Utilization Management - LPN

CVS Health
$22.40 - $48.67 / hour
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary Utilizes clinical skills to support the coordination, documentation and communication of medical services and benefit administration determinations. Leverages Licensed Practical Nurse and Licensed Vocational Nurse (LPN/LVN) licenses and experience to ensure sound medical care, chart documentation, and patient follow-up. Required Qualifications Licensed Practical Nurse Basic awareness of problem solving and decision making skills. Basic awareness of digital literacy skills. Basic knowledge of medical terminology. Ability to deal tactfully with customers and community. Ability to handle sensitive information ethically and responsibly. Ability to consider the relative costs and benefits of potential actions to choose the most appropriate option. Ability to function in clinical setting with diverse cultural dynamics of clinical staff and patients. Preferred Qualifications Bachelor's degree preferred Specialized training/relevant professional qualification Education Bachelor's degree preferred/specialized training/relevant professional qualification. Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $22.40 - $48.67 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan . No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 04/03/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
RN Utilization Review Full-time
CVS Health

Utilization Management Nurse Consultant - Open to residents in Pacific Standard Time Zone

CVS Health NV
$29.10 - $62.32 / hour
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Must Reside in PST Time Zone Position Summary Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours. This is a full-time, remote role. Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care. Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs. Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization. Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function. Typical office working environment with productivity and quality expectations. Work requires the ability to perform close inspection of handwritten and computer generated documents as well as a PC monitor. Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer. Ability to multitask, prioritize and effectively adapt to a fast-paced changing environment. Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding. Effective communication skills, both verbal and written. Required Qualifications Must reside in Pacific Standard Time Zone 2+ years of experience as a Registered Nurse in adult acute care/critical care setting. Must have active current and unrestricted RN licensure in state of residence. Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours. Preferred Qualifications 2+ years of clinical experience required in med surg or specialty area. Managed Care experience preferred, especially Utilization Management. Preference for those residing in PST zones. Education Associates Degree required BSN preferred Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $29.10 - $62.32 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan . No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 04/30/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
RN Utilization Review NICU Full-time
Centene

NICU RN Clinical Review Nurse Concurrent Review

Centene Los Angeles, CA
$27.02 - $48.55 / hour
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. ****NOTE: This is a fully remote role with a focus on NICU services. Preference will be given to applicants (1) with active compact nursing licensure, (2) experience in neonatal intensive care unit (NICU), and (3) willingness to work eastern time zone schedule. Additional Details: • Department: PHCO UM NICU • Business Unit: Corporate • Schedule: Monday-Friday 8 am - 5pm ET with rotating weekends (Saturday, Sunday) and holidays **** Position Purpose: Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member. Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines Reviews member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities Collaborates with care management on referral of members as appropriate Performs other duties as assigned Complies with all policies and standards Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience. 2+ years of acute care experience required. Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. License/Certification: LPN - Licensed Practical Nurse - State Licensure required For Health Net of California: RN license required Pay Range: $27.02 - $48.55 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
RN Utilization Review NICU Full-time
Centene

NICU RN - Clinical Review Nurse - Concurrent Review

Centene Los Angeles, CA
$27.02 - $48.55 / hour
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. ****NOTE: This is a fully remote role with a focus on NICU services. Preference will be given to applicants (1) with active compact nursing licensure, (2) experience in neonatal intensive care unit (NICU), and (3) willingness to work eastern time zone schedule. Additional Details: • Department: PHCO UM NICU • Business Unit: Corporate • Schedule: Monday-Friday 8 am - 5pm ET with rotating weekends (Saturday, Sunday) and holidays **** Position Purpose: Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member. Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines Reviews member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities Collaborates with care management on referral of members as appropriate Performs other duties as assigned Complies with all policies and standards Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience. 2+ years of acute care experience required. Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. License/Certification: LPN - Licensed Practical Nurse - State Licensure required For Health Net of California: RN license required Pay Range: $27.02 - $48.55 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
RN Utilization Review Full-time
CVS Health

Utilization Management Nurse Consultant - Fully Remote

CVS Health
$26.01 - $74.78 / hour
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary CVS Health Aetna has an opportunity for a full-time Utilization Management (UM) Nurse Consultant. As a Utilization Management Nurse Consultant, you will utilize clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. You would be responsible for ensuring the member is receiving the appropriate care at the appropriate time and at the appropriate location, while adhering to federal and state regulated turn-around times. This includes reviewing written clinical records. Key Responsibilities of the UM Nurse Consultant (Includes but is not limited to) Reviews services to assure medical necessity, applies clinical expertise to assure appropriate benefit utilization, facilitates safe and efficient discharge planning and works closely with facilities and providers to meet the complex needs of the member. Facilitate the delivery of appropriate benefits and/or healthcare information which determines eligibility for benefits while promoting wellness activities. Develops, implements and supports Health Strategies, tactics, policies and programs that ensure the delivery of benefits and to establish overall member wellness and successful and timely return to work. Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure, and clinical judgment to render coverage determination/recommendation along the continuum of care. Communicates with providers and other parties to facilitate care/treatment. Identifies members for referral opportunities to integrate with other products, services and/or programs. Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization. Required Qualifications Registered Nurse (RN) with current unrestricted US licensure in their state of residence is required. 2+ years clinical practice experience as an RN required. 2+ Years Utilization Management experience. Must be willing to travel to the local office as needed if living within approximately 45 minutes/miles. Preferred Qualifications Bilingual proficiency preferred. 1+ year(s) experience utilizing multiple computer systems and applications including Microsoft Word, Excel, Outlook, and web-based applications. Education Associate’s degree in Nursing required. BSN preferred. Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $26.01 - $74.78 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan . No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 04/03/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
RN Utilization Review Full-time
Centene

