Utilization Review Nurse Jobs

RN Utilization Review Temporary
UF Health

RN, Utilization Management

UF Health 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 Evaluates patient medical records to ensure necessity and appropriateness of healthcare services. • Coordinates with healthcare providers to maintain compliance with utilization management guidelines. • Optimizes treatment plans for effective patient care and resource utilization. • Communicates authorization decisions clearly and supports timely discharge planning. • Analyzes utilization data to identify trends and improve care coordination. • Collaborates with interdisciplinary teams to ensure accurate documentation and regulatory compliance. Qualifications Required Education . Graduate from an accredited Nursing school Required experienc e: Registered Nurse (RN) license with 3+ years experience in utilization review or case management Necessary Skills • Knowledge of healthcare utilization guidelines and compliance • Experience evaluating medical necessity and treatment plans • Strong communication skills for authorization decisions • Ability to analyze utilization data and support care coordination License Requirement: Registered Nurse (RN) with a current Florida nursing license required.
RN Utilization Review Outpatient Full-time
UF Health

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

UF Health Tampa, FL
Overview The RN Utilization Managemen t 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 An incumbent in this position will • Evaluates patient medical records to ensure necessity and appropriateness of healthcare services. • Coordinates with healthcare providers to maintain compliance with utilization management guidelines. • Optimizes treatment plans for effective patient care and resource utilization. • Communicates authorization decisions clearly and supports timely discharge planning. • Analyzes utilization data to identify trends and improve care coordination. • Collaborates with interdisciplinary teams to ensure accurate documentation and regulatory compliance. Qualifications Required: Registered Nurse (RN) with a current Florida license required. • 3+ years experience in utilization review or case management • Knowledge of healthcare utilization guidelines and compliance • Experience evaluating medical necessity and treatment plans • Strong communication skills for authorization decisions • Ability to analyze utilization data and support care coordination Licensure/Certification/Registration: Registered Nurse (RN) with a current Florida license required.
RN Utilization Review Full-time
Parkland Health (TX)

Registered Nurse - Care Coordinator - Utilization Review

Parkland Health (TX) Dallas, TX
Location: Main Hospital Bldg - 1st Flr Shift- Days (10hrs) 7:30am-6pm Work Hours: Monday- Friday with rotating weekends **This position will hybrid- must be okay with coming onsite** Employment Type: Full Time Primary Purpose Establishes and maintains an efficient, cost effective care management process by determining patient financial and medical eligibility, medical necessity, and by developing, implementing and monitoring individual patient plans of care and communicating these plans to patients, families, and Parkland staff to ensure quality patient care throughout the healthcare continuum and compliance with program/Parkland policies and procedures. Responsible for the maintaining the knowledge and skill set related to utilization review, care coordination, performance improvement and professional licensure and certification. Minimum Specifications Education Must be a graduate of an accredited school of Nursing. Experience Must have two (2) years of hospital or community based patient care nursing, preferably in assigned clinical area. Equivalent Education and/or Experience Certification/Registration/Licensure Must have current, valid RN license or temporary RN license from the Texas Board of Nursing; or, valid Compact RN license. Must have current healthcare provider BLS for Healthcare Providers certification from one of the following: American Heart Association American Red Cross Military Training Network Required Tests for Placement Skills or Special Abilities Provides care to assigned patient population in accordance with the current State of Texas Nursing Practice Act, established protocols, multidisciplinary plan of care, and clinical area specific standards. Must be able to communicate and collaborate effectively with a diverse group of patients, families and healthcare staff. Must be able to demonstrate a working knowledge of specific patient populations, and be able to demonstrate knowledge of disease processes affecting this group. Must be able to demonstrate a working knowledge of PC operations and the ability to use word processing software in a Windows environment. Must be able to demonstrate a working knowledge of the laws and regulations governing Medicare, Medicaid and community-based funding sources. Must be self-directed and capable of priority setting and problem solving. Must be able to demonstrate patient centered/patient valued behaviors. Responsibilities Conducts assessment of patients on assigned Care Coordination team to develop a case management plan of care. Gathers information from patient, physicians, other pertinent members of the healthcare team. Determines funding sources for patients and potential eligibility if appropriate. Plans and develops specific objectives, goals and actions designed to meet the patient's needs as identified through the assessment process. Utilizes hospital approved review criteria to ensure appropriate bed status. Identifies at-risk populations using approved screening tool and follows established reporting procedures. Ensures appropriate admission status is documented. Collaborates with all members of the multidisciplinary team and the patient to implement the plan of care. Monitors the patient's progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective. Communicates all financial counseling as appropriate. Addresses and resolves system barriers impeding diagnostic or treatment progress. Proactively identifies and resolves delays and obstacles to discharge. Ensures/maintains plan consensus from patient/family, physician, and payer. Serves as patient advocate to secure coverage for needed community services. Mobilizes resources and coordinates the effort to the health care team to achieve a positive patient transition to appropriate next level of care. Communicates plan of care to patient and their family providing updates and reassesses the plan of care to determine effectiveness. Completes appropriate coordinator management documentation. Evaluates the plan of care at appropriate intervals to determine effectiveness in meeting outcomes and goals. Works with nursing and other disciplines to ensure that discharge needs, including teaching, are met. Collaborates with the healthcare team to identify 'best' practices for achieving patient outcomes. Develops reporting mechanisms to communicate outcomes to physicians and other members of the health care team. Responsible for Utilization Management activities for assigned patients. Applies approved utilization criteria to monitor appropriateness of admissions and continued stays, and documents findings based on department standards. Monitors length of stay (LOS) and ancillary resource use on an ongoing basis and takes action to achieve continuous improvement in both areas. Monitors and addresses outcome variances. Identifies causes of outcome variances and implements actions to improve the variances. Seeks the most efficient, cost effective ways to provide appropriate care. Supports cost containment efforts through the recommendation of performance improvement opportunities by the health care team. Communicates with Care Management team to facilitate covered-day reimbursement certification and/or authorization for assigned patients. Discusses payer criteria and issues on a case-by-case basis with clinical staff and follows up to resolve problems with payers as needed. Transitions patients through the health care system based upon individual and patient population needs. Directs liaison activities to appropriately integrate the patient into the health care continuum including procuring of services, health promotion and counseling, disease prevention, health education and screening, and community resource linkage. Engages in special projects and serves on committees, as assigned. Requisition ID: 988689
RN Utilization Review Full-time
Silver Cross Hospital

