Utilization Review Nurse Jobs

RN ER Utilization Review Full-time
GBMC Healthcare

Utilization Review Nurse (Full-Time)

GBMC Healthcare Towson, MD
$68,281.18 - $110,274.20 / year
Under general supervision, provides consultative support to the admitting teams concerning patient status determinations and utilization of hospital resources facilitating quality, cost-effective patient outcomes for patients requiring hospital services. Works collaboratively with interdisciplinary staff internal and external to the organization facilitating appropriate status determinations through the utilization review process supporting quality, cost-effective patient outcomes. Responsible for analyzing clinical information and performing timely initial and concurrent reviews using InterQual screening software to identify appropriate medical necessity, length of stay, and level of care based upon evidence based clinical guidelines Education: Bachelor of Science in Nursing (BSN) OR Associate of Science in Nursing and currently enrolled in a BSN program with an expected graduation date within three (3) years. Licensure, Certifications: Current state of Maryland Registered Nurse license Bachelor of Science in Nursing (BSN) Certification in Utilization Management and/or Care Management highly desired. Experience: Five (5) years diversified, progressive experience in acute care and/or other settings within the continuum required. Two (2) years of Utilization Review and Case Management experience which includes utilization review processes and discharge planning, and working with Re-Admission Initiatives preferred. Skills: · Advanced knowledge of InterQual and/or MCG admission criteria · Knowledge of healthcare regulatory standards · Advanced skill in using computer software · Advanced skill in oral and written communication · Advanced skill in critical thinking · Ability to work independently and resolve complex problems · Ability to remain calm under pressure and intense time constraints · Ability to assess discharge needs for patients · Strong analytical and problem-solving skills · Strong interpersonal communication and influencing skills necessary to interact effectively with physicians, payers, regulatory agencies, staff, and other health professional · Strong organizational and time management skills · Ability to operate independently and balance multiple priorities · Proficiency in electronic medical record review Principal Duties and Responsibilities: Reviews available electronic medical records during the pre-admission process to determine appropriate patient status, optimizing correct patient classification and corresponding payer notifications. Reviews the appropriateness of admission and continued stay criteria for a defined group of patients Develops initial admission reviews for patients requiring hospital services and provides timely status recommendations to admitting providers a concurrent stay and/or discharge plan of care in accordance with departmental and payer clinical guidelines. Maintains a working knowledge of contractual and clinical criteria guidelines. Coordinates services with managed care companies and other third party payers. Discusses on-site reviewer issues with payer, either via the telephone or in person Assures timely utilization compliance with all payers who require authorizations and clinical submission. Demonstrates knowledge of reimbursement mechanisms. Considers patient’s financial resources for meeting healthcare needs (insurance reimbursement, managed care plans, entitlement programs, and personal resources). Participates as an active partner with physicians and interdisciplinary teams, providing education ancillary, and nursing staffregarding admission decisions including status determinations, financial and clinical outcomes, and documentation requirements and standards. Maintains current knowledge on all regulatory changes that affect care delivery or reimbursement of acute care services. Uses knowledge of national and local coverage determinations to appropriately advise physicians. Identifies system obstacles that affect patient outcomes and participates in interdisciplinary decisions and care of the patient. consults with interdisciplinary team members to address problems, and makes recommendations to problem solve. Assists with discharge planning, by preventing un-necessary hospital utilization, assist in the appropriate return of and placement of patients to post acute care, community based care and appropriate alternate levels of care. Demonstrates mastery in InterQual level of care guidelines. Possesses proficiency in utilization review systems, clinical support systems, and business support applications. Promotes use of evidence-based protocols to influence high quality and cost-effective care. Escalates clinically and financially complex cases to leadership, offering possible solutions through discussion and feedback. Engages regularly in formal and informal dialogue about quality; directly addressing concerns and promoting continuous improvement. Performs concurrent reviews and additional duties as assigned. All roles must demonstrate GBMC Values: Respect I will treat everyone with courtesy. I will foster a healing environment. Treats others with fairness, kindness, and respect for personal dignity and privacy Listens and responds appropriately to others’ needs, feelings, and capabilities Excellence I will strive for superior performance in every aspect of my work. I will recognize and celebrate the accomplishments of others. Meets and/or exceeds customer expectations Actively pursues learning and self-development Pays attention to detail; follows through Accountability I will be professional in the way I act, look and speak. I will take ownership to solve problems. Sets a positive, professional example for others Takes ownership of problems and does what is needed to solve them Appropriately plans and utilizes required resources for various job duties Reports to work regularly and on time Teamwork I will be engaged and collaborative. I will keep people informed. Works cooperatively and collaboratively with others for the success of the team Addresses and resolves conflict in a positive way Seeks out the ideas of others to reach the best solutions Acknowledges and celebrates the contribution of others Ethical Behavior I will always act with honesty and integrity. I will protect the patient. Demonstrates honesty, integrity and good judgment Respects the cultural, psychosocial, and spiritual needs of patients/families/coworkers Results I will set goals and measure outcomes that support organizational goals. I will give and accept help to achieve goals. Embraces change and improvement in the work environment Continuously seeks to improve the quality of products/services Displays flexibility in dealing with new situations or obstacles Achieves results on time by focusing on priorities and manages time efficiently Pay Range $68,281.18 - $110,274.20 Final salary offer will be based on the candidate's qualifications, education, experience and alignment with our organizational needs. Equal Employment Opportunity GBMC HealthCare and its affiliates are Equal Opportunity employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity and expression, age, national origin, mental or physical disability, genetic information, veteran status, or any other status protected by federal, state, or local law.
RN Utilization Review Telehealth Full-time
Molina Healthcare