Clinical Review Nurse - Correspondence

Centene MI
$27.02 - $48.55 / hour
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. Position Purpose: Drafts correspondence letters based on review outcomes in accordance with National Committee for Quality Assurance (NCQA) standards. Works with senior management to identify and implement opportunities for improvement. Performs clinical review of outcomes including creating and editing denial letters with the correspondence team based on denial determinations in accordance with National Committee for Quality Assurance (NCQA) standards Contributes to correspondence letter template creation and maintenance with the correspondence team Investigates denials through comprehensive review of clinical documentation, clinical criteria/guidelines, and policy, including insurance rejections due to coding issues and provides supplemental information to resolve denial claims Assists with issues and/or questions related to correspondence with the state, local, and federal agencies including third party payer to ensure issues are resolved in a timely manner Maintains and monitors cases to ensure timely resolution and logs of actions and/or decisions are appropriately documented Coordinates with interdepartmental teams on training needed within the utilization management team based on trends Provides feedback to leadership to improve clinical processes and procedures to prevent recurrences based on industry best practices Performs other duties as assigned Complies with all policies and standards This is a remote position. Candidates must reside in the Central or Eastern time zones. Work Schedule: Monday through Friday 10:00 AM – 6:30 PM CST or 11:00 AM – 7:30 PM EST The ideal candidate will have prior experience in prior authorization, concurrent review, or utilization review . Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. License/Certification: LPN - Licensed Practical Nurse - State Licensure required and Pay Range: $27.02 - $48.55 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
RN Utilization Review NICU Full-time
Centene

NICU Clinical Review Nurse - Concurrent Review

Centene OK
$27.02 - $48.55 / hour
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. Remote Role : Seeking RN with NICU experience. Must reside in Oklahoma. Hours: Monday-Friday, 8AM to 5PM Position Purpose: Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member. Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines Reviews member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities Collaborates with care management on referral of members as appropriate Performs other duties as assigned. Complies with all policies and standards. Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience. 2+ years of acute care experience required. Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. License/Certification: RN - Registered Nurse - State Licensure and/or Compact State Licensure Pay Range: $27.02 - $48.55 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
RN Utilization Review Full-time
Mohawk Valley Health System

RN - Case Manager - Utilization Review - Full Time - Days

Mohawk Valley Health System Utica, NY
$40.19 - $56.51 / hour
Job Summary The RN - Utilization Management gathers clinical information to determine appropriateness of admission, continued stay, medical necessity, and appropriateness of patient status throughout a patient’s hospital stay. Efficiently processes payer authorization requests to obtain certification from insurance or payers. Collaborates with care managers, providers, discharge planners and other care team members. Core Job Responsibilities Complete initial admission reviews within 24 hours of admission, including reviews for those that were admitted during hours without an access nurse on duty. Ensure the appropriate level of patient care by utilizing expert level of clinical decision making, standard level of care criteria, commercial payor criteria, and attending physician communication and input. Consult with Physician Advisor for the cases not meeting criteria. Ensure that Physician Advisor Medical Necessity documentation is placed on the medical record and is available to the Attending Physician. Coordinate peer to peer telephone calls between insurance representatives/payers and attending physicians or physician advisors as needed to appeal concurrent UR denials. Complete daily utilization review of all observation/outpatient/in-bed patients. Collaborate with Care Manager to determine discharge plan is within observation parameters. Communicate with physicians regarding observation length of stay and plan of care. Assist with ensuring that any status (class) order changes are documented, timed and dated in medical record and are accurate in EPIC. Consult Care Managers for admissions which meet re-admission criteria. Complete Continued Stay reviews on Medicare/Medicaid/Medicare HMO, VA, Hospice, and Self-pay patients. Provide support and/or coverage to the Managed Care Reviewer for commercial UR and continued stay requests. Maintain appropriate computer databases and apply appropriate tools for utilization review. Perform related duties as assigned. Education/Experience Requirements REQUIRED: Graduate of an accredited school of nursing program 3-5 years of applied clinical experience as a RN. 1 year of experience in Hospital Case Management. Knowledge and experience with Care Guidelines, Medical Necessity Criteria and/or other UM criteria sets. Ability to assess medical records and make determinations on length of stay and proper procedures. Knowledge of documentation and billing practices, ability to identify billing problems and research issues at hand. Excellent interpersonal, verbal and written communication skills. Proficient with MS Office (Excel) and Epic EMR. PREFERRED: BSN Licensure/Certification Requirements REQUIRED: NYS License as a Registered Nurse. Disclaimer Qualified applicants will receive consideration for employment without regard to their age, race, religion, national origin, ethnicity, age, gender (including pregnancy, childbirth, et al), sexual orientation, gender identity or expression, protected veteran status, or disability. Successful candidates might be required to undergo a background verification with an external vendor. Job Details Req Id 97475 Department CASE MGMT Shift Days Shift Hours Worked 9.50 FTE 0.93 Work Schedule NYSNA - 9.5 x 4 Employee Status A1 - Full-Time Union 2004 - NYSNA Pay Range $40.19 - $56.51/Hourly
RN Utilization Review Full-time
MaineGeneral Health

Utilization Review Registered Nurse (RN) - 40 hrs/wk, Days

MaineGeneral Health Augusta, ME
Job Summary: MaineGeneral Health is seeking an experienced Utilization Review Registered Nurse (RN) to join our collaborative team. In this role, you will evaluate the medical necessity and appropriateness of patient care, ensuring alignment with clinical guidelines and payer requirements while supporting efficient, high-quality outcomes. If you have a passion for service excellence and enjoy working closely with interdisciplinary teams to optimize patient care and resource utilization, we want to hear from you! Job Description: Position: Utilization Review Registered Nurse (RN) Location: Alfond Center for Health, Augusta Schedule: Full-time (40 hours/week) Shift: Days (8-4:30) Monday - Friday 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 patients' 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 Bring: Active State of Maine Registered Nurse (RN) license, or ability to obtain promptly (required) Prior experience in Utilization Review, Case Management, or Care Coordination (strongly preferred) Strong critical thinking, communication, and organizational skills Ability to work independently while collaborating effectively across teams Why Join MaineGeneral Health: Collaborative, team-focused work environment Meaningful impact on patient outcomes and care efficiency Flexible scheduling within a weekday-only schedule A health system committed to excellence, compassion, and community Scheduled Weekly Hours: 40 Scheduled Work Shift: Day (United States of America) 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. Loan Reimbursement is available for this position dependent upon current degree level. Please discuss benefit with the recruiter. 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 are 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 .
RN Psych Utilization Review Full-time
CareSource

