Utilization Review Nurse Jobs

RN Manager/Supervisor Utilization Review Full-time
Personal Touch Home Aides of New York

(RN) Quality Review Manager- Registered Nurse

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

Utilization Management Claims Review Nurse RN II

L.A. Care Health Plan Los Angeles, CA
$88,854 - $142,166 / year
Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job Summary The Utilization Management (UM) Claims Review Nurse RN II is responsible for conducting clinical review of medical claims to ensure services were medically necessary, appropriately documented, accurately billed, and compliant with established clinical policies and regulatory standards. This position supports payment integrity initiatives through retrospective and pre-payment review processes, helps reduce unnecessary denials, and monitors for potential fraud, waste, and abuse (FWA). The UM Claims Review Nurse RN II collaborates closely with internal teams to ensure accurate adjudication and compliance. This position collaborates closely with internal stakeholders and external entities to support compliance with state, federal, and accreditation requirements. Duties Perform claims pre-payment review by supporting the Claims team in evaluating flagged claims prior to adjudication to ensure services are medically necessary, documentation supports billed services, coding is accurate and aligned with authorization when applicable, and unnecessary denials are reduced through accurate clinical validation. Conduct comprehensive retrospective reviews, applying established clinical criteria, policies, and regulatory guidelines to determine medical necessity and appropriateness of services rendered. Complete Provider Dispute Review (PDR) clinical evaluations for disputed claims requiring medical necessity scrutiny and clinical determination. Apply internal and external clinical policies, including those developed by the Clinical Policy team, to ensure compliance with guidelines intended to limit fraud, waste, and abuse (FWA). Ensure adherence to federal and state regulations, and accreditation standards. Monitor trends related to contested claims and identify potential FWA concerns; escalate findings in accordance with organizational compliance protocols. Collaborate with internal teams to support payment integrity initiatives. Provide clear, well-documented clinical rationales supporting approval, denial, or adjustment decisions. Maintain productivity and quality standards consistent with departmental expectations. Participate in audits, regulatory readiness activities, and quality improvement initiatives as assigned. Document review outcomes clearly and accurately within designated systems, ensuring audit readiness and traceability. Remain current with evolving clinical guidelines, coding standards, reimbursement methodologies, and regulatory requirements. Perform other duties as assigned. Duties Continued Education Required Associate's Degree in Nursing Education Preferred Bachelor's Degree in Nursing Experience Required: At least 5 years of experience in Clinical Nursing. At least 3 years of experience with Medi-Cal and Medicare in a managed care environment. Experience in performing and creating clinical documentation. Experience in regulatory compliance for a health plan. Preferred: Experience with Provider Dispute Review (PDR) processes. Experience applying clinical guidelines (e.g., InterQual, MCG, or internally developed criteria) in processes. Prior experience in payment integrity, compliance, or fraud, waste, and abuse (FWA) monitoring. Skills Required: Knowledge of medical necessity criteria, reimbursement principles, and managed care operation. Working knowledge of clinical policies. Working knowledge of CPT/HCPC Codes, and ICD-10. Proficient in claims processing systems and electronic medical record platforms. Strong problem-solving skills and the ability to identify discrepancies, assess risk, and recommend actionable solutions. Strong verbal and written communication skills. Ability to work independently with a high degree of initiative, organization, and self-direction. Ability to work effectively with diverse teams in cross-functional work groups. Ability to multitask, re-prioritize tasking, and streamline day-to-day operations. Familiarity with regulatory and accreditation standards (e.g., CMS, Medi-Cal, NCQA). Understanding of the managed care industry and market conditions. High organizational and time-management skills. Preferred: Strong analytical and investigative skills with the ability to synthesize clinical and claims information into clear, defensible determinations are highly valued. Advanced knowledge of medical necessity criteria tools such as InterQual or MCG. Extensive knowledge in claims reviews includes retrospective reviews, pre-payment claims review, and medical necessity determinations. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California License Licenses/Certifications Preferred Required Training Physical Requirements Light Additional Information Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. L.A. Care offers a wide range of benefits including Paid Time Off (PTO) Tuition Reimbursement Retirement Plans Medical, Dental and Vision Wellness Program Volunteer Time Off (VTO)
RN Utilization Review Full-time
Albany Medical Center

Utilization Management Specialist (RN): Salary, 40hrs/week - DAYS

Albany Medical Center Albany, NY
$84,783 - $131,414 / year
Department/Unit: Care Management/Social Work Work Shift: Day (United States of America) Salary Range: $84,783.00 - $131,414.00 Under direction of the Manager of Utilization Management, the Utilization Management Specialist is responsible for the coordination, processing and tracking of all potential utilization concerns from the third party payors for Albany Medical Center; and to do other related work as required. This individual will act as a liaison with all payors and review agents, providing required acuity information regarding patients and issuing notice of non-coverage as appropriate. This position is also responsible for the processing of adverse determinations received from third party payors, coordinating with Patient Financials Services, Admitting/Access Operations, attending physicians, Medical Director and AMC Case Managers and R1 Physician advisory services. Requirements: Graduate of a professional academic nursing program in which a Diploma, Associate Degree or Baccalaureate Degree is conferred. Bachelor's degree preferred. A Bachelor’s Degree in a Health-related field is required. Registered nurse with a New York State current license A minimum of 5 years clinical experience in acute care setting with at least two years in case or utilization management. Skills and Knowledge: Knowledge of care delivery documentation systems and related medical record documents. Strong broad-based clinical knowledge and understanding of pathology/physiology. Excellent written and verbal communication skills and critical thinking skills. Experience with Milliman MCG, InterQual criteria, and knowledge of IPRO and retrospective review process. Ability to work independently and demonstrate organizational and time management skills. Computer literacy and familiarity with basic office equipment and software. Working knowledge of Medicare reimbursement system and coding structures preferred. Essential Duties & Responsibilities , including but not limited to: Mission, Core Values and Service Excellence: Contributes to the creation of a compassionate and caring environment for patients, families and colleagues through displays of kindness and active listening. Recognizes and appreciates that each employee’s work is valuable and contributes to the success of the Mission. Demonstrates excellence in daily work. Actively participates in performance and quality improvement activities and works toward enhancing customer/patient satisfaction. Exhibits positive service excellence skills to patients, visitors and coworkers by greeting others in a friendly manner, keeping customers/patients/colleagues informed about progress, delays and changes. Demonstrates effective teamwork by interacting in a positive manner with colleagues and creating a collaborative work environment. Initiates open communication, conveys positive intent, offers assistance. Contributes to a safe and secure environment for patients, visitors, colleagues by following established procedures and protocols, which address the needs of a diverse patient population and workforce. Demonstrates stewardship by thoughtful and responsible use of resources including maintaining a clean and hospitable environment, starting work on time, displaying a consciousness regarding costs, supplies and department finances. Demonstrates respect for individual differences of each person by acknowledging the essence of each person, appreciating and responding to unique, spiritual, personal and cultural backgrounds of patients, families and colleagues. Strategic and Operational Planning Supports the Manager in planning, organizing, directing of the Utilization Management services of AMC; and to do other related work as required. Participates in the development of departmental goals and develops plans to achieve those goals. Planning and Program Development Act as contact person for payors regarding utilization issues, i.e., carve outs, denials, downgrading and potential utilization concerns, providing required communication regarding patient acuity. Coordination of appeal of adverse determination, working with Service Case manager, Attending physician, Case manager, Medical Director, R1 Physician advisory services. for concurrent resolution of issue, prevention of retrospective denial and delay in payment for the institution. Maintain all correspondence and provide follow up with third party payors, commercial insurers, and IPRO. In conjunction with the service Case Manager, issue HINN notice and reinstatement to patients when indicated with focus on accuracy, timeliness, and diplomacy. Demonstrate in-depth knowledge of utilization criteria for Medicare, Medicaid, and private insurers. Delegates and coordinates the work of Utilization Review ASA support staff. Tracks denials and develops action plans to decrease bad debt. Maintain database of utilization issues and identify trends in payor activity through generation of statistical reports. Complete end of month reports. Educational Leadership Working knowledge of how to research changes in CMS and payor regulations and project impact of these changes on AMC and communicate this information. Demonstrates proper use of MCG and documentation requirements through case review and inter-rate reliability studies. Attends all mandatory hospital in-service education. Ability to analyze data and identify trends and project expected response to changes in health care reimbursement system. Hospital-wide Leadership Models AMC cares standards Demonstrates wiliness to participate in hospital wide initiatives. Patient Safety Assists in the development of policies and procedures, standards of care and practice, and in the monitoring processes in relations to those standards. Maintains complete confidentiality of patient information, in addition to hospital and individual physician practice pattern data. Provides information and in services as necessary to physicians and ancillary staff. Practices in an environmentally safe and healthy manner. Thank you for your interest in Albany Med Health System!​ Albany Med Health System is an equal opportunity employer. This role may require access to information considered sensitive to Albany Med Health System, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that: Access to information is based on a “need to know” and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Med Health System policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification.
RN Utilization Review Part-time
Riverside Health System