Care Review Clinician (RN) Kentucky

Molina Healthcare KY
$23.76 - $51.49 / hour
JOB DESCRIPTION Job SummaryProvides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines. • Analyzes clinical service requests from members or providers against evidence based clinical guidelines. • Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. • Conducts reviews to determine prior authorization/financial responsibility for Molina and its members. • Processes requests within required timelines. • Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner. • Requests additional information from members or providers as needed. • Makes appropriate referrals to other clinical programs. • Collaborates with multidisciplinary teams to promote the Molina care model. • Adheres to utilization management (UM) policies and procedures. Required Qualifications • At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience. • Registered Nurse (RN). License must be active and unrestricted in state of practice. • Ability to prioritize and manage multiple deadlines. • Excellent organizational, problem-solving and critical-thinking skills. • Strong written and verbal communication skills. • Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications • Certified Professional in Healthcare Management (CPHM). • Recent hospital experience in an intensive care unit (ICU) or emergency room. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $23.76 - $51.49 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
RN Utilization Review Full-time
Cottage Health

Utilization Management Case Manager

Cottage Health Santa Barbara, CA
$60 - $92 / hour
Job Description Santa Barbara Cottage Hospital seeks a Utilization Management Case Manager for their Care Management department responsible for the utilization management, quality assurance, and discharge planning activities for assigned services/areas/patients within Cottage Health. Case management activities will result in quality outcomes, optimal care/cost management of services and/or procedures, a high level of customer satisfaction and contribution to an overall value-oriented experience of stakeholders and persons served. QUALIFICATIONS: All job qualifications listed indicate the minimum level necessary to perform this job proficiently. Education: Minimum: Associate's Degree in Nursing (ADN). Preferred: Bachelor's Degree in Nursing (BSN). Certifications, Licenses, Registrations: Minimum: Current California Nursing license in good standing. Preferred: Certification in Case Management. Years of Related Work Experience: Minimum: 2 years direct patient care experience in an acute care setting. Other patient care experience may be considered. Preferred: Previous experience as a case manager in an acute care setting. About Us Cottage Health is a leading acute care hospital system, located on the central coast of California, widely known for our superior patient care, innovation, medical research and education. Our health system operates primarily in Santa Barbara, CA, since 1888, and consists of three acute care hospitals, a Rehabilitation Hospital, multiple clinics and a multi-site Urgent Care system. Our mission is to serve the central coast communities with excellence, integrity, and compassion. Every day we touch thousands of lives in many different ways, resolute in our mission to put patients first. We take pride in helping our patients get back to living their lives - in the places they love. Pay for non-physician positions is determined based on related years of experience and internal equity. Eligible employees may also receive additional forms of compensation, including shift differentials, on-call pay, incentive pay, and bonus opportunities, where applicable. Manager and above positions may participate in Cottage Health’s annual management incentive program. Physician compensation is determined based upon specialty and may include bonus potential. For more information on our comprehensive Total Rewards offerings, please visit https://cottagehealth.org/careers/total-rewards . If you're already a Cottage Health employee, please apply on this link only.
RN Utilization Review Full-time
North Star Behavioral Health

Utilization Review Nurse (RN)