Clinical Care Reviewer II - Multi State License - RN - Behavioral Health

CareSource
$62,700 - $100,400 / year
Job Summary: Clinical Care Reviewer II – Behavioral Health is responsible for processing medical necessity reviews for appropriateness of authorization for behavioral health care services, assisting with discharge planning activities (i.e. outpatient services, home health services) and care coordination for members. Essential Functions: Complete prospective, concurrent and retrospective review of Behavioral Health services Identify, document, communication and coordinate care engaging collaborative care partners to facilitation transition to an appropriate level of care Engage with medical director when additional clinical expertise if needed Maintain knowledge of state and federal regulations, including State Contracts and Provider Agreements, benefits, and accreditation standards Identify and refer quality issues to Quality Improvement Identify and refer appropriate members for Care Management Provide guidance to non-clinical staff Provide guidance and support to LPN staff Attend medical advisement and State Hearing meetings, as requested Assist Team Leader with special projects or research, as requested Perform any other job related duties as requested. Education and Experience: Associates of Science (A.S) in Nursing required or Bachelor of Science (B.S) in Social Work required Three (3) years clinical experience required Utilization Management/Utilization Review experience preferred Medicaid/Medicare/Commercial experience preferred Competencies, Knowledge and Skills: Proficient data entry skills and ability to navigate clinical platforms successfully Working knowledge of Microsoft Outlook, Word, and Excel Effective oral and written communication skills Ability to work independently and within a team environment Attention to detail Proper grammar usage and phone etiquette Time management and prioritization skills Customer service oriented Decision making/problem solving skills Strong organizational skills Change resiliency Licensure and Certification: Current, unrestricted Registered Nurse (RN) Licensure or Licensed Social Worker (LSW) required MCG Certification is required or must be obtained within six (6) months of hire required Working Conditions: General office environment; may be required to sit or stand for extended periods of time Travel is not typically required Compensation Range: $62,700.00 - $100,400.00 CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package. Compensation Type (hourly/salary): Hourly Organization Level Competencies Fostering a Collaborative Workplace Culture Cultivate Partnerships Develop Self and Others Drive Execution Influence Others Pursue Personal Excellence Understand the Business This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds. #LI-JM1
RN Utilization Review Full-time
UCHealth

Utilization Management RN

UCHealth Aurora, CO
$38.91 - $60.31 / hour
Description Location: UCHealth UCHlth Admin 2450 Peoria, US:CO:Aurora Department: UCHlth Patient Line Referrals Work Schedule: Full Time, 64.00 hours per pay period (2 weeks) Shift: Days Pay: $38.91 - $60.31 / hour. Pay is dependent on applicant's relevant experience Summary: Ensures that services are delivered and documented in a manner that balances quality of care with efficiency, cost-containment and compliance. Responsibilities: Reviews admissions and service requests within assigned unit for prospective, concurrent, and retrospective medical necessity and/or compliance with reimbursement policy criteria. Provides case management and/or consultation for complex cases. Assists departmental staff with issues related to Milliman (or similar) guidelines, status determination, medical records/documentation, precertification, reimbursement and concurrent denials appeals. Collaborates closely with case managers to make sure status’ and level of care is accurate. Communicates with payers as needed to ensure patient accounts are secured. Assesses and coordinates patient's discharge planning needs with members of the healthcare team. Within scope of job, requires critical thinking skills, decisive judgement and the ability to work with minimal supervision. Must be able to work in a fast-paced environment and take appropriate action. Requirements: Registered NurseBachelor's degree in Nursing. State licensure as a Registered Nurse (RN). 3 years of relevant experience. Preferred: 3 years of utilization or case management experience. BLS through the American Heart Association or the American Red Cross CPR for the Professional Rescuer with card in-hand before start date. BLS or CPR card must be good through sixty days of hire. Employees are our number one asset. UCHealth promotes a culture that invests in professional success and personal well-being through a comprehensive total rewards program. * Recognition Performance bonus: UCHealth offers a 3-Year Incentive Bonus to recognize employee contributions to our success in quality, patient experience, organizational growth, financial goals and tenure. The bonus accumulates annually each October and is paid out in October during the third year of employment. Performance-based pay increase: The Annual Merit Pay Increase recognizes work performance that meets or consistently exceeds performance standards documented through UCHealth's established evaluation process and accounts for increased experience, skills and cost of living. Market reviews: All UCHealth positions are reviewed annually to ensure UCHealth base pay aligns with market standards. Base pay rates are adjusted as needed to stay market competitive. Health and well-being Medical, dental and vision coverage. Access to 24/7 mental health and well-being support for employees and dependents. Discounted gym memberships and fitness resources. Free Care.com membership. Voluntary benefits such as accident insurance, critical illness insurance, group legal plan, identity theft protection, pet insurance, auto and home insurance, and employee discount programs. Time away from work: Paid time off (PTO), paid family and medical leave (inclusive of Colorado FAMLI), leaves of absence. New employees receive an initial PTO load with first paycheck. Employer-provided basic life and accidental death and dismemberment coverage with buy-up coverage options. Employer-provided short-term disability and long-term disability with a buy-up coverage option. Retirement and savings 403(b) plan with employer matching contribution. Additional 457(b) plan may be available. Flexible spending accounts for health care and dependent day care; health savings account available when enrolled in high-deductible (HD) medical plan. Education and career growth UCHealth provides access to academic degrees and certificate programs to promote professional and personal growth. Up to 100% of tuition, books and fees paid for by UCHealth for specific educational degrees. Other programs may qualify for up to $10,000/year pre-paid by UCHealth or up to $5,250/year in the form of tuition reimbursement. Access to LinkedIn Learning, which offers thousands of virtual courses and seminars, and internal professional development opportunities. Employees have access to free assistance navigating the Public Service Loan Forgiveness program and submitting their federal student loans for forgiveness. * Eligibility for some programs is based on an employee's scheduled work hours. We improve lives. In big ways through learning, healing, and discovery. In small, personal ways through human connection. But in all ways, we improve lives. UCHealth always welcomes talent. This position will be open for a minimum of three days and until a top applicant is identified. UCHealth recognizes and appreciates the rich array of talents and perspectives that equal employment and diversity can offer our institution. As an equal opportunity employer, UCHealth is committed to making all employment decisions based on valid requirements. No applicant shall be discriminated against in any terms, conditions or privileges of employment or otherwise be discriminated against because of the individual's race, color, national origin, language, culture, ethnicity, age, religion, sex, disability, sexual orientation, gender, veteran status, socioeconomic status, or any other characteristic prohibited by federal, state, or local law. UCHealth does not discriminate against any qualified applicant with a disability as defined under the Americans with Disabilities Act and will make reasonable accommodations, when the do not impose an undue hardship on the organization. Who We Are (uchealth.org) AF123
RN Utilization Review Full-time
Molina Healthcare

Care Review Clinician (RN)