Registered Nurse Peer Review-Labor Pool-Days

Riverside Health System Newport News, VA
Newport News, Virginia Labor Pool-Days Available The Peer Review Analyst is responsible for supporting activities related to the peer review process. The peer review process includes daily review of cases entered into the Riverside safety event reporting application "rCare" risk and peer review modules as well as other case finding methods as assigned, such as review of morbidity and mortality cases. Independently performs review of electronic medical records for potential, assigned and referred cases, and develops a summary of the case with focus questions. Maintains knowledge of the rCare risk and peer review modules and all associated policies, procedures, workflows, and business rules. Has knowledge of standard reports and is able to run standard reports and create on demand reports to routinely check for rCare file completeness, identify outstanding items to follow up on, determine the volume of cases by peer review committee, department or unit as requested. Runs reports to verify activity and status of cases referred to each peer review committee, as well as cases closed and adjudicated for outcomes. What you will do Support all aspects of the rCare Peer Review Process and complete assignments in a timely manner. Review cases referred to peer review are entered into the rCare Peer Review module, and require a case summary with timeline when appropriate, with focused questions posed to the assigned peer reviewer. Conducts an initial review and develops a case summary if the case requires further review. The case summary should identify focused questions for review by the Peer Review Coordinator for collaboration with Chief Medical Officer and Quality Director, identifies cases appropriate for referral to peer review. Identify and use multiple methods for case finding using triggers, quality screens, complication reports, and mortality reports as well as rCare risk/safety event reports, patient/family complaints, EPIC reports, service line dashboards, etc. Obtains and seeks continual education related to the peer review process. Follows up with assigned peer reviewer to assure timely responses and referral to the appropriate Peer Review committee for further discussion and adjudication. Maintains an electronic log with the status report of peer review cases by medical specialty that includes cases identified for potential external peer review. Assures all peer reviewed cases have a completed analysis, conclusions, recommendations and actions documented in both the case summary. Qualifications Education Bachelors Degree, Nursing (Preferred) Experience 3-4 years Recent patient care in acute care setting (Required) Computer experience including Microsoft Office Suite (Work, Excel) and data entry skills (Required) 3-4 years Related experience in quality, patient safety or risk management (Preferred) Knowledge of report building and graphs (Preferred) Licenses and Certifications Registered Nurse (RN) - Virginia Department of Health Professions (VDHP) Upon Hire(Required) To learn more about being a team member with Riverside Health System visit us at https://www.riversideonline.com/careers .
RN Utilization Review Full-time
L.A. Care Health Plan

Utilization Management Clinical Quality Nurse Reviewer RN II

L.A. Care Health Plan Los Angeles, CA
$88,854 - $142,166 / year
Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job Summary The Utilization Management Clinical Quality Nurse Reviewer RN II, under the purview of the Utilization Management (UM) Department Leadership Team, is responsible for conducting and tracking targeted and random internal department documentation audits. This role ensures that UM practices and supporting documentation are compliant with all regulatory requirements. The Incumbent also serves as a Subject Matter Expert during external audits as well as leads pre- and post-audit preparation/follow-up. This position actively participates in the development and review of policies and procedures to certify compliance with regulatory guidelines and mandates. This position focuses on UM cases for all lines of business to identify areas of opportunity for increasing positive audit outcomes and improved service to L.A. Care’s membership. This position is responsible for identifying and monitoring staff (non-clinical, nurse, and physician) performance against key performance indicator trends that warrant recognition or remediation. This position performs data mining and analysis and creates reports on audit findings, as well as makes recommendations, to submit to the department's Quality Assurance Team and UM Management. Duties Facilitates the development, review, and revision of organizational and departmental process flows to ensure compliance with relevant regulatory, organizational, and departmental guidelines. Keenly focuses on practices and documentation of clinical staff, serving as a resource on state and federal industry mandates applicable to UM functions. Generates results of findings, enhances, and analyzes various reports related, but not limited to, quality and accuracy of case documentation. Works with department leadership to assess for all opportunities related to quality improvements. Compiles and presents quality report cards that measure adherence to quality and regulatory compliance. Keeps UM Leadership apprised of departmental and industry trends, deficiencies, and any potential risks, and collaborates with the team to develop and execute mitigation efforts. Serves as a consultant to the organization's Compliance team on an ad hoc basis. Performs other duties as assigned. Duties Continued Education Required Associate's Degree in Nursing Education Preferred Bachelor's Degree Master's Degree in Nursing Experience Required: At least 5 years of experience in Clinical Nursing. Minimum of 2 years of auditing clinical documentation. Active participation in at least two state regulatory audits and one federal regulatory audits. Previous experience with Medi-Cal and Medicare in a managed care environment and experience with mitigation planning and implementation. Preferred: Experience performing clinical documentation for a health plan. Active participation in at least three state regulatory audits, at least one National Committee for Quality Assurance (NCQA) audit and/or Centers for Medicare and Medicaid Services (CMS) audit. Background in teaching and/or clinical education. Skills Required: Superior verbal and written communication skills. Advanced computer proficiency in both Microsoft Word and Excel. Strong analytical and team building skills. Ability to work independently and be self-directed. Ability to work effectively with diverse team members. Strong problem-solving skills. Ability to multitask and streamline day-to-day operations. Ability to translate regulatory requirements into auditable tools. Preferred: Proven ability to lead successful performance improvement projects. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California License Licenses/Certifications Preferred Required Training Physical Requirements Light Additional Information Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. L.A. Care offers a wide range of benefits including Paid Time Off (PTO) Tuition Reimbursement Retirement Plans Medical, Dental and Vision Wellness Program Volunteer Time Off (VTO)
LPN Utilization Review MDS Full-time
Confidential Healthcare Facility

Utilization Review (MDS) – RN/LPN

Confidential Healthcare Facility Valley Stream, NY
$90,000 - $125,000 / hour
Utilization Review (MDS) – RN/LPN Location: Valley Stream, New York Job Type: Full-Time Schedule: Hybrid (Onsite Required 4 Days per Week) Compensation: $90,000 – $125,000 annually (DOE) About the Role We are seeking an experienced Utilization Review (MDS) RN/LPN to support Skilled Nursing Facility (SNF) operations and ensure accurate clinical review, care coordination, and reimbursement optimization. This position plays a key role in managing utilization review activities, supporting MDS-related processes, and collaborating with interdisciplinary teams to achieve positive clinical and financial outcomes. The ideal candidate will possess a strong background in skilled nursing, utilization review, managed care, and reimbursement processes. Key Responsibilities Utilization Review & MDS Management Conduct utilization review activities for SNF residents to ensure appropriate level of care and reimbursement. Review admissions, continued stays, payer changes, and discharge planning activities. Coordinate prior authorizations, clinical updates, denials, reconsiderations, and appeals with managed care organizations. Monitor reimbursement opportunities and ensure compliance with payer guidelines and regulatory requirements. Collaborate with interdisciplinary teams to support care planning and clinical outcomes. Review and analyze MDS assessments for accuracy, completeness, and reimbursement optimization. Participate in utilization review meetings and daily census management activities. Ensure timely issuance and submission of denial notices, NOMNCs, and related documentation. Maintain detailed and accurate records of all utilization management activities. Qualifications Required Active and unrestricted RN or LPN license . Minimum 3 years of experience in Skilled Nursing Facilities (SNF), utilization review, MDS coordination, managed care, case management, or related healthcare settings. Strong understanding of: MDS processes and reimbursement methodologies Utilization review and utilization management Prior authorizations and payer requirements Denials management and appeals Medicare, Medicaid, and managed care reimbursement Experience working with EMR systems and insurance portals. Excellent organizational, communication, and problem-solving skills. Ability to manage multiple priorities in a fast-paced environment. Preferred RAC-CT, CPC, CPUR, CCM, or related certifications. Experience working within the New York healthcare market. Why Join Us? Competitive salary: $90,000 – $125,000 DOE Hybrid work schedule with strong work-life balance Opportunity to make a direct impact on patient outcomes and reimbursement success Collaborative interdisciplinary team environment Professional growth and advancement opportunities Stable and growing healthcare organization How to Apply If you are an experienced RN or LPN professional with expertise in Utilization Review, MDS, and managed care , we encourage you to apply and become part of a team dedicated to delivering exceptional patient care while ensuring operational excellence. Apply today to advance your healthcare career with a meaningful and impactful role. INDCONF3
RN Utilization Review Full-time
Swedish Health Services