North Star Behavioral Health Augusta, GA
Responsibilities Lighthouse Care Center of Augusta is seeking a dedicated, compassionate Utilization Review Nurse, RN to add to our growing team. Lighthouse Care Center of Augusta Lighthouse Care Center of Augusta (LCCA) is a multi-discipline behavioral healthcare center that offers mental health services to the communities of surrounding Augusta, Georgia. The Lighthouse Care Center of Augusta is an acute and residential treatment facility providing balanced, top-notch clinical care to children, adolescents and young adults. We provide a carefully-structured and supportive environment, and our education program is accredited through the Georgia Accrediting Commission. Utilization Review Nurse, RN Under the direction of the Director of Utilization Management. Website: https://www.LighthouseCareCenters.com Job Duties/ Responsibilities: Review clinical content of medical records Participate in treatment team meetings Collaborate with physicians, therapist, nurses and pertinent staff on gathering the necessary data to communicate with insurance companies/authorizing entities to ensure initial precertification and continued authorization is achieved Utilization Review/Business Office Coordinator will ensure input of pre-certifications and continued stay reviews into Midas Follow-up on unfinished pre-certifications from the day before Coordinate with the treatment team on any follow-ups necessary Verify insurance coverage at the first of the month, and post patient payments into MS4 Trained in all aspects relative to timely gathering clinical criteria, communication of clinical criteria, and entry of supporting clinical criteria into computer based systems Additional job duties Benefit Highlights: Referral Bonus Program Challenging and rewarding work environment Competitive Compensation & Generous Paid Time Off Excellent Medical, Dental, Vision and Prescription Drug Plans 401(K) with company match and discounted stock plan SoFi Student Loan Refinancing Program Career development opportunities within UHS and its 300+ Subsidiaries Pet Insurance More information is available on our Benefits Guest Website: uhsguest.com About Universal Health Services: Headquartered in King of Prussia, PA, Universal Health Services, Inc. (NYSE: UHS) is one of the nation’s largest and most respected providers of hospital and healthcare services. Since our founding in 1979, UHS has grown steadily into a premier Fortune 500® corporation perennially recognized by multiple esteemed national rating entities. Through its subsidiaries, UHS operates inpatient acute care facilities, inpatient behavioral health facilities, outpatient and other facilities, nationwide virtual behavioral health services, an insurance offering, a physician network and various related services with physical locations in the U.S., Puerto Rico, Ireland and United Kingdom. www.uhs.com . From Fortune , ©2025 , 2026 Fortune Media IP Limited. All rights reserved. Used under license. Qualifications Education and Experience: Registered Nurse (RN) preferred or License Professional Nurse (LPN) Current GA or Multistate Valid RN or LPN license Must have 2 years of experience in a psychiatric health care setting, delivery of care to psychiatric and/or chemically dependent patients and utilization review EEO Statement: All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws. Avoid and Report Recruitment Scams We are aware of a scam whereby imposters are posing as Recruiters from UHS, and our subsidiary hospitals and facilities. Beware of anyone requesting financial or personal information. At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skill set and experience with the best possible career path at UHS and our subsidiaries. During the recruitment process, no recruiter or employee will request financial or personal information (e.g., Social Security Number, credit card or bank information, etc.) from you via email. Our recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc. If you suspect a fraudulent job posting or job-related email mentioning UHS or its subsidiaries, we encourage you to report such concerns to appropriate law enforcement. We encourage you to refer to legitimate UHS and UHS subsidiary career websites to verify job opportunities and not rely on unsolicited calls from recruiters.
RN Utilization Review Full-time
Kaiser Permanente

Case Management Utilization RN, FT Day

Kaiser Permanente Bellflower, CA
Job Summary: Works collaboratively with an MD to coordinate and screen for the appropriateness of admissions and Continued stays. Makes recommendations to the physicians for alternate levels of care when the patient does not meet the medical necessity for Inpatient hospitalization. Interacts with the family, patient and other disciplines to coordinate a safe and acceptable discharge plan. Functions as an indirect caregiver, patient advocate and manages patients in the most cost effective way without compromising quality. Transfers stable non-members to planned Health care facilities. Responsible for complying with AB 1203, Post Stabilization notification. Complies with other duties as described. Must be able to work collaboratively with the Multidisciplinary team, multitask and in a fast pace environment. Essential Responsibilities: Plans, develops, assesses and evaluates care provided to members. Collaborates with physicians, other members of the multidisciplinary health care team and patient/family in the development, implementation and documentation of appropriate, individualized plans of care to ensure continuity, quality and appropriate resource use. Recommends alternative levels of care and ensures compliance with federal, state and local requirements. Assesses high risk patients in need of post-hospital care planning. Develops and coordinates the implementation of a discharge plan to meet patients identified needs. Communicates the plan to physicians, patient, family/caregivers, staff and appropriate community agencies. Reviews, monitors, evaluates and coordinates the patients hospital stay to assure that all appropriate and essential services are delivered timely and efficiently. Participates in the Bed Huddles and carries out recommendations congruent with the patients needs. Coordinates the interdisciplinary approach to providing continuity of care, including Utilization management, Transfer coordination, Discharge planning, and obtaining all authorizations/approvals as needed for outside services for patients/families. Conducts daily clinical reviews for utilization/quality management activities based on guidelines/standards for patients in a variety of settings, including outpatient, emergency room, inpatient and non-KFH facilities. Acts as a liaison between in-patient facility and referral facilities/agencies and provides case management to patients referred. Refers patients to community resources to meet post hospital needs. Coordinates transfer of patients to appropriate facilities; maintains and provides required documentation. Adheres to internal and external regulatory and accreditation requirements and compliance guidelines including but not limited to: TJC, DHS, HCFA, CMS, DMHC, NCQA and DOL. Educates members of the healthcare team concerning their roles and responsibilities in the discharge planning process and appropriate use of resources. Provides patients with education to assist with their discharge and help them cope with psychological problems related to acute and chronic illness. Per established protocols, reports any incidence of unusual occurrences related to quality, risk and/or patient safety which are identified during case review or other activities. Reviews, analyses and identifies utilization patterns and trends, problems or inappropriate utilization of resources and participates in the collection and analysis of data for special studies, projects, planning, or for routine utilization monitoring activities. Coordinates, participates and or facilitates care planning rounds and patient family conferences as needed. Participates in committees, teams or other work projects/duties as assigned.
RN Utilization Review Per Diem
Kaiser Permanente