Molina Healthcare Long Beach, CA
$27.73 - $54.06 / hour
JOB DESCRIPTION Job SummaryProvides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines. • Analyzes clinical service requests from members or providers against evidence based clinical guidelines. • Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. • Conducts reviews to determine prior authorization/financial responsibility for Molina and its members. • Processes requests within required timelines. • Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner. • Requests additional information from members or providers as needed. • Makes appropriate referrals to other clinical programs. • Collaborates with multidisciplinary teams to promote the Molina care model. • Adheres to utilization management (UM) policies and procedures. Required Qualifications • At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience. • Registered Nurse (RN). License must be active and unrestricted in state of practice. • Ability to prioritize and manage multiple deadlines. • Excellent organizational, problem-solving and critical-thinking skills. • Strong written and verbal communication skills. • Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications • Certified Professional in Healthcare Management (CPHM). • Recent hospital experience in an intensive care unit (ICU) or emergency room. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $27.73 - $54.06 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
RN Utilization Review Full-time
Molina Healthcare

Care Review Clinician (RN)

Molina Healthcare Long Beach, CA
$27.73 - $54.06 / hour
JOB DESCRIPTION Job SummaryProvides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines. • Analyzes clinical service requests from members or providers against evidence based clinical guidelines. • Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. • Conducts reviews to determine prior authorization/financial responsibility for Molina and its members. • Processes requests within required timelines. • Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner. • Requests additional information from members or providers as needed. • Makes appropriate referrals to other clinical programs. • Collaborates with multidisciplinary teams to promote the Molina care model. • Adheres to utilization management (UM) policies and procedures. Required Qualifications • At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience. • Registered Nurse (RN). License must be active and unrestricted in state of practice. • Ability to prioritize and manage multiple deadlines. • Excellent organizational, problem-solving and critical-thinking skills. • Strong written and verbal communication skills. • Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications • Certified Professional in Healthcare Management (CPHM). • Recent hospital experience in an intensive care unit (ICU) or emergency room. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $27.73 - $54.06 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
RN Utilization Review Full-time
CVS Health

Utilization Management Nurse Consultant (Weekend)

CVS Health PA
$29.10 - $62.32 / hour
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary This is a fulltime remote Utilization Review opportunity. Working hours are four 10hr days including every Weekend , both Saturday and Sunday, and two weekday shifts of 10hrs each (to be determined). Also includes holiday and late rotations. 12.5% Shift Premium applies once M-F training schedule completed and UMNC participating in non-traditional, weekend shift rotation. Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care. Communicates with providers and other parties to facilitate care/treatment. Identifies members for referral opportunities to integrate with other products, services and/or benefit programs. Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization. Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function. UMNC meets set productivity and quality expectations. Effective communication skills, both verbal and written Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding. Ability to multitask, prioritize and effectively adapt to a fast-paced changing environment. Work requires sitting for extended periods, talking on the telephone and typing on the computer. Work from home position: During work hours, Colleagues who are working from home must be available by phone, videoconference, and email in a manner and frequency that is required by the Colleague's Leader. Colleagues must be available from time to time to come into the office or client location on a given day for work-related meetings, training sessions or other events, as directed by their Leader. Required Qualifications Active and unrestricted Registered Nurse in state of residence 3+ years of experience as a Registered Nurse 1+ years of clinical experience in acute setting (ex: ER, triage, ICU, Med/Surg) Willing and able to work four 10hr days including every Weekend, both Saturday and Sunday, and two weekday shifts of 10hrs each (to be determined), also includes Holiday and late rotations. 12.5% Shift Premium applies once M-F training schedule completed and UMNC participating in non-traditional, weekend shift rotation Preferred Qualifications Utilization review experience Experience with LTAC, skilled rehab, or home health Managed Care experience Education Minimum Diploma RN acceptable or Associate degree in Nursing required BSN preferred Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $29.10 - $62.32 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan . No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 04/07/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
RN Manager/Supervisor Psych Utilization Review Full-time
Humana

Manager, Utilization Management Behavioral Health Nursing

Humana OK
$94,900 - $130,500 / year
Become a part of our caring community The Manager, Utilization Management Behavioral Health Nursing utilizes clinical nursing skills to support the coordination, documentation and communication of behavioral health services and/or benefit administration determinations. The Manager, Utilization Management Behavioral Health Nursing works within specific guidelines and procedures; applies advanced technical knowledge to solve moderately complex problems; receives assignments in the form of objectives and determines approach, resources, schedules and goals. The Manager, Utilization Management Behavioral Health Nursing uses clinical knowledge, communication skills, and independent critical thinking skills towards interpreting criteria, policies, and procedures to provide the best and most appropriate treatment, care or services for members. Coordinates and communicates with providers, members, or other parties to facilitate optimal care and treatment. Nursing license is required. Decisions are typically related to resources, approach, and tactical operations for projects and initiatives involving own departmental area. Requires cross departmental collaboration, andconducts briefings and area meetings; maintains frequent contact with other managers across the department. Use your skills to make an impact Required Qualifications Must reside in the state of Oklahoma Registered Nurse or LPC or LMFT or LMSW is required Minimum 2 years of Utilization Management or case management experience Previous Leadership or management experience, to include leading people/teams in UM practices Preferred Qualifications Advanced degree in nursing, healthcare, or business CMS criteria WAH Internet Statement To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. Satellite, cellular and microwave connection can be used only if approved by leadership. Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense. Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information. HireVue As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule. SSN Alert Humana values personal identity protection. Please be aware that applicants may be asked to provide their Social Security Number, if it is not already on file. When required, an email will be sent from Humana@myworkday.com with instructions on how to add the information into your official application on Humana’s secure website. Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. Scheduled Weekly Hours 40 Pay Range The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc. $94,900 - $130,500 per year This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance. Description of Benefits Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities. About us About Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer at Humana.com and at CenterWell.com. ​ Equal Opportunity Employer It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.
RN Utilization Review Part-time
St. Peter's Health Partners