Utilization Review RN - Case Management

Swedish Health Services Seattle, WA
$52.26 - $81.13 / hour
Description The Utilization Review (UR) Nurse has a strong clinical background blended with a well-developed knowledge and skills in Utilization Management (UM), medical necessity and patient status determination. This individual supports the UM program by developing and maintaining effective, efficient processes for determining the appropriate admission status based on regulatory and reimbursement requirements of commercial and government payers. The UR nurse is responsible for performing admission, concurrent and retrospective UR related reviews and functions to ensure that appropriate data is tracked, evaluated and reported. This individual actively participates in process improvement initiatives, working with multiple departments and multi-disciplinary staff. This role requires current and accurate knowledge regarding commercial and government payers as well as accreditation regulations/guidelines/criteria related to UM. Providence caregivers are not simply valued – they’re invaluable. Join our team at Swedish Shared Services and thrive in our culture of patient-focused, whole-person care built on understanding, commitment, and mutual respect. Your voice matters here, because we know that to inspire and retain the best people, we must empower them. Required Qualifications Bachelor's Degree in Nursing degree (BSN) from an accredited school of nursing. Washington Registered Nurse License upon hire. 3 years of Registered nursing experience in the clinical setting. Preferred Qualifications ACM or CCM certification upon hire. 1 year of Case management experience. Why Join Providence? Our best-in-class benefits are uniquely designed to support you and your family in staying well, growing professionally and achieving financial security. We take care of you, so you can focus on delivering our mission of improving the health and wellbeing of each patient we serve. About Providence At Providence, our strength lies in Our Promise of “Know me, care for me, ease my way.” Working at our family of organizations means that regardless of your role, we’ll walk alongside you in your career, supporting you so you can support others. We provide best-in-class benefits and we foster an inclusive workplace where diversity is valued, and everyone is essential, heard and respected. Together, our 120,000 caregivers (all employees) serve in over 50 hospitals, over 1,000 clinics and a full range of health and social services across Alaska, California, Montana, New Mexico, Oregon, Texas and Washington. As a comprehensive health care organization, we are serving more people, advancing best practices and continuing our more than 100-year tradition of serving the poor and vulnerable. Posted are the minimum and the maximum wage rates on the wage range for this position. The successful candidate's placement on the wage range for this position will be determined based upon relevant job experience and other applicable factors. These amounts are the base pay range; additional compensation may be available for this role, such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities. Providence offers a comprehensive benefits package including a retirement 401(k) Savings Plan with employer matching, health care benefits (medical, dental, vision), life insurance, disability insurance, time off benefits (paid parental leave, vacations, holidays, health issues), voluntary benefits, well-being resources and much more. Learn more at providence.jobs/benefits. Applicants in the Unincorporated County of Los Angeles: Qualified applications with arrest or conviction records will be considered for employment in accordance with the Unincorporated Los Angeles County Fair Chance Ordinance for Employers and the California Fair Chance Act. About The Team Providence Swedish is the largest not-for-profit health care system in the greater Puget Sound area. It is comprised of eight hospital campuses (Ballard, Edmonds, Everett, Centralia, Cherry Hill (Seattle), First Hill (Seattle), Issaquah and Olympia); emergency rooms and specialty centers in Redmond (East King County) and the Mill Creek area in Everett; and Providence Swedish Medical Group, a network of 190+ primary care and specialty care locations throughout the Puget Sound. Whether through physician clinics, education, research and innovation or other outreach, we’re dedicated to improving the wellbeing of rural and urban communities by expanding access to quality health care for all. Providence is proud to be an Equal Opportunity Employer. We are committed to the principle that every workforce member has the right to work in surroundings that are free from all forms of unlawful discrimination and harassment on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law. We believe diversity makes us stronger, so we are dedicated to shaping an inclusive workforce, learning from each other, and creating equal opportunities for advancement. For any concerns with this posting relating to the posting requirements in RCW 49.58.110(1), please click here where you can access an email link to submit your concern. Requsition ID: 438062 Company: Swedish Jobs Job Category: Health Information Management Job Function: Revenue Cycle Job Schedule: Per-Diem Job Shift: Day Career Track: Nursing Department: 3900 SS CASE MANAGEMENT Address: WA Seattle 1730 Minor Ave Work Location: Swedish Metropolitan Park East-Seattle Workplace Type: On-site Pay Range: $52.26 - $81.13 The amounts listed are the base pay range; additional compensation may be available for this role, such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities.
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
Baptist Health South Florida

Utilization Review Registered Nurse, Case Management, FT, 07A-7:30P Local Remote

Baptist Health South Florida Boca Raton, FL
$73,860.80 - $96,019.04 / year
Baptist Health is the region's largest not-for-profit healthcare organization, with 12 hospitals, over 29,000 employees, 4,500 physicians and 200 outpatient centers, urgent care facilities and physician practices across Miami-Dade, Monroe, Broward and Palm Beach counties. With internationally renowned centers of excellence in cancer, cardiovascular care, orthopedics and sports medicine, and neurosciences, Baptist Health is supported by philanthropy and driven by its faith-based mission of medical excellence. For 26 years, we've been named one of Fortune's 100 Best Companies to Work For, and in the 2025-2026 U.S. News & World Report Best Hospital Rankings, Baptist Health was the most awarded healthcare system in South Florida, earning 63 high-performing honors. What truly sets us apart is our people. At Baptist Health, we create personal connections with our colleagues that go beyond the workplace, and we form meaningful relationships with patients and their families that extend beyond delivering care. Many of us have walked in our patients' shoes ourselves and that shared experience fuels out commitment to compassion and quality. Our culture is rooted in purpose, and every team member plays a part in making a positive impact – because when it comes to caring for people, we're all in. At Baptist Health, we’re committed to supporting our employees at every stage of their journey, both personally and professionally. Our approach is rooted in a “grow our own” philosophy, designed to help our team members build meaningful, long-term careers with us, supported by benefits that make a real difference, including: Career growth and development opportunities , with clear pathways and ongoing support Comprehensive health and wellness resources that go beyond traditional benefits A wellness program that can help employees eliminate their medical plan deductible, reducing out-of-pocket healthcare costs Tuition reimbursement to support continued learning and advancement And so much more Together, these benefits and others reflect our commitment to caring for our people, so they can build fulfilling careers with us while making a meaningful impact every day. Description: The purpose of this position is to conduct initial, concurrent, retrospective chart review for clinical financial resource utilization. Coordinates with healthcare team for optimal/efficient patient outcomes, while decreasing length of stay (LOS) and avoid delays and denied days. They are accountable for a designated patient caseload and provides intervention, coordination to decrease avoidable delays, denial of reimbursement. Specific functions within this role include: Screens pre-admission, admission process using established criteria for all points of entry. Facilitates communication between payers, review agencies, healthcare team. Identify delays in treatment or inappropriate utilization and serves as a resource. Coordinates communication with physicians. Identify opportunities for expedited appeals and collaborates to resolve payer issues. Ensures/Maintains effective communication with Revenue Cycle Departments. Estimated salary range for this position is $73860.80 - $96019.04 / year depending on experience. Qualifications: Degrees: Associates. Licenses & Certifications: MCG Care Guidelines Specialist. Registered Nurse. Additional Qualifications: RNs hired prior to 2-2012 (10/1/2017 at Bethesda or 7/1/2019 at BRRH) with an Associates Degree in Nursing are not required to have a BSN to continue their non-leadership role as an RN. however, they are required to complete the BSN within 3 years of job entry date. MCG Specialist Certification ISC/HRC required within 12 months of job entry date. 3 years of Nursing experience preferred. Excellent written, interpersonal communication and negotiation skills. Strong critical thinking skills and the ability to perform clinical/chart review abstract information efficiently. Strong analytical, data management and computer skills. Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components. Current working knowledge of payer and managed care reimbursement preferred. Ability to work independently and exercise sound judgment in interactions with the health care team and patients/families. Knowledgeable in local, state, and federal legislation and regulations. Ability to tolerate high volume production standards. Minimum Required Experience: 3 Years of Nursing experience with 1 year of previous Utilization Review experience required. EOE, including disability/vets
RN Utilization Review Full-time
Centene

Clinical Review Nurse - Concurrent Review (RN)

Centene Woodland Hills, 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. Location: Remote. Must work PST hours. *Must hold RN license in California. 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: For Health Net of California: RN license required. Must be licensed in CA. 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 Part-time
Capital Health