Utilization Review Nurse

Silver Cross Hospital New Lenox, IL
$34.73 - $45.15 / hour
Silver Cross Hospital is an extraordinary place to work. We’re known for our culture of excellence and delivery of unrivaled experiences for our patients, their families, the communities we serve…and for each other. Come join us! It’s the way you want to be treated. Position Summary: Performs medical record review for severity of illness and intensity of service; liaison function with external review agencies to ensure compliance with regulations affecting financial reimbursement; identifies variance from established pathways Essential Duties and Responsibilities: Collects information from clinical medical record for severity of illness and intensity of service and documents such in clinical database Monitors all levels of care for appropriateness and communicates variance; evaluates plan of care to ensure it is based on accepted standards Provides information to external review organizations, documents pertinent communications Refers to designated physician advisor those patients not meeting criteria as well as quality of care concerns Maintains knowledge and incorporates current standards into practice Required Qualifications : Knowledge of clinical norms; excellent communication skills; critical thinking skills; organized and efficient time management skills Education and Training : Nurse, Registered (RN) licensure BSN preferred. 2-5 years previous Utilization Review experience preferred. Current CPR Relevant hospital nursing; hospital case management; insurance case management or utilization management experience preferred Work Shift Details: Days, Primarily remote; onsite orientation requirement; weekend and holiday rotation; on site requirement for meetings and mandatory training Department: CONTINUUM OF CARE Benefits for You At Silver Cross Hospital, we care about your health and well-being and that is why we work hard to provide quality and affordable benefit options for you and your eligible family members. Silver Cross Hospital and Silver Cross Medical Groups offer a comprehensive benefit package available for Full-time and Part-time employees which includes: · Medical, Dental and Vision plans · Life Insurance · Flexible Spending Account · Other voluntary benefit plans · PTO and Sick time · 401(k) plan with a match · Wellness program · Tuition Reimbursement Registry employees who meet eligibility may participate in our 401(k) Savings plan with a potential match. However, registry employees are ineligible for Health and Welfare benefits. The final pay rate offered may be more than the posted range based on several factors including but not limited to: licensure, certifications, work experience, education, knowledge, demonstrated abilities, internal equity, market data, and more. The expected pay for this position is listed below: $34.73 - $45.15
RN Utilization Review Telehealth Other
Devoted Health