RN Utilization Management - Per diem

St. Peter's Health Partners Albany, NY
$38 - $50.18 / hour
Employment Type: Part time Shift: Day Shift Description: Samaritan Hospital in Troy, NY is looking for an experienced RN to work as a Registered Professional Utilization Management Nurse (UMRN). Shift: 8 hrs The team is willing to help train the right candidate as long as they meet the minimum requirements and have the desire and ability to learn and grow into this wonderful opportunity to progress in their nursing career. We at St. Peter’s Health Partners recognize that nursing is one of the most challenging careers and the most rewarding. We work with nurses to ensure that their professional experiences meet the expectations they had when they chose nursing. We recognize the crucial role you play in the care of every patient treated and we have worked hard to ensure that you find the professional culture, the career support, medical resources and the career opportunities you’re seeking. St. Peter’s Hospital is a member of Trinity Health. Trinity Health employs more than 120,000 colleagues at dozens of hospitals and hundreds of health centers in 21 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions. The selected candidate will : Be responsible for the utilization management, both concurrent and retroactive for inpatient and outpatient services in accordance with the utilization program which meets the requirements of JCAHO and third party payor contracts. Be responsible for the length of stay and level of care to provide effective and efficient health care services that best serve the needs of the patient. Work within and contribute to an environment where the mission is actualized, patient focused outcomes are achieved and high quality professional practice is realized. Minimum requirements: Current and valid NYS RN license Bachelor of Science in nursing, or willingness to purse defined plan for matriculation in program demonstrated by ongoing course work each semester BLS certification 2 years of experience in acute setting or one year in community health Must have some week day availability to orient Preferred requirements: Discharge planning and community resource knowledge Basic knowledge of the utilization management process Working knowledge of recognized industry clinical standards, i.e. Interqual, Milliman Care Guidelines. Maintain the highest level of customer service while completing day to day duties and responsibilities Critical thinking skills to problem solve Excellent time management and organizational skills High level of efficiency to communicate in a fast pace work environment Engage within a team setting to help promote a strong team culture Passion to learn, grow and develop in the nursing field Pay Range: $38.00hr-$50.18hr Pay is based on experience, skills, and education. Exempt positions under the Fair Labor Standards Act (FLSA) will be paid within the base salary equivalent of the stated hourly rates. The pay range may also vary within the stated range based on location. Our Commitment Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.
RN Utilization Review Full-time
UF Health

RN, Utilization Management | Utilization Management

UF Health Lady Lake, FL
Overview Plays a critical role in evaluating patient medical records to ensure the necessity and appropriateness of healthcare services. Involves coordinating with healthcare providers to maintain compliance with utilization management guidelines and optimizing treatment plans for effective patient care and resource utilization. Requires clear communication of authorization decisions and ongoing monitoring to support timely discharge planning. Analyzes utilization data to identify trends and collaborates with interdisciplinary teams to enhance care coordination while ensuring accurate documentation and regulatory compliance. Responsibilities Key Responsibilities Evaluates patient medical records to ensure the necessity and appropriateness of healthcare services. Coordinates with healthcare providers to ensure compliance with utilization management guidelines. Supports the optimization of treatment plans to promote effective patient care and appropriate resource utilization. Communicates authorization decisions clearly and supports timely discharge planning. Analyzes utilization data to identify trends and opportunities to improve care coordination. Collaborates with interdisciplinary teams to ensure accurate documentation and regulatory compliance. Qualifications Education & Experience: Registered Nurse (RN) with a current Florida license required. Three (3) years of critical care nursing experience, or Five (5) years of medical-surgical nursing experience, or Three (3) years of utilization review, case management, or third-party payer experience. Qualifications Active Registered Nurse (RN) license with 3+ years of experience in utilization review or case management. Strong knowledge of healthcare utilization management guidelines and regulatory compliance. Experience evaluating medical necessity and optimizing treatment plans. Excellent communication skills with the ability to clearly convey authorization decisions. Ability to analyze utilization data and support effective care coordination. Strong organizational skills with the ability to manage multiple priorities simultaneously. Ability to work independently and collaboratively with multidisciplinary teams. Strong attention to detail and innovative problem-solving skills. Flexibility to adjust work hours and days based on departmental needs. Motor Vehicle Operator Designation: Employees in this position will not operate vehicles for an assigned business purpose. Note: Please indicate the appropriate operator designation on the Request for Personnel (RFP) form at the time of submission. Licensure/Certification/Registration: Registered Nurse (RN) with a current Florida license required.
RN Utilization Review Full-time
CareSource

Clinical Care Reviewer II - RN - Multistate License

CareSource Dayton, OH
$62,700 - $100,400 / hour
Job Summary: Clinical Care Reviewer II is responsible for processing medical necessity reviews for appropriateness of authorization for health care services, assisting with discharge planning activities (i.e. DME, home health services) and care coordination for members, as well as monitoring the delivery of healthcare services. Essential Functions: Complete prospective, concurrent and retrospective review such as acute inpatient admissions, post-acute admissions, elective inpatient admissions, outpatient procedures, homecare services and durable medical equipment Identify, document, communicate, and coordinate care, engaging collaborative care partners to facilitate transitions to an appropriate level of care Engage with medical director when additional clinical expertise if needed Maintain knowledge of state and federal regulations governing CareSource, State Contracts and Provider Agreements, benefits, and accreditation standards Identify and refer quality issues to Quality Improvement Identify and refer appropriate members for Care Management Provide guidance to non-clinical staff Provide guidance and support to LPN clinical staff as appropriate Attend medical advisement and State Hearing meetings, as requested Assist Team Leader with special projects or research, as requested Perform any other job related duties as requested. Education and Experience: Associates of Science (A.S) Completion of an accredited registered nursing (RN) degree program required Three (3) years clinical experience required Med/surgical, emergency acute clinical care or home health experience preferred Utilization Management/Utilization Review experience preferred Medicaid/Medicare/Commercial experience preferred Competencies, Knowledge and Skills: Proficient data entry skills and ability to navigate clinical platforms successfully Working knowledge of Microsoft Outlook, Word, and Excel Effective oral and written communication skills Ability to work independently and within a team environment Attention to detail Proper grammar usage and phone etiquette Time management and prioritization skills Customer service oriented Decision making/problem solving skills Strong organizational skills Change resiliency Licensure and Certification: Current, unrestricted Registered Nurse (RN) Licensure in state(s) of practice required MCG Certification or must be obtained within six (6) months of hire required Working Conditions: General office environment; may be required to sit or stand for extended periods of time Travel is not typically required Compensation Range: $62,700.00 - $100,400.00 CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package. Compensation Type (hourly/salary): Hourly Organization Level Competencies Fostering a Collaborative Workplace Culture Cultivate Partnerships Develop Self and Others Drive Execution Influence Others Pursue Personal Excellence Understand the Business This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds. #LI-JM1
RN Utilization Review Full-time
CareSource