Utilization Review RN - PT - Day - Utilization Resource Mgmt Pennington NJ

Capital Health Hopewell, VA
$39.40 - $51.47 / hour
Capital Health is the region's leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advanced technology. Capital Health is a dynamic health care resource accredited by the DNV that includes two hospitals, an outpatient center, satellite ED, and an expansive network of primary and specialty care. Capital Health Medical Group is made up of more than 600 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region. Capital Health recognizes that attracting the best talent is key to our strategy and success as an organization. As a result, we aim for flexibility in structuring competitive compensation offers to ensure we can attract the best candidates. The listed pay range or pay rate reflects compensation for a full-time equivalent (1.0 FTE) position. Actual compensation may differ depending on assigned hours and position status (e.g., part-time). Pay Range: $39.40 - $51.47 Scheduled Weekly Hours: 40 Position Overview *Please note - this is not a remote position* Performs a variety of utilization and resource management activities to promote quality, clinical and cost-effective outcomes. Assesses patients treatment plans, communicates to third party payers, and collaborates with healthcare team members. Performs functions which help to optimize lengths of stay, utilize resources efficiently, and promote cost effective practices without negatively impacting patient care. Adheres to established standards, practices and procedures. MINIMUM REQUIREMENTS Education: Associate's degree in nursing. Graduate of an accredited school of nursing. CPHQ, CCM or CPUR preferred. Experience: Five years' clinical nursing and three years quality management, utilization review or discharge planning experience. Other Credentials: Registered Nurse - NJ Knowledge and Skills: Special Training: Basic computer skills including the working knowledge of Microsoft Office, UR software and EMR. Possesses familiarity with MCG guidelines. Mental, Behavioral and Emotional Abilities: Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form. Usual Work Day: 8 Hours Reporting Relationships Does this position formally supervise employees? No If set to YES, then this position has the authority (delegated) to hire, terminate, discipline, promote or effectively recommend such to manager. ESSENTIAL FUNCTIONS Performs chart review of identified patients to identify quality, timeliness and appropriateness of patient care. Conducts admission reviews for Medicare, Medicaid beneficiaries, as well as private insurers and self pay patients, based on appropriate guidelines. Uses these criteria guidelines to screen for appropriateness for inpatient level of care or observation services based on physician certification (physicians H&P, treatment plan, potential risks and basis for expectation of a 2 midnight stay). Refers cases as appropriate, to the UR physician advisor for review and determination. Gathers clinical information to conduct continued stay utilization review activities with payers on a daily basis. Performs concurrent and retrospective clinical reviews with various payers, utilizing the appropriate guidelines as demonstrated by compliance with all applicable regulations, policies and timelines. Adheres to CMS guidelines for utilization reviews as evidenced by utilization of the relevant guidelines and appropriate referrals to the physician advisor and the UR Committee. Identifies, develops and implements strategies to reduce length of stay and resource consumption. . Confers proactively with admitting physician to provide coaching on accurate level of care determinations at point of hospital entry. Keeps current on all regulatory changes that affect delivery or reimbursement of acute care services. Uses knowledge of national and local coverage determinations to appropriately advise physicians. Understands and applies federal law regarding use of Hospital Initiated Notice of Non-Coverage (HINN) and Lifetime Reserve Days letters. Identifies and records consistently any information on any progression of care or patient flow barriers using the Avoidable Days tool in Utilization software program. Consults with medical staff, care team and case managers as necessary to resolve immediate progression of care barriers through appropriate administrative and medical channels. Engages care team colleagues in collaborative problem solving regarding appropriate utilization of resources. Recognizes and responds appropriately to patient safety and risk factors. Represents Utilization Management at various committees, professional organizations an physician groups as needed. Promotes the use of evidence based protocols and or order sets to influence high quality and cost effective care. Identifies, develops and implements strategies to reduce lengths of stay and resource consumption in patient population. Participates in performance improvement activities. Promotes medical documentation that accurately reflects findings and interventions, presence of complication or comorbidities, and patient's need for continued stay. Identifies and records episodes of preventable delays or avoidable days due to failure of progression of care processes. Maintains appropriate documentation in Utilization software system on each patient to include specific information of all resource utilization activities. Participates actively in daily huddles, patient care conferences, and hospitalist or nurse handoff reports to maintain knowledge about intensity of services and the progression of care. Identifies potentially wasteful or misused resources and recommends alternatives if appropriate by analyzing clinical protocols. Performs other duties as needed. PHYSICAL DEMANDS AND WORK ENVIRONMENT Frequent physical demands include: Sitting , Standing , Walking Occasional physical demands include: Climbing (e.g., stairs or ladders) , Carry objects , Push/Pull , Twisting , Bending , Reaching forward , Reaching overhead , Keyboard use/repetitive motion , Talk or Hear Continuous physical demands include: Lifting Floor to Waist 15 lbs. Lifting Waist Level and Above 15 lbs. Sensory Requirements include: Accurate Near Vision, Accurate Far Vision, Accurate Color Discrimination, Accurate Depth Perception, Accurate Hearing Anticipated Occupational Exposure Risks Include the following: N/A This position is eligible for the following benefits: Medical Plan Prescription drug coverage & In-House Employee Pharmacy Dental Plan Vision Plan Flexible Spending Account (FSA) - Healthcare FSA - Dependent Care FSA Retirement Savings and Investment Plan Basic Group Term Life and Accidental Death & Dismemberment (AD&D) Insurance Supplemental Group Term Life & Accidental Death & Dismemberment Insurance Disability Benefits – Long Term Disability (LTD) Disability Benefits – Short Term Disability (STD) Employee Assistance Program Commuter Transit Commuter Parking Supplemental Life Insurance - Voluntary Life Spouse - Voluntary Life Employee - Voluntary Life Child Voluntary Legal Services Voluntary Accident, Critical Illness and Hospital Indemnity Insurance Voluntary Identity Theft Insurance Voluntary Pet Insurance Paid Time-Off Program The pay range listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future. When determining base salary and/or rate, several factors may be considered including, but not limited to location, years of relevant experience, education, credentials, negotiated contracts, budget, market data, and internal equity. Bonus and/or incentive eligibility are determined by role and level. The salary applies specifically to the position being advertised and does not include potential bonuses, incentive compensation, differential pay or other forms of compensation, compensation allowance, or benefits health or welfare. Actual total compensation may vary based on factors such as experience, skills, qualifications, and other relevant criteria.
LPN Utilization Review Full-time
Guthrie

LPN Utilization Management Reviewer - Case Management - Full Time

Guthrie Cortland, NY
$20.38 - $31.81 / hour
This position is eligible for up to $15,000.00 Sign on Bonus for those that are eligible. ($7,500.00 for those with less than one year of experience) Summary The LPN Utilization Management (UM) Reviewer, in collaboration with Care Coordination, Guthrie Clinic offices, other physician offices, and the Robert Packer Hospital Business Office, is responsible for the coordination of Utilization Management (UM) processes and requirements of prior authorization/certification for reimbursement of patient care services. The responsibilities include: - Facilitating communication between physician offices, payers, Care Coordination and other hospital departments as appropriate to obtain prior authorization required to meet contractual reimbursement requirements and to assist in ensuring generation of clean claims in a timely manner - Securing authorization as appropriate - Documenting payer authorization - Facilitating issue resolution with payer sources in collaboration with other hospital departments or clinic offices as appropriate - Demonstrating ongoing competence in payer requirements, as defined collaboratively with Patient Business Services and Care Coordination Additionally, the position works closely with the Care Coordination department to support data collection and aggregation associated with UM processes and operations. Experience Minimum of five years clinical experience in an acute health care setting. Must possess strong communication and organizational skills, be able to work independently and to complete work within specified time frames. Knowledge of health benefit plans and related UM requirements preferred. Experience with CPT/ICD coding, medical record or chart auditing, and experience in utilization management processes preferred. Knowledge of computer applications (such as Microsoft word processing and spreadsheets) desirable Education/License Current LPN licensure or eligibility for licensure required Essential Functions 1. Conducts validation of the authorization/certification process for elective short procedures and inpatient care services in collaboration with physician offices, hospital Business Office, Care Coordination and other hospital departments as appropriate.2. Ensures documentation and communication of authorizations and certifications as appropriate. 3. Performs routine admission and discharge notification according to payer requirements. 4. Assists to ensure compliance with documentation requirements and guidelines of third-party payers, regulatory and government agencies. 5. Develops and maintains collaborative relationships with members of the healthcare team. - Proactively researches case findings related to payer audits of UM decisions and prepares input for supporting documentation to complete the revenue cycle process, coordinates as necessary with the hospital Business Office, physician offices, Care Coordination, Medical Director and other hospital departments as appropriate.1. Serves as liaison with payers, hospital Business Office, physician offices, Care Coordination and other hospital departments as appropriate for resolution of issues or questions. 2. Collaborates with the hospital Business Office, physician offices, Care Coordination and other hospital departments as appropriate to track and monitor the status for denials and appeals. - Participates in performance improvement and educational activities.1. Serves as an educational resource to other members of the healthcare team with regards to changes in reimbursement, payers, and/or utilization requirements. 2. Participates in departmental long-range planning to meet the needs identified through utilization management activities. 3. Demonstrates appropriate problem solving and decision-making skills. 4. Maintains the required 8 hours of continuing education per year. Other Duties It is understood that this description is not intended to be all inclusive, and that other duties may be assigned as necessary in the performance of this position. Pay Range $20.38-$31.81/hr Dependent on years of applicable experience.
RN Utilization Review Full-time
Temple Health

RN-Utilization Review- 40/hrs, Day Shifts (Temple Hospital)

Temple Health Philadelphia, PA
Utilizing InterQual and other appropriate criteria, responsible for reviewing all admissions and continued stay of patients in conformance with the established criteria set forth in the hospital's utilization management and quality assurance plan. Will determine the medical necessity for admission and continued stays for patients within department's scope of service and to meet the hospital's objectives for assuring a high quality of patient care as well as assuring the effective and efficient utilization of available health services. Identifies appropriate level of care for inpatients and outpatients requiring overnight care. Education Other Graduate Of An Accredited School Of Nursing Required Bachelor's Degree BSN Required Experience 1 year experience of recent Utilization Review in acute care or in insurance company setting. Required 1 Year Experience In Medical-surgical Setting. Required 1 year experience in working with competency utilizing InterQual criteria. Required General Experience In Working With Utilization Review Standards Required Licenses PA Registered Nurse License Required Certified Case Manager Preferred Multi State Compact RN License Required Or
RN Utilization Review Full-time
Wooster Community Hospital Health System