Clinical Guide Part A: Utilization Management Nurse

Devoted Health
$85,000 - $95,000 / year
Job Description Schedule: The weekly schedule choice is either Monday - Friday 10am-7pm EST OR Tuesday - Saturday 9am-6pm EST A bit about this role: The Clinical Guide Part A will be part of the Utilization Management team, responsible for inpatient, behavioral health, and/or post-acute authorization review in alignment with CMS and Medicare Advantage regulations. Reviews medical records to evaluate the medical necessity and appropriateness of requested inpatient and/or post-acute services in accordance with established clinical criteria and CMS guidelines. Your Responsibilities and Impact will include: Review Medical Records: Conduct prospective (pre-service), concurrent, and retrospective utilization review to evaluate medical necessity, appropriate level of care (Inpatient vs. Observation), and post-acute services in accordance with established clinical criteria and CMS guidelines. Evaluate Treatment Plans: Assess the appropriateness, timing, and setting of requested services, ensuring alignment with medical necessity criteria and Medicare Advantage requirements. Recommend alternative levels of care when clinically appropriate. Inpatient & Behavioral Health Review: Perform initial, concurrent, and discharge reviews for inpatient and behavioral health admissions. Ensure admission status accuracy and regulatory compliance with CMS timeliness (TAT) standards. Post-Acute Review: Conduct initial authorization and concurrent review for post-acute services (SNF, LTACH, ARU, Home Health), evaluating ongoing medical necessity and appropriate length of stay. Issue NOMNC when coverage criteria are no longer met. Medical Director Collaboration: Refer cases that do not meet criteria to the Medical Director for secondary review and final determination. Prepare clinical summaries and coordinate peer-to-peer (P2P) discussions. Manage authorization reopen requests as appropriate. Resource Stewardship: Monitor utilization of inpatient and post-acute services to promote appropriate resource use while maintaining high-quality, member-centered care. Regulatory & Documentation Compliance: Maintain accurate, defensible documentation of all determinations. Ensure adherence to CMS regulations, Medicare Advantage requirements, and internal compliance standards. Required skills and experience: Unrestricted RN license with a minimum of 4 years of clinical experience. Minimum 3 years of Utilization Management or Inpatient UR experience within a health plan or hospital setting. Strong knowledge of CMS regulations and Medicare Advantage requirements. Experience preparing cases for Medical Director review Able to work in a fast paced environment that is constantly evolving. Desired skills and experience: Experience with AI/LLM Certified in InterQual #LI-Remote #LI-DS1 Salary Range: $85,000-$95,000 / year The pay range listed for this position is the range the organization reasonably and in good faith expects to pay for this position at the time of the posting. Once the interview process begins, your talent partner will provide additional information on the compensation for the role, along with additional information on our total rewards package. The actual base salary offered will depend on a variety of factors, including the qualifications of the individual applicant for the position, years of relevant experience, specific and unique skills, level of education attained, certifications or other professional licenses held, and the location in which the applicant lives and/or from which they will be performing the job. Our Total Rewards package includes: Employer sponsored health, dental and vision plan with low or no premium Generous paid time off $100 monthly mobile or internet stipend Stock options for all employees Bonus eligibility for all roles excluding Director and above; Commission eligibility for Sales roles Parental leave program 401K program And more.... *Our total rewards package is for full time employees only. Intern and Contract positions are not eligible. Founded in 2017, Devoted Health is on a mission to dramatically improve the health and well-being of older Americans by caring for everyone like they are family, and that includes our employees. Our robust and seamlessly integrated care platform merges advanced data and AI access with world-class clinical and service experiences to create a member experience that is unlike the industry norm. To continue building upon our mission, we want to bring together those who share our values, embrace change and advancement, and are enthusiastic about where we're going — all the while bringing their own unique qualities, experiences, and expertise, in hopes of further changing the healthcare experience. Devoted is an equal opportunity employer. We are committed to a safe and supportive work environment in which all employees have the opportunity to participate and contribute to the success of the business. We value diversity and collaboration. Individuals are respected for their skills, experience, and unique perspectives. This commitment is embodied in Devoted’s Code of Conduct, our company values and the way we do business. As an Equal Opportunity Employer, the Company does not discriminate on the basis of race, color, religion, sex, pregnancy status, marital status, national origin, disability, age, sexual orientation, veteran status, genetic information, gender identity, gender expression, or any other factor prohibited by law. Our management team is dedicated to this policy with respect to recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, employee activities and general treatment during employment.
RN Utilization Review Part-time
Silver Cross Hospital