Clinical Care Reviewer II - Nevada Licensed - RN - PST Hours

CareSource
$62,700 - $100,400 / hour
Job Summary: Clinical Care Reviewer II is responsible for processing medical necessity reviews for appropriateness of authorization for health care services, assisting with discharge planning activities (i.e. DME, home health services) and care coordination for members, as well as monitoring the delivery of healthcare services. Essential Functions: Complete prospective, concurrent and retrospective review such as acute inpatient admissions, post-acute admissions, elective inpatient admissions, outpatient procedures, homecare services and durable medical equipment Identify, document, communicate, and coordinate care, engaging collaborative care partners to facilitate transitions to an appropriate level of care Engage with medical director when additional clinical expertise if needed Maintain knowledge of state and federal regulations governing CareSource, State Contracts and Provider Agreements, benefits, and accreditation standards Identify and refer quality issues to Quality Improvement Identify and refer appropriate members for Care Management Provide guidance to non-clinical staff Provide guidance and support to LPN clinical staff as appropriate Attend medical advisement and State Hearing meetings, as requested Assist Team Leader with special projects or research, as requested Perform any other job related duties as requested. Education and Experience: Associates of Science (A.S) Completion of an accredited registered nursing (RN) degree program required Three (3) years clinical experience required Med/surgical, emergency acute clinical care or home health experience preferred Utilization Management/Utilization Review experience preferred Medicaid/Medicare/Commercial experience preferred Competencies, Knowledge and Skills: Proficient data entry skills and ability to navigate clinical platforms successfully Working knowledge of Microsoft Outlook, Word, and Excel Effective oral and written communication skills Ability to work independently and within a team environment Attention to detail Proper grammar usage and phone etiquette Time management and prioritization skills Customer service oriented Decision making/problem solving skills Strong organizational skills Change resiliency Licensure and Certification: Current, unrestricted Registered Nurse (RN) Licensure in state(s) of practice required MCG Certification or must be obtained within six (6) months of hire required Working Conditions: General office environment; may be required to sit or stand for extended periods of time Travel is not typically required Compensation Range: $62,700.00 - $100,400.00 CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package. Compensation Type (hourly/salary): Hourly Organization Level Competencies Fostering a Collaborative Workplace Culture Cultivate Partnerships Develop Self and Others Drive Execution Influence Others Pursue Personal Excellence Understand the Business This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds. #LI-JM1
RN Utilization Review Full-time
Elevance Health

Lead Clinical Review Nurse

Elevance Health Mason, OH
Anticipated End Date: 2026-04-30 Position Title: Lead Clinical Review Nurse Job Description: Location: This role enables associates to work virtually full-time, except for required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. The Lead Clinical Review Nurse is responsible for serving as a team lead for nursing staff who collaborate with cross functional teams and healthcare providers to promote quality audits, and to promote education, training for the DRGV team. Effective use of resources for the most complex or elevated issues. Ensures clinically high quality, cost effective care through assessing coding of inpatient admissions, focused surgical and diagnostic procedures by utilizing the applicable coding guidelines and industry standards, accurately interpreting coding clinics, and other approved coding advice. Works with medical directors in interpreting appropriateness of care and accurate claims payment. May also manage appeals. How you'll make a difference: Conducts retrospective reviews, and appropriateness of coding to ensure compliance with applicable criteria and contracts. Ensures member access to quality healthcare in a cost effective setting according to contract. Consults with clinical reviewers and/or medical directors to ensure appropriate coding assignment. Collaborates with providers to verify correct DRG assignment aiding in identification of any coding errors. Facilitates transition of patient information for correct interpretation and regulatory requirements and standards. Serves as the team lead and responds to the most complex audit issues. Ensures consistency in audit application. May lead cross-functional teams, projects, initiatives, process improvement activities, and requires previous auditing experience. May serve as departmental liaison to other areas of the business unit or as representative on enterprise initiatives. Minimum Requirements: Requires AS in nursing and minimum of 7 years of acute care clinical experience; or any combination of education and experience, which would provide an equivalent background. Prior managed care experience required. Current unrestricted RN license in applicable state(s) required. Preferred skills, qualifications and experience: BS in nursing preferred. Knowledge of medical payment methodologies process and ability to interpret and apply provider contracts, strongly preferred. Claims Auditing experience is strongly preferred CCS, RHIT, RHIA coding certificate Job Level: Non-Management Exempt Workshift: 1st Shift (United States of America) Job Family: MED > Licensed Nurse Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health. Who We Are Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. How We Work At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business. We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few. Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws. Elevance Health is an Equal Employment Opportunity employer, and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act. Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration .
RN Utilization Review Full-time
Franciscan Health

RN Utilization Review Coordinator

Franciscan Health Mishawaka, IN
$56,971.20 - $84,749.60 / year
Work From Home Work From Home Work From Home, Indiana 46544 The Utilization Review Coordinator performs admission screening for patients in a bed for medical necessity, and reviews for appropriateness of setting and utilization. WHO WE ARE With 12 ministries and access points across Indiana and Illinois, Franciscan Health is one of the largest Catholic health care systems in the Midwest. Franciscan Health takes pride in hiring coworkers that provide compassionate, comprehensive care for our patients and the communities we serve. WHAT YOU CAN EXPECT Schedule: Monday - Friday, 8am - 4:30pm EST Perform concurrent reviews for appropriateness of utilization to optimize clinical and financial outcomes. Communicate with physicians, patients, members of the Healthcare team, Coordinated Business Office staff, Denial Management staff, and third-party payors to justify the admission or continued stay. Notify appropriate staff members of any admission, service, length of stay, lack of medical necessity criteria, as well as denials/appeals and issuing of letters to patients. Provide Physician, Patient, Family, Staff and Student education. Act as a resource person for the case management department regarding payer rules, regulations, policies and procedures, and utilization issues. Perform admission necessity screening using criteria as established by the various federal, state and private sector programs. QUALIFICATIONS Associate degree in nursing/patient care required Bachelor's Degree in nursing/patient care preferred Registered Nurse (RN - Indiana licensure) required 3 years of nursing/patient care experience required 2 years of Utilization or Case Management experience preferred TRAVEL IS REQUIRED: Never or Rarely JOB RANGE: Utilization Review Coordinator $56971.20-$84749.60 INCENTIVE: Not Applicable EQUAL OPPORTUNITY EMPLOYER It is the policy of Franciscan Alliance to provide equal employment to its employees and qualified applicants for employment as otherwise required by an applicable local, state or Federal law. Franciscan Alliance reserves a Right of Conscience objection in the event local, state or Federal ordinances that violate its values and the free exercise of its religious rights. Franciscan Alliance is committed to equal employment opportunity. Franciscan provides eligible employees with comprehensive benefit offerings. Find an overview on the benefit section of our career site, jobs.franciscanhealth.org .
CMA Utilization Review Full-time
Jefferson Health