2217 Utilization Review Nurse PT

Wooster Community Hospital Health System Wooster, OH
2217 Utilization Review Nurse PT MAIN FUNCTION: The Utilization Management Nurse Reviewer (RN) serves as the Subject Matter Expert for the organization for patient admission status (inpatient and observation) and works with Providers, Case Management, and the Revenue Cycle team in a consultative manner to ensure appropriate admission status. The UM RN protects the financial interests of the organization by ensuring that the UM review cycle is successfully completed from the point of admission through and including appeal of any denials received. The UM RN is an integral part of the Revenue Cycle team by tracking and trending payer issues and reporting the same to team leaders in order to address identified concerns with payer representatives. REPORTS TO: Manager of Utilization and Denials and System Director of Revenue Cycle MUST HAVE REQUIREMENTS: LPN or RN possessing an active Ohio license 3-5 years clinical nursing experience in varied settings 1-3 year UM experience in an acute care setting Experience using InterQual and/or Milliman criteria. Solid working knowledge of reimbursement methodology. Strong organization, prioritizing and delegation skills. Demonstrated emotional intelligence – self-control, self-awareness, social awareness and relationship management. Excellent oral and written communication Ability to work independently in a fast-paced environment, meeting all deadlines. Ability to problem solve complex, multifaceted situations. Ability to use computers and analytical software. PREFERRED ATTRIBUTES: Bachelor’s degree. UM certification. Strong background in Medicare/Medicaid regulations related to UM and billing compliance. Experience using MCG Indicia tools. POSITION EXPECTATIONS: All expectations detailed below are considered Americans with Disabilities Act (ADA) essential. Follows Appropriate Service Standards Clinical review of 100% of acute bedded patients admitted to inpatient or observation against medical necessity criteria (InterQual or MCG) utilizing provided tools (Meditech, MCG Indicia, payer portals) and prescribed process for appropriateness of status. Clinical review includes the life cycle of the admission, starting with initial case review (ICR) through and including resolution of any claims denied for status or medical necessity. Ensures continued stay reviews are submitted timely per the payer’s requirements, and that responses from the payer include coverage for all days of the stay. Monitors submitted cases for a response from the payer in a timely manner to respond appropriately to any threatened or actual denials immediately to avoid the appeal process whenever possible. Submits reconsiderations immediately (when available) according to the prescribed process. Confers with the Physician Risk Advisor (PRA) on any concerns with current patient status, then communicates needed changes to the attending provider via provided communication tools. Fully documents all case reviews in MCG Indicia/Meditech, including all pertinent information, such as method and proof of submission of all case reviews, results of case reviews and any denials received, communication with PRA and attending providers. Facilitates Peer-to-peer opportunities between the attending provider and the payer. Attends the daily huddle with Case Management and PRA to keep apprised of any changes, and to contribute to the huddle as the Subject Matter Expert on status. Strong collaboration with Case Management, serving as the SME for utilization and status. Ensures that denials are identified in the prescribed manner and ensures all appeals are submitted timely to the payer. Adheres to department productivity standards (35-40 reviews per shift) Assigns submitted appeals to the UM Clerical support team member for follow-up on appeal response. Collaborates with the UM Lead Nurse Reviewer to identify opportunities for improvement through daily work processes and communicates to leadership. Collaborates with the PRA, Director and UM Lead Nurse Reviewer for issues/concerns to submit to the quarterly UM Committee. Performs other duties as assigned, including but not limited to: Demonstrates professional responsibility required of a Utilization Review Nurse. Complies with all department and organization policies at all times. Maintains compliance with all state/federal guidelines and standards, as well as CMS Conditions of Participation. Demonstrates a positive attitude, openness to change and responsiveness to constructive feedback.
RN Utilization Review Internship
Children's Hospital Colorado

Registered Nurse Utilization Review Flex

Children's Hospital Colorado Aurora, CO
$50.68 / hour
Job Overview The Utilization Review RN participates as a member of a multidisciplinary team to support medical necessity reviews, ensure compliance, and actively participate in denial mitigation. It is a collaborative approach that uses pre-established guidelines and criteria to perform review activities to ensure the proper utilization of hospital services and payment of those services by Medicare, Medicaid, and other third-party payors. Department Name: Utilization Management Job Status: flex, not eligible for benefits Shift: variable - must have availability to work at least 24 hours per 2-week pay period. Shifts may include dayshift, evening shift, and weekend shifts, depending on unit staffing needs. Duties & Responsibilities Assesses all new inpatient admissions for identification of status and medical necessity for admission; communicates clinical review process with appropriate Payors. Assesses the continuity of care in conjunction with the Case Managers regarding the continued medical necessity of hospitalization and the status of the discharge plan; communicates this to the appropriate payors. Coordinates with other members of the healthcare team to help identify and control inappropriate resource utilization. Conducts concurrent admission and continued stay reviews based on appropriate utilization review criteria. Utilizes information provided by Patient Access regarding authorized length of stay and follows up with third-party payors on an ongoing basis, documents communications regarding continued authorizations. Follows up on denials communicated to the department and works with the revenue cycle staff to assist with appeals. Maintains and demonstrates appropriate clinical knowledge to assist physicians in providing documentation of severity of illness and intensity of service to assure that criteria for acute hospitalization are met. Employees are expected to comply with all regulatory requirements, including CMS and Joint Commission Standards. Minimum Qualifications EDUCATION – Bachelor of Science in Nursing (BSN) EXPERIENCE – Three years of nursing experience in a pediatric setting or three years of Case Management experience. Needs to include recent UR experience in a hospital or with a Third-Party Payor CERTIFICATION(S) – BLS/CPR from the American Heart Association with at least six (6) months left before expiration is required upon hire LICENSURE – Current Colorado Registered Nurse (RN) license or RN license multistate compact Salary Information Hourly Rate of Pay: $50.68 Benefits Information As a Children’s Hospital Colorado team member, you will receive a competitive pay and benefits package designed to take care of your needs that includes base pay, incentives, paid sick leave and a robust wellness program. As part of our Total Rewards package, Children's Colorado offers an annual employee bonus program that rewards eligible team members based on organizational performance. If organizational goals are met for the year, the bonus is paid out the following April. Children’s Colorado delivers annual base pay increases to eligible team members based on their performance over the previous year. EEO Statement It is our intention that all qualified applicants be given equal opportunity and that selection decisions be based on job-related factors. We do not discriminate on the basis of race, color, religion, national origin, sex, age, disability, or any other status protected by law or regulation. Be aware that none of the questions are intended to imply illegal preferences or discrimination based on non-job-related information. The position is expected to stay open until the posted close date. Please submit your application as soon as possible as the posting is subject to close at any time once a sufficient pool of qualified applicants is obtained. Colorado Residents: In any materials you submit, you may redact or remove age-identifying information such as age, date of birth, or dates of attendance at or graduation from an educational institution. You will not be penalized for redacting or removing this information.
RN Utilization Review Full-time
Southeast Health