Utilization Review Nurse

Silver Cross Hospital New Lenox, IL
$34.73 - $45.15 / hour
Silver Cross Hospital is an extraordinary place to work. We’re known for our culture of excellence and delivery of unrivaled experiences for our patients, their families, the communities we serve…and for each other. Come join us! It’s the way you want to be treated. Position Summary: Performs medical record review for severity of illness and intensity of service; liaison function with external review agencies to ensure compliance with regulations affecting financial reimbursement; identifies variance from established pathways Essential Duties and Responsibilities: Collects information from clinical medical record for severity of illness and intensity of service and documents such in clinical database Monitors all levels of care for appropriateness and communicates variance; evaluates plan of care to ensure it is based on accepted standards Provides information to external review organizations, documents pertinent communications Refers to designated physician advisor those patients not meeting criteria as well as quality of care concerns Maintains knowledge and incorporates current standards into practice Required Qualifications : Knowledge of clinical norms; excellent communication skills; critical thinking skills; organized and efficient time management skills Education and Training : Nurse, Registered (RN) licensure BSN preferred. 2-5 years previous Utilization Review experience preferred. Current CPR Relevant hospital nursing; hospital case management; insurance case management or utilization management experience preferred Work Shift Details: Various, Day; weekend rotation; holiday rotation; occasional on site requirement for meetings and mandatory training Department: CONTINUUM OF CARE Benefits for You At Silver Cross Hospital, we care about your health and well-being and that is why we work hard to provide quality and affordable benefit options for you and your eligible family members. Silver Cross Hospital and Silver Cross Medical Groups offer a comprehensive benefit package available for Full-time and Part-time employees which includes: · Medical, Dental and Vision plans · Life Insurance · Flexible Spending Account · Other voluntary benefit plans · PTO and Sick time · 401(k) plan with a match · Wellness program · Tuition Reimbursement Registry employees who meet eligibility may participate in our 401(k) Savings plan with a potential match. However, registry employees are ineligible for Health and Welfare benefits. The final pay rate offered may be more than the posted range based on several factors including but not limited to: licensure, certifications, work experience, education, knowledge, demonstrated abilities, internal equity, market data, and more. The expected pay for this position is listed below: $34.73 - $45.15
RN Utilization Review Full-time
Palmetto General Hospital

Utilization Review RN, Case Management/UR, Full Time, Day Shift, Job ID # 1815702

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

Physician Peer Review RN Coordinator (not a remote position)

Infirmary Health Mobile, AL
Overview Responsibilities Coordinates, organizes, and facilitates Mobile Infirmary Medical Center (MIMC) physician peer review and professional practice evaluation processes. Ensures timely, objective, and confidential review of clinical events, supports medical staff leaders in evaluating practitioner performance, and maintains compliance with all Infirmary Health (IH), regulatory, and accreditation standards. Qualifications Minimum Qualifications: Bachelor of Science in Nursing (BSN) 3 of the most recent 5 years’ experience in acute care clinical setting Strong analytical and critical thinking skills Ability to perform with a high level of professionalism, discretion, and confidentiality Proficient computer skills in Microsoft Office and EHR systems (i.e. Epic) Licensure, Registration, Certification: One of the following: Current Alabama RN license Current Multi State RN License in accordance with Nurse Licensure Compact (NLC) for Alabama* *Infirmary Health abides by the NLC requirements and guidelines for the state of Alabama Desired Qualifications: Master of Science in Nursing (MSN) Working knowledge of quality, peer review, risk management, or medical staff services and processes Experience working or coordinating physician peer review in a hospital setting Working knowledge of clinical care standards and physician practice patterns Knowledge of FPPE/OPPE and Joint Commission standards Licensure, Registration, Certification: Certified Professional in Healthcare Quality (CPHQ) through the National Association for Healthcare Quality (NAHQ) Certified Professional in Patient Safety (CPPS) through the Certification Board for Professionals in Patient Safety (CBPPS)
RN Utilization Review Full-time
Havenwyck Hospital