Utilization management assistant

Jefferson Health Jackson, TN
$17 - $22.98 / hour
Job Details Summary Works under the direction of the U.M. Manager to provide assistance with utilization review process including communicating clinical information/reviews to third party and governmental payers to ensure certification/approval of inpatient hospital services for the Medical Assistance patient population. Job Description Summary Works under the direction of the U.M. Manager to provide assistance with utilization review process including communicating clinical information/reviews to third party and governmental payers to ensure certification/approval of inpatient hospital services for the Medical Assistance patient population. Job Duties Interacts with co-workers, visitors, and other staff consistent with the values of Jefferson.(Do not delete, move or over-write this statement) Negotiates with payer (DPW) and other commercial payers to obtain authorization for appropriate level of care and length of stay. Responsible for meeting insurer timeframes regarding review of clinical information. Provides prompt feedback regarding denials and other payer determinations to the U.M. Manager. Coordinates appeal requests (telecom and other payers) with payers as directed by U.M. Manager. Interacts with co-workers and other staff consistent with the core values of the hospital. Minimum Qualifications Computer literate, strong knowledge of medical terminology required. Knowledge of the techniques and the ability to work with a variety of individuals and groups in a constructive and collaborative manner. Communication techniques Ability to manage multiple concurrent objectives, projects, groups, or activities, making effective judgments as to prioritizing and time allocation Answers phones in a prompt and courteous manner directing calls and messages to the appropriate individual. Collaborates with Business Services to ensure accuracy of patient information. Communicates updated information to all appropriate parties in a timely manner. Communicates with the Supervisor/UMA colleagues when experiencing capacity to work on additional cases or need assistance. Communicates with third party payers for verification of insurance benefits/coverage on assigned patients. Communicates timely, relevant and accurate information to the U.M. Manager and U.M. RNs. Documents all approvals, denials, updates and other pertinent information in relevant applications. Effectively communicates all forms of clinical information to all payers. Ensures payer and customer satisfaction through effective communication and positive customer service skills at all times. Ensures utilization management information is submitted to relevant third party payers within the defined timeframes. Identifies and communicates cases requiring clinical review for the U.M. Manager, including timeframes for submission of reviews. Keeps supervisor informed of changes in workload. Keeps supervisor informed of Third Party Payer patterns and trends. Maintains confidentiality of patient information. Maintains routine and frequent communication with U.M. Manager/U.M. RN on the status of their referral requests. Notifies U.M. Manager and/or UM Nurses or Case Manager of the need for utilization information. Obtains authorization for appropriate level of care and length of stay from third party payers. On a daily basis, organizes and creates a priority work list to ensure clinical reviews are completed timely. Works with U.M. Manager to prioritize competing requests. Participates in daily sessions with the U.M. Manager to ensure key issues are prioritized and addressed that day. Proactively communicates any change in payer information to Supervisor and/or Manager and Seamless Access and documents changes appropriately. Provides updates to the U.M. Manager or UR Nurse if there are “pending” approvals and additional clinical information is needed for the third party payer to make a determination. Provides prompt feedback regarding adverse determinations and denials to appropriate staff. Responsible for meeting insurer timeframes regarding utilization management information. Scans approvals and denials into the electronic medical record. Physical Demands Lift and carry 40-50 lbs. Examples: Push/pull patients on bed, stretcher (requires 29 lbs. push force), lateral transfers up to 50 lbs. of the patient's weight. Frequent to continuous standing/walking. Patient transporters can walk 8-10 miles per shift. *Patient care providers may be required to perform activities specific to their role including kneeling, bending, squatting and performing CPR. Job Description Disclaimer: This position description provides the major duties/responsibilities, requirements and working conditions for the position. It is intended to be an accurate reflection of the current position, however management reserves the right to revise or change as necessary to meet organizational needs. Other responsibilities may be assigned when circumstances require. Salary Range $17.00 to $22.98 Hourly The actual hiring rate will be determined based on candidate experience, skills and qualifications. This position is not eligible for an annual incentive. Work Shift Workday Day (United States of America) Worker Sub Type Regular Employee Entity Kennedy University Hospitals, Inc Primary Location Address 25 E Laurel Road, Stratford, New Jersey, United States of America Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University , home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students. Jefferson Health , nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years. Jefferson is committed to providing equal educa­tional and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status. Benefits Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts. Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service. All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps ), have access to medical (including prescription) insurance. For more benefits information, please click here
RN Utilization Review Full-time
Children's Health