Utilization Review Nurse

Southeast Health Dothan, AL
Southeast. Always the right career direction. Job Description Summary The Utilization Review Nurse screens medical records in accordance with contractual agreement and regulatory requirements for medical necessity on admission and continued stay in the acute care setting. The Utilization Review case manager collaborates with all components of the healthcare system, managing appropriate use of acute care to aid in the achievement of quality outcomes, fiscal responsibility, and patient satisfaction. Job Description Essential Functions Performs admissions and continued stay reviews of all inpatients and outpatient/observation patients in a bed; at times, this may be retrospective. Performs precertification on procedures ordered while patients are hospitalized. Issues required Medicare/Medicaid notifications of medical necessity changes to patients while hospitalized. Issues notifications of non-coverage letters to patients if received during hospital stay. Documents clear billing notes into the Electronic Medical Record (EMR) payer communications navigator to avoid billing denials. Performs medical necessity denial appeals. Maintains a close, collaborative relationship with the medical staff to promote continuity of care and avoid delays in service. Performs other duties as requested by primary manager that do not compromise moral code of conduct or protocols set in place for patient or employee safety Supervised Positions None Qualifications Minimum Education Required Associates degree in Nursing Current Registered Nurse license in the State of Alabama Minimum Education Preferred Bachelor’s degree or higher in Nursing Minimum Experience Required Two (2) years acute care experience Must pass Blue Cross Blue Shield Iterator Reliability Test with 90% within six (6) months of hire Minimum Experience Preferred Three (3) years acute care experience One (1) year utilization review experience Required Knowledge/ Skills/ Abilities Maintain current licensure in the State of Alabama Demonstrates appropriate utilization of the skills of the Registered Nurse as approved by the Alabama Board of Nursing Ability to quickly adapt to changing circumstances in fast-paced environment Actively accepts, understands, and practices appropriate standards of nursing practice. Must demonstrate basic knowledge of discharge planning needs Demonstrates advanced computer skills (ability to generate reports, graph trends). Clinical knowledge and experience in the care of patients with multiple and complex diagnoses, disease process, and care needs. Ability to prioritize work and meet deadlines. Ability to problem solve in a proactive, creative manner, using sound judgment based on factual information and clinical knowledge. Ability to develop leadership skills and to serve as a role model for clinical staff. Ability to lead and actively participate in multidisciplinary teams. Ability to work independently within a team structure. Demonstrates responsibility for educational requirements as evidenced by reading all assigned related references, and attending all required educational meetings, or webinars, and completing annual Symplr requirements. Demonstrates commitment to organizations five (5) priorities and Six Ground Rules Person in this position is required to understand, agree upon and follow our Six Ground Rules: No excuses. We are a team. Bring up your ideas. Poor performance will be addressed. ‘That’s not my job’ is not acceptable Manage Up. Shift Day Shift Details 8:00 am - 4:30 pm FTE 1 Type Regular Join one of Forbes 500 best mid-sized employers in America. Equal Employment Employer Southeast Health is committed to provide equal employment opportunity (EEO) to all persons regardless of age, color, national origin, citizenship status, physical or mental disability, race, religion, creed, gender, sex, sexual orientation, gender identity and/or expression, genetic information, marital status, status with regard to public assistance, veteran status, or any other characteristic protected by federal, state or local law. In addition, Southeast Health will provide reasonable accommodations for qualified individuals with disabilities.
RN Utilization Review Full-time
UnitedHealthcare

Preservice Review Nurse - PST time zone - Remote

UnitedHealthcare Las Vegas, NV
$28.94 - $51.63 / hour
At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and optimized. Ready to make a difference? Join us to start Caring. Connecting. Growing together The Preservice Review RN is responsible for reviewing requests received from providers, using approved protocols and criteria. (Milliman Care Guidelines or Healthcare Operations Protocols). The RN is expected to approve those requests that meet medical necessity, along with benefit level, and the contractual status of the provider / facility as appropriate for self-funded lines of business. This position is also a resource to new staff and may precept as well. Candidates must be available to work Monday - Friday from 8:00 am - 5:00 pm PST. *** You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. Primary Responsibilities Evaluate and assess each request verifying eligibility and specific product Determine benefit level based on site of service Utilize written criteria to approve, pend or send the case to the medical director for review Send cases for pending process when appropriate Maintain at least 98% accuracy of clinical review case notes in Facets Maintain productivity standards and maintain compliance with all regulatory agencies including NCQA, DOL, DOI for each state, Medicaid, CMS and OPM Maintain at least 98% accuracy in summarizing cases for the Medical Director to review using appropriate protocols based members clinical and benefit information Maintain compliance with turnaround times based on the member's product, the type of request and the specific regulatory agency Be knowledgeable of and comply with the Nurse Practice Act for each state that licensure is required to perform SHL business Precepts / act as a resource for new staff You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications A current, unrestricted RN license for the state of Nevada 2+ years of recent critical care, ER and/or med-surg nursing experience Proficient with Microsoft Word to create, edit, save and send documents Proven ability to navigate a Windows environment, Microsoft Outlook, and conduct Internet searches Preferred Qualifications 2+ years Utilization Management experience in managed care, acute or rehab setting Knowledge of utilization review process and prior authorization process in a managed health care industry Knowledge of ICD9 / CPT coding and Milliman Care Guidelines Soft Skills Detail oriented, excellent organizational skills Ability to work well under pressure with sound decision making ability Excellent written and oral communication skills All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $28.94 to $51.63 per hour based on full-time employment. We comply with all minimum wage laws as applicable. Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants. At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission. UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations. UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.
RN ER Utilization Review Full-time
Albany Medical Center

Utilization Review Nurse: Emergency Dept

Albany Medical Center Albany, NY
$84,783 - $131,414 / year
Department/Unit: Care Management/Social Work Work Shift: Day (United States of America) Salary Range: $84,783.00 - $131,414.00 Responsible for Utilization Management, Quality Screening and Delay Management for assigned patients. Most qualified candidates will have experience in Emergency/Trauma Care and/or previous Utilization Review roles. Qualifications and Ideal Characteristics Registered nurse with a New York State current license. Bachelor's degree required. Masters degree preferred. Minimum of three years clinical experience in an assigned service. Recent experience in case management, utilization management and/or discharge planning/home care in a high volume, acute care hospital preferred. PRI and Case Management certification preferred. Assertive and creative in problem solving, critical thinking skills, systems planning and patient care management. Self-directed with the ability to adapt in a changing environment. Basic knowledge of computer systems with skills applicable to utilization review process. Excellent written and verbal communication skills. Working knowledge of MCG criteria and ability to implement and utilize. Understanding of Inpatient versus Outpatient surgery and ICD10-Coding (preferred) and Observation status qualifications. Ability to work independently and demonstrate organizational and time management skills. Strong analytic, data management and PC skills. Working knowledge of Medicare regulatory requirements, Managed Care Plans A. Mission, Core Values and Service Excellence Contributes to the creation of a compassionate and caring environment for patients, families, and colleagues through displays of kindness and active listening. Recognizes and appreciates that each employee’s work is valuable and contributes to the success of the Mission. Demonstrates excellence in daily work. Willing to actively participate in performance and quality improvement activities and to work towards enhancing customer/patient satisfaction. Exhibits positive service excellence skills to patients, visitors, and coworkers by greeting others in a friendly manner, keeping customers/patients/colleagues informed about progress, delays, and changes. Demonstrates effective teamwork by interacting in a positive manner with colleagues and creating a collaborative work environment. Initiates open communication, conveys positive intent, offers assistance. Contributes to a safe and secure environment for patients, visitors, colleagues by following established procedures and protocols. Demonstrates stewardship by thoughtful and responsible use of resources including maintaining a clean and hospitable environment, starting work on time, displaying a consciousness regarding costs, supplies and department finances. Demonstrates respect for individual differences of each person by acknowledging the essence of each person, appreciating, and responding to unique, spiritual, personal, and cultural backgrounds of patients, families, and colleagues. B. Utilization Management Completes Utilization Management and Quality Screening for assigned patients. Applies MCG criteria to monitor appropriateness of admissions and continued stays, and documents findings based on Departmental standards. While performing utilization review identifies areas for clinical documentation improvement and contacts appropriate department. Identifies at-risk populations using approved screening tool and follows established reporting procedures. Monitors LOS and ancillary resource use on an ongoing basis. Takes actions to achieve continuous improvement in both areas. Refers cases and issues to Medical Director and Triad Team in compliance with Department procedures and follows up as indicated. Communicates covered day reimbursement certification for assigned patients. Discusses payor criteria and issues and a case-by-case basis with clinical staff and follows up to resolve problems with payors as needed. Uses quality screens to identify potential issues and forwards information to the Quality Department. Demonstrates proper use of MCG and documentation requirements through case review and inter-rater reliability studies. Delay Management Facilitates removal of delays and documents delays when they exist. Reports internal and external delays to the Triad Team. Collaborates with the health care team and appropriate department in the management of care across the continuum of care by assuring communication with Triad Team and health care team. Maintains complete confidentiality of patient information, in addition to hospital and individual physician practice pattern data. Provides information and inservices as necessary to physicians and ancillary staff. Thank you for your interest in Albany Med Health System!​ Albany Med Health System is an equal opportunity employer. This role may require access to information considered sensitive to Albany Med Health System, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that: Access to information is based on a “need to know” and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Med Health System policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification.
RN Utilization Review Full-time
UF Health

RN, Utilization Management | Utilization Management

UF Health St. Augustine, FL
Overview Make an impact by supporting the right care at the right time through utilization management excellence. 💻 Work Style: Onsite 📍 Location: St. Agustine, FL 🕒 FTE: Full-Time (1.0 FTE) ⏰ Schedule: Monday – Friday, 3:00 PM – 11:00 PM 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 determine the medical necessity and appropriateness of healthcare services. Coordinates with healthcare providers and care teams to ensure compliance with utilization management guidelines and payer requirements. Supports effective treatment planning, patient care coordination, and appropriate resource utilization. Communicates authorization decisions and utilization determinations while supporting timely discharge planning efforts. Analyzes utilization management data and trends to identify opportunities for improved care coordination and operational efficiency. Collaborates with interdisciplinary teams to ensure accurate documentation, regulatory compliance, and quality patient outcomes. Qualifications Education & Licensure Registered Nurse (RN) with a current Florida nursing license required. Experience & Skills Minimum of three (3) years of experience in utilization review, utilization management, or case management required. Knowledge of healthcare utilization guidelines, payer requirements, and regulatory compliance standards. Experience evaluating medical necessity, treatment plans, and appropriate levels of care. Strong communication and collaboration skills related to authorization determinations and care coordination. Demonstrated ability to analyze utilization data, identify trends, and support patient care and discharge planning initiatives.
RN Manager/Supervisor Utilization Review Full-time
The Christ Hospital Health Network