Utilization Management Case Manager

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

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

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

Case Manager RN Utilization Review FT McAllen

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

Utilization Review/Management Coordinator

UHS Grand Rapids, MI
Responsibilities Benefit Highlights: Challenging and rewarding work environment Competitive Compensation & Generous Paid Time Off Excellent Medical, Dental, Vision and Prescription Drug Plan 401(K) with company match and discounted stock plan Career development opportunities within UHS and its 300+ Subsidiaries Shift differentials are paid for evening, night and weekend shifts Position Summary The Utilization Review Coordinator is dedicated to gather and coordinating information regarding patient symptomatology and treatment modalities for the purpose of internal and concurrent reviews with insurance companies. Essential Job Functions and Responsibilities 1. Negotiates and advocates on behalf of the patient and the Hospital. 2. Assesses and interprets most appropriate level of care based upon patient present level of functioning and responsiveness to treatment interventions. Provides clinical appropriateness data (verbal and written) to outside utilization review agencies and insurance companies according to policy and procedure. 3. Review discharges, as assigned. Calculate length of stay and document number of days certified for billing purposes. Report discharges to outside reviews as indicated , including discharge plan and medications. 4. Complete continued stay reviews with external review agencies as indicated . 5. Complete pre-certifications, as assigned. 6. Prioritizes daily workload between various types of reviews and discharges to ensure timely completion. 7. Assist with denial/appeals, including maintenance of denial log for assigned cases. 8. Provide Utilization Review guidance consultative services to UR department and to all departments when requested. Services include analysis of medical records, data and participation in committees as requested. 9. Analyzes patient clinical information to determine patient length of stay and level of care. 10. Review all assigned Medicare charts for medical necessity and report findings to treatment team weekly. 11. Maintains Utilization Review files and logs in a neat, accurate and orderly form. 12. Provides feedback to the Department Manager on the development/modification of the utilization review plan. 13. Attends treatment team daily to review assigned cases with team. 14. Complete and updates MIDAS reports daily, as assigned. 15. Assume Hospital Safety Responsibilities. Qualifications Minimum Skills, Experience, Licensure and Educational Requirements 1. RN/MA/MSW. 2. Professional licensure in the State of Michigan. 2. Experience working with psychiatric utilization review criteria. 3. Knowledge of psychiatric program delivery and utilization review criteria. About Universal Health Services One of the nation’s largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (NYSE: UHS) has built an impressive record of achievement and performance, growing since its inception into a Fortune 500 corporation. Headquartered in King of Prussia, PA, UHS has 99,000 employees . Through its subsidiaries, UHS operates 28 acute care hospitals, 331 behavioral health facilities, 60 outpatient and other facilities in 39 U.S. States, Washington, D.C., Puerto Rico and the United Kingdom. EEO Statement All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws. Avoid and Report Recruitment Scams We are aware of a scam whereby imposters are posing as Recruiters from UHS, and our subsidiary hospitals and facilities. Beware of anyone requesting financial or personal information. At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skill set and experience with the best possible career path at UHS and our subsidiaries. During the recruitment process, no recruiter or employee will request financial or personal information (e.g., Social Security Number, credit card or bank information, etc.) from you via email. Our recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc. If you suspect a fraudulent job posting or job-related email mentioning UHS or its subsidiaries, we encourage you to report such concerns to appropriate law enforcement. We encourage you to refer to legitimate UHS and UHS subsidiary career websites to verify job opportunities and not rely on unsolicited calls from recruiters.
RN Utilization Review Per Diem
UHS