Utilization Management RN II

Children's Health Dallas, TX
Job Title & Specialty Area: Utilization RN II Department: Utilization Management Location: Children's Health Dallas Shift: Monday through Friday Job Type: Remote, but there will be a monthly onsite attendance requirement Why Children's Health? At Children's Health, our mission is to Make Life Better for Children, and we recognize that their health plays a crucial role in achieving this goal. Through our cutting-edge treatments and affiliation with UT Southwestern, we strive to deliver an extraordinary patient and family experience, ensuring that every moment, big or small, contributes to their overall well-being. Our dedication to promoting children's health extends beyond our organization and encompasses the broader community. Together, we can make a significant difference in the lives of children and contribute to a brighter and healthier future for all. Summary: The Utilization Management Nurse II is responsible for determining and managing medical necessity of acute inpatient admissions utilizing clinical criteria. This includes communication with the Physician's admitting patients to a Children's Health System of Texas (CHST) facility and collaboration with the Physician Advisor during the review process. The UM RN II has advanced knowledge in utilization management within several specialty areas. Responsibilities: * Accountable for current knowledge of utilization management responsibilities, including payer information; business rules; regulatory guidelines; and policies and procedures. * Performs initial, concurrent, discharge, and retrospective reviews on assigned caseload. Reviews inpatient medical necessity criteria utilizing Indicia or InterQual, CHST clinical pathways, and clinical knowledge to determine appropriateness of admission, level of care, and continued stay. * Will be responsible for leading efforts on audits, observations, and/or rechecks. * Analyzes patient records to determine legitimacy of admission, treatment, and length of stay in health-care facility to comply with government and insurance company reimbursement policies: Analyzes insurance, governmental, and accrediting agency standards to determine criteria concerning admissions, treatment, and length of stay of patients. * Combines clinical, business and regulatory knowledge and skill to reduce significant financial risk and exposure caused by concurrent and retrospective denial of payments for services provided. * Takes on additional case load and serves as primary resource for UM RNs. Serves as first contact for questions before escalation to UM leadership. Maintains productivity and optimum case load, delegating appropriately to maximize skills set, productivity and effectiveness. * Collaborates with Patient Access Services as it relates to inpatient authorization, predetermination, pre/prior authorization, and status changes. * Communicates with Commercial or MMC (Medicaid Managed Care) payers to certify inpatient days as required. Utilizes various methods to obtain necessary information: telephone, fax, secure email, secure web portal. Removing completed cases from the Midas worklist. * Maintain accurate documentation of all communication and interventions in EMR. * Escalate payer problems and trends to Denials Management Specialist or UM Manager. * Proactively intervenes with medical necessity, or level of care denials by exercising all real-time options to overturn decision. Actions include, but not limited to, requesting expedited appeal, use of third-party Physician Advisor, facilitation of peer to peer with CHST Physician. * Identifies issues and strategies to modify and/or enhance the utilization management program. * Advances clinical expertise through attendance at in-hours education opportunities, reading journals, and attendance at conferences. * Hosts informational (.i.e.‘drift’) meetings and maintains meeting minutes for staff reference. Attends department/program meetings regularly. * Maintains a level of productivity and quality consistent with complexity of the assignment; facility policies and guidelines; established principles, ethics and standards of practice of professional nursing. * Other job duties as assigned How You’ll Be Successful: WORK EXPERIENCE * At least 8 years clinical nursing experience Required * At least 2 years of Utilization Review experience Required * At least 1 year Previous experience with InterQual or Milliman Required EDUCATION * Four-year Bachelor's degree or equivalent experience Bachelor's of Nursing Preferred * Two-year Associate's degree or equivalent experience Associate's Degree of Nursing Required LICENSES AND CERTIFICATIONS * Registered Nurse Required A Place Where You Belong We put our people first. We welcome, value, and respect the beliefs, identities and experiences of our patients and colleagues. We are committed to delivering culturally effective care, creating meaningful partnerships in the communities we serve, and equipping and developing our team members to make Children’s Health a place where everyone can contribute. Holistic Benefits – How We’ll Care for You: · Employee portion of medical plan premiums are covered after 3 years. · 4%-10% employee savings plan match based on tenure · Paid Parental Leave (up to 12 weeks) · Caregiver Leave · Adoption and surrogacy reimbursement As an equal opportunity employer, Children's Health does not discriminate against employees or applicants because of race, color, religion, sex, gender identity and expression, sexual orientation, age, national origin, veteran or military status, disability, or genetic information or any other Federal or State legally protected status or class. This applies to all aspects of the employer-employee relationship including but not limited to recruitment, hiring, promotion, transfer pay, training, discipline, workforce adjustments, termination, employee benefits, and any other employment-related activity.
RN Utilization Review Full-time
CVS Health

Utilization Management Nurse Consultant - Medical Review (Remote)

CVS Health
$26.01 - $56.14 / hour
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Information Schedule: Monday–Friday 8:00am-5:00pm EST Location: 100% Remote (U.S. only) About Us American Health Holding, Inc. (AHH), a division of Aetna/CVS Health, is a URAC-accredited medical management organization founded in 1993. We provide flexible, cost-effective care management solutions that promote high-quality healthcare for members. Position Summary Join a team that’s making a difference in the lives of patients facing complex medical journeys. As a Utilization Management (UM) Nurse Consultant specializing in Medical Review, you’ll play a vital role in ensuring members receive timely, medically necessary care through thoughtful clinical review and collaboration with providers. This fully remote position offers the opportunity to apply your clinical expertise in a fast-paced, desk-based environment where precision, communication, and compassion intersect. Key Responsibilities Utilizes clinical experience and skills in a collaborative process to implement, coordinate, monitor and evaluate medical review cases. Applies the appropriate clinical criteria/guideline and plan language or policy specifics to render a medical determination to the client. Applies critical thinking, evidenced based clinical criteria and clinical practice guidelines. Med Review nurses use specific criteria to authorize procedures/services or initiate a Medical Director referral as needed. Assists management with training new nurse reviewers/business partners or vendors to include initial and ongoing mentoring and feedback. Actively cross-trains to perform reviews of multiple case types to provide a flexible workforce to meet client needs. Recommends, tests, and implements process improvements, new audit concepts, technology improvements, etc. that enhance production, quality, and client satisfaction. Must be able to work independently without personal distractions to meet quality and metric expectations. Remote Work Expectations This is a 100% remote role; candidates must have a dedicated workspace free of interruptions. Dependents must have separate care arrangements during work hours, as continuous care responsibilities during shift times are not permitted. Required Qualifications Active, unrestricted RN license in your state of residence with multistate/compact licensure privileges. Ability to obtain licensure in non-compact states as needed. Minimum 3 years of clinical experience. 5 years demonstrated to make thorough independent decisions using clinical judgement. 5 Years proficient use of equipment experience including phone, computer, etc. and clinical documentation systems. 1+ Year of Utilization Review Management and/or Medical Management experience. Commitment to attend a mandatory 3-week training (Monday–Friday, 8:30am–5:00pm EST) with 100% participation. Preferred Qualifications Experience with interpreting Plan Language, Policies, and Benefits to determine medical necessity. MCG Milliman, CPB or other criteria guideline application experience is preferred. Education Associate's degree in nursing (RN) required, BSN preferred. Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $26.01 - $56.14 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan . No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 03/28/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
RN Utilization Review Full-time
CVS Health

Clinical Claims Review Nurse

CVS Health
$26.01 - $68.55 / hour
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. • This role requires the nurse to exercise clinical judgment and perform the following duties: • Review and interpret clinical documentation obtained from medical records or systems. • Apply clinical decision-making to utilize appropriate clinical criteria and policies for post-service claims • Coordinate clinical resolutions independently, with clinician/MD support as required • Act as a resource for customer service and claims processing teams • Train new staff and provide cross-training to existing team members • Identify trends and provide feedback to leadership if discrepancies or potential fraudulent activities are identified Remain current with applicable laws, regulations, and internal workflows to ensure full compliance with organizational and state-specific requirements • Required Qualifications • Nursing degree (RN) • A minimum of 2–3 years of professional experience as a licensed Registered Nurse (RN), or equivalent clinical experience • Strong analytical skills to assess medical claims Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $26.01 - $68.55 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan . No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 04/01/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.