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

The Christ Hospital Health Network Cincinnati, OH
Job Description The Manager, Utilization Review-RN oversees hospital utilization review functions. This role is responsible for the planning, operations, and daily oversight of the department to facilitate the highest quality, cost-effective care and appropriate case status based on evidence-based criteria. This position oversees department alignment with payer policy and revenue cycle processes. The manager should support appropriate use of healthcare resources, regulatory compliance, and safe, efficient patient transitions across the continuum of care. Responsibilities Leadership & Team Management Supervise and support Utilization Review Nurses and administrative support staff. Develop and maintain job descriptions and policies and procedures to be compliant with accrediting and regulatory agencies. Provide coaching, performance evaluations, and staff development. Develop, maintain and oversee orientation plans for new staff, conducting new hire reviews according to Human Resource policies. Develop staffing plans, schedules, and productivity benchmarks to ensure clinical competency and patient coverage. Foster a collaborative, patient-centered team environment Create and implement action plans based upon employee satisfaction surveys and other feedback. Provide interdepartmental training and support on case management and utilization review requirements, tools, and processes. Participate in development, implementation and oversight of budget Represent department by presenting information in committees and workgroups. Utilization Review Oversight Ensure accurate application of evidence-based criteria such as InterQual and Milliman Care Guidelines. Ensure timely clinical reviews and follow-up for payer approvals. Collaborate with Physician Advisor (PA) to ensure criteria are applied appropriately for correct patient status. Monitor admission status, length of stay (LOS), and medical necessity. Oversee payer communications and processes, including authorizations, concurrent reviews, and denial management. Remain current on individual payer policies. Collaborate with Revenue Cycle partners to analyze trends and implement strategies to reduce denials. Regulatory Compliance & Quality Ensure compliance with Medicare Conditions of Participation and other federal/state requirements. Maintain readiness for audits (e.g., CMS, Joint Commission). Develop and enforce policies, procedures, and documentation standards. Lead quality improvement initiatives focused on denial reductions and appropriate case status Support processes to achieve optimal clinical and financial outcomes. Provide input and oversight of platforms/systems for effective documentation and data tracking. Care Coordination & Collaboration Collaborate with physicians, nursing leadership, finance, and ancillary departments to facilitate patient access to the most appropriate level of care across the continuum and to continuously improve quality of care. Participate in interdisciplinary rounds as needed and escalation processes. Serve as a liaison between department and external payers or agencies. Data Analysis & Reporting Collaborate with IT and data analytics partners to coordinate collection, analysis and reporting of outcomes data reflecting the effectiveness of the UR department. Track and report key performance indicators (KPIs), including: Denial rates and peer to peer outcomes Appropriate status and observation to inpatient conversions Discharge delays Use data to drive operational improvements and strategic planning. Performs other duties as assigned to support the work of the department and health system. Qualifications EDUCATION: Graduate of accredited school of nursing or other healthcare professional field. Master’s degree in a health-related field, health care management or business management strongly preferred with a minimum of 3 years case management/utilization review experience or a Bachelor of Science in Nursing (BSN) with a minimum of 5 years case management/utilization review experience required. YEARS OF EXPERIENCE: 3+ years of leadership or supervisory experience preferred, Lean/Six Sigma or process improvement experience preferred. REQUIRED SKILLS AND KNOWLEDGE: Strong knowledge of payer systems, Medicare/Medicaid, and regulatory requirements. Participation in professional organizations and ongoing professional development relating to utilization review. Experience with EHR systems and utilization review software. Leadership and team development Clinical and regulatory expertise Financial and utilization management Critical thinking and problem-solving Communication (oral and written) and conflict resolution Data analysis and performance improvement Technology/systems proficiency Time management and multi-tasking. LICENSES REGISTRATIONS &/or CERTIFICATIONS: Active OH RN License required; Certified Case Manager (CCM)/Accredited Case Manager (ACM) preferred
RN Utilization Review Full-time
University of Maryland Medical System

Utilization Review, RN Flex

University of Maryland Medical System Towson, MD
Job Requirements Job Summary A Utilization Review (UR) Nurse is a registered nurse who bridges the gap between healthcare providers and insurance companies. They evaluate patient medical records to ensure treatments, procedures, and hospital stays are clinically necessary, cost-effective, and meet established insurance guidelines. Medical Necessity Reviews: They verify that admissions, surgeries, and treatments are medically necessary by comparing patient charts to standardized, evidence-based guidelines like Milliman Care Guidelines (MCG) or InterQual. Concurrent & Retrospective Reviews: They review ongoing hospital stays (concurrent) to authorize continuing care, and review charts after discharge (retrospective) to prevent claim denials and ensure accurate billing. Insurance Liaison: They act as a go-between, submitting clinical data to insurance companies to secure prior authorizations and ongoing approvals so the hospital gets properly reimbursed. Resource Optimization: They monitor the patient's progress to ensure they are in the appropriate level of care (e.g., observation vs. inpatient) and help coordinate discharges to lower levels of care. Work Experience Education 4 year/ Bachelor's degree in Nursing (Required) Master's Degree In Nursing (Preferred) Experience and Skills Required Skills: Strong Verbal Communications Skills, Strong Written Communications Skills, Excel Intermediate Level, PowerPoint - Intermediate Level, MS Word - Intermediate Level, Excellent Organizational Skills
RN Utilization Review Full-time
UnitedHealthcare

Secondary Review Nurse - Indiana

UnitedHealthcare Indianapolis, IN
$28.94 - $51.83 / hour
At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us to start Caring. Connecting. Growing together. The Secondary Review Nurse plays a critical role in evaluating clinical requests for Home and Community-Based Services (HCBS). This position ensures that care provided is medically necessary, cost-effective, and tailored to the individual needs of each member, while remaining compliant with state regulations. If you reside within the state of Indiana , you will enjoy the flexibility to work remotely * as you take on some tough challenges. Primary Responsibilities Participate in secondary reviews for HCBS services and Medicaid services Review and process prior authorization requests for LTSS and HCBS services Apply clinical judgment and decision support tools to determine medical necessity and appropriateness of services Collaborate with care managers, physicians, and other stakeholders to ensure continuity of care and alignment with the members' service plan Monitor utilization patterns and identify opportunities for improved care coordination and cost containment Document all clinical decisions and communications in accordance with regulatory and organizational standards Support quality improvement initiatives and participate in developing education and training for staff Identify potential quality of care concerns, including instances of over/or underutilization of services and escalate these issues as needed Stay current with established guidelines and regulatory requirements You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear directions on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications Current, unrestricted RN license for Indiana 3+ years of clinical experience in a hospital, acute care, home health / hospice, direct care or case management and the ability to quickly identify needs and issues 2+ years of experience with completing functional assessments for LTSS services 2+ years of Medicaid, Medicare, or Managed Care experience and with Long-Term Services and Supports Intermediate level of knowledge of LTSS experience determining eligibility and appropriate allocation of services Intermediate level of computer/typing proficiency to enter/retrieve data in electronic clinical records; experience with email, internet research, use of online calendars and other software applications Preferred Qualifications Pre-authorization experience Utilization Management experience Case Management experience Knowledge of state and federal guidelines Home health or hospice Proven problem-solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action All Telecommuters will be required to adhere to UnitedHealth Group's Telecommuter Policy. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $28.94 to $51.83 per hour based on full-time employment. We comply with all minimum wage laws as applicable. At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location, and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups, and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission. UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations. UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. #RPO #GREEN
RN Utilization Review Full-time
UnitedHealthcare

Secondary Review Nurse - Indiana

UnitedHealthcare Indianapolis, IN
$28.94 - $51.83 / hour
At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us to start Caring. Connecting. Growing together. The Secondary Review Nurse plays a critical role in evaluating clinical requests for Home and Community-Based Services (HCBS). This position ensures that care provided is medically necessary, cost-effective, and tailored to the individual needs of each member, while remaining compliant with state regulations. If you reside within the state of Indiana , you will enjoy the flexibility to work remotely * as you take on some tough challenges. Primary Responsibilities Participate in secondary reviews for HCBS services and Medicaid services Review and process prior authorization requests for LTSS and HCBS services Apply clinical judgment and decision support tools to determine medical necessity and appropriateness of services Collaborate with care managers, physicians, and other stakeholders to ensure continuity of care and alignment with the members' service plan Monitor utilization patterns and identify opportunities for improved care coordination and cost containment Document all clinical decisions and communications in accordance with regulatory and organizational standards Support quality improvement initiatives and participate in developing education and training for staff Identify potential quality of care concerns, including instances of over/or underutilization of services and escalate these issues as needed Stay current with established guidelines and regulatory requirements You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear directions on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications Current, unrestricted RN license in the state of Indiana 3+ years of clinical experience in a hospital, acute care, home health / hospice, direct care or case management, able to quickly identify needs and issues 2+ years of experience with completing functional assessments for LTSS services 2+ years of experience with Medicaid, Medicare, or Managed Care and Long Term Services and Supports Intermediate level of knowledge of LTSS experience determining eligibility and appropriate allocation of services Intermediate level of computer/typing proficiency to enter/retrieve data in electronic clinical records; experience with email, internet research, use of online calendars and other software applications Preferred Qualifications Pre-authorization experience Utilization Management experience Case Management experience Knowledge of state and federal guidelines Home health or hospice Proven problem-solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action All Telecommuters will be required to adhere to UnitedHealth Group's Telecommuter Policy. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $28.94 to $51.83 per hour based on full-time employment. We comply with all minimum wage laws as applicable. At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location, and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups, and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission. UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations. UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment. #RPO #GREEN
RN Manager/Supervisor Utilization Review Full-time
State of Ohio