UTILIZATION MANAGMENT (UM) COORDINATOR - PRN

UHS Franklin, TN
Responsibilities At Rolling Hills , our mission is to offer compassionate, safe, effective behavioral healthcare treatment. We use solution-focused strategies and diligently strive for a safe and positive environment for patients, families, and employees. We never forget that we provide care and comfort to people in need. The Utilization Management Coordinator monitor appropriate utilization of services throughout the course of treatment for patients admitted to the inpatient and outpatient programs and coordinates authorizations with third-party payers. The UM Coordinator reviews cases for appropriateness of admission, continued stay, and discharge planning while assisting in the promotion and maintenance of high quality patient care. Qualifications Education/Training : Must possess a current RN license or Master's Degree in Behavioral Health field (e.g. Counseling, Social Work, Psychology) Licensure/Certification: Current TN Driver License Current CPR (training provided) Current Handle With Care (training provided) Experience: Experience in a psychiatric setting as a counselor or nurse preferred; reading, writing, and mathematical skills at the masters' degree level; skills in application of DSM methodology; excellent telephone etiquette and tact; audible speech, with good enunciation; ability to interact effectively with persons of widely diverse roles, backgrounds, cultures, and socio-economic classes; effective oral and written communication skills; skills in analyzing and evaluating information; ability to concentrate on tasks and meet deadlines; basic data entry skills preferred; organizational, time management, problem solving, meet deadlines; basic data entry skills preferred; crisis management skills necessary; flexibility, creativity, and the ability to manage stress are necessary. EEO Statement All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers such as, openly support and fully commit to recruitment, selections, placement, promotion and compensation of individuals withouth regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws. We believe that diversity and inclusion amoung our teammates is critical to our success. Notice At UHS and all our subsidiares, our Human Resources deparments and recruiters are here to help prospective cadidates by matching skillset and expereince with the best possiblke career path at UHS and our subsidiares. We take pride in creating a highly efficient and best-in-class candidate experience. During the recrtuitment process, no recruiter or employee will request financial or personal information (Social Security Number, credit card or bank information, etc.) from you via email. The recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc. If you are suspicious of a job posting or job-related email mentioning UHS or its subsidiaries, let us know by contacting us at https://uhs.alertline.com or 1-800-852-3449. UHS is a registered trademark of UHS of Delaware, Inc., the management company for Universal Health Services, Inc. and a wholly-owened subsidiary of Universal Health Services, Inc. Universal Health Services, Inc. is a holding company and operates through its subsidiaries including its managment company, UHS of Delaware, Inc. All healthcare and management operations are conducted by subsidiares of Universal Health Services, Inc. To the extent any reference to UHS or UHS facilities on this webiste including any statements, articles or other publications contained herein relates to our healthcare or management operations it is referring to Universal Health Services' subsidiaries including UHS of Delaware. Further, the terms "we", "us", "our" or "the company" in such context similarly refer to the operations of Universal Health Services' subsididares including UHS of Delware. Any employment referenced in this website is not with Universal Health Servicesk, Inc. but solely with one of its subsidiares including but not limited to UHS of Delware, Inc. UHS is not accepting unsolicted assistance from search firms for this employment opportunity. Please, no phone calls or emails. All resumes submitted by search firms to any employee at UHS via email, the Internet or in any form and/or method without a valid written search agreement in place for this posiiton will be deemed the sole property of UHS. No fee will be paid in the event the candidate is hired by UHS as a result of the referral or through other means.
NP Manager/Supervisor Utilization Review Full-time
UHS

Utilization Review Manager

UHS Grand Rapids, MI
Responsibilities Benefit Highlights: · Excellent Medical, Dental, Vision and Prescription Drug Plans · Student Loan Repayment Program · 401(k) and Roth 401(k) with Company Match · Employee Stock Purchase Program · Competitive Compensation & Paid Time Off · Disability, Life, Pet Insurance and much more! More information is available on our Benefits Guest Website: benefits.uhsguest.com Forest View Hospital , located just seven miles southeast of downtown Grand Rapids, Michigan, is a private 108 bed psychiatric facility that serves children, adolescents and adults. We are licensed by the State of Michigan, fully accredited by The Joint Commission and we bring more than 45 years of experience to the evaluation, diagnosis and treatment of a wide range of behavioral health problems. As a part of our continued success and growth, we are seeking qualified applicants for a Utilization Review Manager. Position Description: The Utilization Manager is responsible for directing and overseeing the Utilization Program for Inpatient and Outpatient services. This includes the implementation of case management scenarios, consulting with all services to ensure the provision of an effective treatment plan for all patients, oversees the response to requests for services and interfaces with managed care organizations, external reviewers, and other payors. More information is available on our Benefits Guest Website: benefits.uhsguest.com Forest View also has a focus on furthering your Education and Career Development: · Career ladder focus with opportunities to cross train, build skills and grow in leadership · Tuition reimbursement assistance program · Tuition savings through a partnership with Chamberlain University · In-house Psychiatric Nurse Residency Transition-to-Practice Orientation (20 CEUs) · Career development opportunities across UHS and our 300+ locations! · HealthStream online learning catalogue with plenty of free CEU courses Qualifications Job Requirements: Education: Bachelor's Degree required. Experience: A minimum of three years’ experience in Utilization Management Required. License: State of Michigan licensure as LLP, LPC, LLPC LMSW, LLMSW, or Registered Nurse RN. About Universal Health Services One of the nation’s largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (UHS) has built an impressive record of achievement and performance. During the year, UHS was again recognized as one of the World’s Most Admired Companies by Fortune; and listed in Forbes ranking of America’s Largest Public Companies. Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory care access points, an insurance offering, a physician network and various related services located all over the U.S. States, Washington, D.C., Puerto Rico and the United Kingdom. www.uhs.com EEO Statement All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws. We believe that diversity and inclusion among our teammates is critical to our success. Avoid and Report Recruitment Scams At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skill set and experience with the best possible career path at UHS and our subsidiaries. During the recruitment process, no recruiter or employee will request financial or personal information (e.g., Social Security Number, credit card or bank information, etc.) from you via email. Our recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc. If you suspect a fraudulent job posting or job-related email mentioning UHS or its subsidiaries, we encourage you to report such concerns to appropriate law enforcement. We encourage you to refer to legitimate UHS and UHS subsidiary career websites to verify job opportunities and not rely on unsolicited calls from recruiters.
RN Utilization Review Telehealth Full-time
Gainwell Technologies LLC