Clinical Review Nurse Supervisor (Medicaid Health Systems Administrator 1)

State of Ohio Uptown District, OH
$39.22 / hour
What You Will Do At ODM Office: Legal Counsel Bureau: Program Integrity Classification: Medicaid Health Systems Administrator 1 RN (PN: 20092018) Job Overview The Ohio Department of Medicaid (ODM) is seeking a Registered Nurse (RN) to be a part of our Surveillance/Utilization Review Section (SURS). SURS is charged with helping the agency review utilization of Medicaid services, detect fraud, waste and abuse and recover inappropriate payments to providers. As a Clinical Review Nurse Supervisor your responsibilities will include: Helping to manage an over $ 7million/ year hospital utilization contract Reviewing necessary medical record reviews and making a determination on hospital appeals. Supervising and training RNs, Auditors, and Analysts in identifying fraud, waste, and abuse in the Medicaid program. Participating/leading meetings with external stakeholders including law enforcement Developing and implementing changes to processes and procedures as needed in a team environment Evaluating provider clinical compliance with state and federal Program Integrity rules Evaluating provider medical documentation and billing practices for fraud, waste and abuse Recovering overpayments for medically unnecessary services via administrative procedures and/or referrals to health oversight agencies Responding to provider clinical reconsideration (appeal) requests Consulting on clinical matters with ODM policy units and other state agencies Coordinating clinical Program Integrity efforts with ODM contractors and managed care plans Presenting findings from clinical reviews of provider non-compliance Responding to inquiries from the public, consumers, providers, and other agencies Completion of graduate core program in business, management or public administration, public health, health administration, social or behavioral science or public finance; 12 mos. exp. in the delivery of a health services program or health services project management (e.g., health care data analysis, health services contract management, health care market & financial expertise; health services program communication; health services budget development, HMO & hospital rate development, health services eligibility, health services data base analysis); Current & valid license as registered nurse as issued by Ohio Board of Nursing, pursuant to Sections 4723.03-4723.09 of Ohio Revised Code; Or 12 months experience as Medicaid Health Systems Specialist, 65293, may be substituted for the experience required, but not for the mandated licensure. Note: education & experience is to be commensurate with approved position description on file. Or equivalent of Minimum Class Qualifications for Employment noted above may be substituted for the experience required, but not for the mandated licensure. Technical Skills: Nursing Professional Skills: Collaboration, Confidentiality, Continuous Improvement, Innovation, Verbal Communication, Written Communication Agency Contact Name and Information HumanResources@medicaid.ohio.gov Unposting Date May 31, 2026, 10:59:00 PM Work Location Lazarus 5 Primary Location United States of America-OHIO-Franklin County-Columbus Compensation $39.22/hour Schedule Full-time Work Hours 8:00 am - 5:00 pm Classified Indicator Classified Union Exempt from Union Professional Skills Collaboration, Innovation, Verbal Communication, Written Communication, Confidentiality, Continuous Improvement Agency Overview About Us: Investing in opportunities for Ohioans that work for every person and every family in every corner of our state is at the hallmark of Governor DeWine’s agenda for Ohio’s future. To ensure Ohio is “the best place to live, work, raise and family and start a business,” we must have strong schools, a great quality of life, and compassion for those who need our help. Responsibilities Ohio Department of Medicaid plays a unique and necessary role in supporting the governor’s vision. As the single state Medicaid agency responsible for administering high-quality, person-centric healthcare, the department is committed to supporting the health and wellbeing of nearly one in every four Ohioans served. We do so by: Delivering a personalized care experience to more than three million people served. Improving care for children and adults with complex behavioral health needs. Working collectively with our partners and providers to measurably strengthen wellness and health outcomes. Streamlining administrative burdens so doctors and healthcare providers have more time for patient care. Ensuring financial transparency and operational accountability across all Medicaid programs and services.
RN Utilization Review Per Diem
Yale New Haven Health

RN-Utilization Coordinator-Geriatric Psychiatry-Per Diem

Yale New Haven Health Bridgeport, CT
Overview To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day. At Bridgeport Hospital, we are committed to providing quality medical care and treatment that is coordinated and centered on the patient's specific needs. We strive to achieve benchmarks as a Patient Centered Medical Home and provide health care in a setting where patients are at the center of their care team. All employees of Bridgeport Hospital are part of the patients care team and contribute to the team approach of promoting access, continuous, comprehensive care and work to provide quality improvement in the care provided to their patients. SUMMARY In collaboration with physician(s), actively participates in the quality review process and assures continual improvement of nursing practice and quality patient care. Essential duties and responsibilities include the following . Other duties may be assigned. EEO/AA/Disability/Veteran. RESPONSIBILITIES Provides indirect care to select patients and families. Demonstrates knowledge of developmental stages and applies development theories/concepts when planning and implementing care for the adult patient as observed by supervisor and as indicated by feedback from staff. In conjunction with Care Coordinator monitors patient records to assess the effective utilization of hospital resources. Conducts admission reviews utilizing hospital approved criteria within 24 hours of admission to determine length of stay and compliance with third party payer regulations as evidenced by lack of denials. Acts as an advisor to physicians concerning documentation requirements of third party payers and contractual obligations. Reviews patients records to identify areas of under or over utilization or delays in the scheduling of hospital services. Monitors lab tests, consultations, and diagnostic tests daily to prevent duplication of services and insure completion in a timely manner as observed by supervisor and feedback from staff . Facilitates patients progress through hospital system by monitoring effective utilization of hospital services as evidenced by random review of lengths of stay. Provides appropriate information to third party payers in accordance with departmental policy and procedures as evidenced by third party coverage of hospital staff . Obtains authorization from insurance companies for Extended Care Facilities and relays information to Care Coordinator and/or Social Worker. Participates in data collection aspects of quality review. Assists staff in the collection of quality review data. JOB DESCRIPTION RESPONSIBILITIES Provides input into the design and the implementation of monitoring and evaluation strategies and tools as indicated by feedback from the Quality Management Department. Works closely with assigned Care Coordinator, Clinical Reimbursement Coordinator, and Medical Director of Care Coordination, and alerts them of all EHR issues, including observation, denials, Code 44's, etc. Utilizes relevant research findings to support and advance nursing practice and improve patient outcomes. Integrates relevant research findings into practice as evidenced by observation and feedback. Develops nursing guidelines, policies, and procedures based on pertinent research findings as evidenced by documentation. Assists health care team members in the development of research proposals as evidenced by feedback. Assists staff in the collection of research data as appropriate as evidenced by feedback from staff. Reviews pertinent research findings with health care team members as evidenced by observation and feedback from staff. Collaborates with Care Coordinator, Clinical Reimbursement Coordinator, and Medical Director of Care Coordination, in evaluating new procedures and nursing care practices with staff as evidenced by feedback. Professional Development Attends educational seminars to maintain and meet expectations set forth by hospital and departmental standards. Attends and participates in in-service meetings and other designated training events that will enhance skills on a regular basis as documented by attendance at training seminars. Maintains knowledge of trends and developments in the field of discharge planning and utilization. EDUCATION (number of years and type required to perform the position duties): BSN degree as of January 2020 EXPERIENCE (number of years and type required to meet an acceptable level of performance): 3-5 years clinical experience in the area of specialty. SPECIAL SKILLS: Strong interpersonal and leadership skills. ACCOUNTABILITY (how this position is held accountable for such as goals achievement, budget adherence, or other areas of accountability): Effective 01/01/2016, an essential function of this position is the requirement to work mandatory rotating Holidays and Weekends in addition to working regularly scheduled hours . COMPLEXITY (describe planning, problem solving, decision making, creative activity, or other special factors inherent in the responsibilities of this position): In personal and job-related decisions and actions, consistently demonstrates the values of integrity (doing the right thing), patient-centered (putting patients and families first), respect (valuing all people and embracing all differences), accountability (being responsible and taking action), and compassion (being empathetic). LICENSURE/CERTIFICATION: Current RN licensure in the State of Connecticut. EEO/AA/Disability/Veteran Additional Information 16 hours per week RN with psychiatric experience required. experience with reimbursement and insurance authorizations preferred YNHHS Requisition ID 162254