Utilization Review Nurse- Remote

Gainwell Technologies LLC Arkansas City, AR
$65,000 - $78,000 / year
It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you’ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development. Summary We are seeking a skilled Utilization Review Nurse to conduct prior authorization, prospective, concurrent, and retrospective reviews for medical necessity and appropriateness of services, following clinical criteria, coverage policies, and contract guidelines. This involves reviewing medical documentation, accurately documenting findings, and ensuring policy compliance. Your role in our mission Review admissions, procedures, services, and supplies for medical necessity and appropriateness, meeting quality and production goals. Use clinical criteria for decision-making, referring complex cases to Medical Directors when needed. Engage with providers to gather clinical information, apply guidelines, and make determinations. Document findings and rationale in medical management systems. Assist in training new nurses, provide feedback, and stay updated on clinical guidelines. Maintain RN license and meet continuing education requirements. What we're looking for Active RN license. 3+ years of inpatient clinical experience. 1+ year in prior authorization reviews using InterQual or MCG. Strong written communication skills in a fast-paced setting. Proficient in Microsoft Office and other computer applications. What you should expect in this role Home-based position. High-speed internet and a distraction-free workspace required. Core hours: 8:00 AM - 6:00 PM ET, with potential for extended hours. Occasional travel (up to 10%) based on business needs. This position is for pipeline purposes, and we welcome applications on an ongoing basis. The pay range for this position is $65,000.00 - $78,000.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits , and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities. We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings. Gainwell Technologies is an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics.
RN Utilization Review Telehealth Full-time
Gainwell Technologies LLC

DRG Nurse Reviewer Appeals and Hearings- Remote

Gainwell Technologies LLC Tampa, FL
$90,000 - $99,000 / year
It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you’ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development. Summary We are seeking a talented individual for a DRG Nurse Reviewer Appeals and Hearings to coordinate and perform all appeal related duties including analyzing and responding appropriately to appeals from providers; reviewing documentation to ensure all aspects of the appeal have been addressed properly and accurately; prepare case files and case summaries for hearings; and participate in in virtual and on-site hearings. Your role in our mission Reviews provider appeals and redeterminations using approved clinical and coding guidelines and documents appeal determinations clearly and concisely. Analyzes and reviews appeal documentation to ensure all aspects of the appeal have been addressed properly and accurately while maintaining production goals and quality standards. Prepares case files and case summaries for hearings and actively participates in hearings in conjunction with the Medical Director. Assists management with training new reviewers to include daily monitoring, mentoring, feedback and education. Maintains current knowledge of clinical criteria guidelines and/or coding guidelines; successfully completes required CEUs to maintain RN license and/or coding certification. Responsible for attending training and scheduled meetings to enhance skills and working knowledge of clinical policies, procedures, rules, and regulations. Actively cross-trains to perform reviews of multiple claim types to provide a flexible workforce to meet client needs. What we're looking for Active, Unrestricted RN license from the United States and in the primary home residency, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), required Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or Certified Professional Medical Auditor (CPMA) required 5+ years clinical experience or 5+ years medical record coding experience preferred Working knowledge of the appeals and hearings process Excellent written communication skills including ability to write clear, concise, accurate, and fact-based rationales in support of appeal determinations. Excellent oral communication skills with particular emphasis on verbally presenting case summaries and decisions. Ability to multi-task in a fast-paced production environment. What you should expect in this role Remote (Work from Home) Up to 25% Travel for onsite hearing testimony This position is for pipeline purposes, and we welcome applications on an ongoing basis. The pay range for this position is $90,000.00 - $99,000.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits , and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities. We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings. Gainwell Technologies is an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics.
Home Health Aide Home Health Utilization Review Home Health Full-time
Fallon Health

Health Aide or CNA $20/hr (*Up to $24/hr) Benefits! Health Ins! Paid Mileage!

Fallon Health Worcester, MA
Overview This is one of the better opportunities out there for Health Aides or CNAs and we will take great care of you! Why?.. + Great benefits! Full-time benefits offering! Health Insurance offerings! Paid Time Off! 12 Holidays! 401K Savings Plan! Tuition Assistance! Vision Care, Life Insurance and more!! + $20/hr to start and far exceeds state pay average! + Extra pay for shifts outside normal workday! Extra $3.50/hr weekdays between 7pm and 7am Monday through Friday (shift ends Friday at 7am) Extra $4.00/hr for weekends beginning at 7pm on Friday and ending 7am on Monday. + Mileage Reimbursement! + Respectful and Desirable Health Aide / CNA Work Setting! Predictable Hours! Safe and highly vaccinated work environment including the member population you care for Our Health Aides and staff love the familiarity and relationships establishes with our members You will likely find more autonomy and flexibility than you have in your current role Our model is low-volume and very member and quality care focused About Fallon Health Founded in 1977, Fallon Health is a leading health care services organization that supports the diverse and changing needs of those we serve. In addition to offering innovative health insurance solutions and a variety of Medicaid and Medicare products, we excel in creating unique health care programs and services that provide coordinated, integrated care for seniors and individuals with complex health needs. Fallon has consistently ranked among the nation’s top health plans, and is accredited by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit fallonhealth.org. About Summit ElderCare : Fallon Health operates the largest Program of All-Inclusive Care for the Elderly (PACE) in New England and the fifth largest in the country. Called Summit ElderCare, Fallon’s PACE helps provide older adults and their caregivers with a welcome alternative to nursing home care. Participants in Summit ElderCare have access to comprehensive medical services and social support at a Summit ElderCare site while they keep the independence of living in their own homes and communities. Summary: Provides personal care, light housekeeping and assistance with ADLs (Activities of Daily Living) as outlined in each SE participant’s plan of care in participant homes as well as at the PACE center; exercises independent judgement; reports any changes in participant status to the IDT; participates in carrying out infection control precautions and increased cleaning and disinfecting of the PACE center as assigned and in accordance with current CDC guidelines Responsibilities Under the supervision of the RN, assists with the Activities of Daily Living (ADL) needs of participants both at the PACE center and in participants’ homes (i.e., community, Assisted Living Facilities, Rest Homes, Supportive Housing programs, etc.) Contributes to the development of a care plan for participants through interaction with other members of the Interdisciplinary Team. Collaborates with members of the Interdisciplinary Team to assure appropriateness and continuity of care. Carries out non-skilled treatments including, but not limited to vital signs, transfers, toileting, bathing, dressing at the PACE Center and in the community. Assists the Supervisor, Recreational Activities and other activities staff with individual and group programs by helping to plan individual treatment programs, increasing participants’ motivation to participate, assisting participants to participate when needed, and assisting with evaluation of program effectiveness. Assists registered therapists and certified therapy assistants with treatments and participant-specific activities which are ordered for each participant and assigned by the registered therapist including, but not limited to, positioning, transfers, ambulation, and exercises. Maintains a clean and safe working and/or living environment in the PACE center and/or participants’ homes. Assists with meal and snack preparation, serving, feeding as needed, and clean-up. Uses safe techniques in all interactions with participants at the PACE Center and in participants’ homes. Provides accurate and timely documentation in the EMR and other systems as required by SE policies and procedures and/or as assigned by supervisor. Participates in carrying out schedule of daily cleaning and disinfecting of the PACE center in accordance with CDC guidelines for increased precautions Actively participates in distribution of work for health aides to ensure care needs of participants and site tasks are completed timely and appropriately including but not limited to community-based care and center-based tasks, as assigned Actively participates in regular team meetings for health aides at respective site Participates in carrying out infection control precautions and increased cleaning and disinfecting of the PACE center as assigned and in accordance with current CDC guidelines Performs all duties in accordance with FH and Summit ElderCare policies and procedures. Qualifications Education: Completion of an approved Home Health Aide or Certified Nursing Assistant Training Program is highly desirable, but we will accept equivalent work experience in lieu of certificate. Certification: Certification as a Home Health Aide or Nursing Assistant is desired. Reliable Transportation Required. Experience: One year of experience working with a frail and/or older adult population preferably in a PACE program. If under one year, must complete Summit Eldercare training program for health aides prior to working with participants independently. Must complete a standardized set of Summit Eldercare competencies for Health Aides on an annual basis. Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. #P03