Case Manager Utilization RN-Per Diem

Kaiser Permanente Riverside, CA
Job Summary: Works collaboratively with an MD to coordinate and screen for the appropriateness of admissions and Continued stays. Makes recommendations to the physicians for alternate levels of care when the patient does not meet the medical necessity for Inpatient hospitalization. Interacts with the family, patient and other disciplines to coordinate a safe and acceptable discharge plan. Functions as an indirect caregiver, patient advocate and manages patients in the most cost effective way without compromising quality. Transfers stable non-members to planned Health care facilities. Responsible for complying with AB 1203, Post Stabilization notification. Complies with other duties as described. Must be able to work collaboratively with the Multidisciplinary team, multitask and in a fast pace environment. Essential Responsibilities: Plans, develops, assesses and evaluates care provided to members. Collaborates with physicians, other members of the multidisciplinary health care team and patient/family in the development, implementation and documentation of appropriate, individualized plans of care to ensure continuity, quality and appropriate resource use. Recommends alternative levels of care and ensures compliance with federal, state and local requirements. Assesses high risk patients in need of post-hospital care planning. Develops and coordinates the implementation of a discharge plan to meet patients identified needs; communicates the plan to physicians, patient, family/caregivers, staff and appropriate community agencies. Reviews, monitors, evaluates and coordinates the patients hospital stay to assure that all appropriate and essential services are delivered timely and efficiently. Participates in the Bed Huddles and carries out recommendations congruent with the patients needs. Coordinates the interdisciplinary approach to providing continuity of care, including Utilization management, Transfer coordination, Discharge planning, and obtaining all authorizations/approvals as needed for outside services for patients/families. Conducts daily clinical reviews for utilization/quality management activities based on guidelines/standards for patients in a variety of settings, including outpatient, emergency room, inpatient and non-KFH facilities. Acts as a liaison between in-patient facility and referral facilities/agencies and provides case management to patients referred. Refers patients to community resources to meet post hospital needs. Coordinates transfer of patients to appropriate facilities; maintains and provides required documentation. Adheres to internal and external regulatory and accreditation requirements and compliance guidelines including but not limited to: TJC, DHS, HCFA, CMS, DMHC, NCQA and DOL. Educates members of the healthcare team concerning their roles and responsibilities in the discharge planning process and appropriate use of resources. Provides patients with education to assist with their discharge and help them cope with psychological problems related to acute and chronic illness. Per established protocols, reports any incidence of unusual occurrences related to quality, risk and/or patient safety which are identified during case review or other activities. Reviews, analyses and identifies utilization patterns and trends, problems or inappropriate utilization of resources and participates in the collection and analysis of data for special studies, projects, planning, or for routine utilization monitoring activities. Coordinates, participates and or facilitates care planning rounds and patient family conferences as needed. Participates in committees, teams or other work projects/duties as assigned.
RN Outpatient Manager/Supervisor Utilization Review Outpatient
L.A. Care Health Plan

Supervisor, Utilization Management RN (Outpatient)

L.A. Care Health Plan MI
$102,183 - $163,492 / year
Salary Range: $102,183.00 (Min.) - $132,838.00 (Mid.) - $163,492.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job Summary The Supervisor of Utilization Management (UM) RN is responsible for executing the day-to-day operations of the UM department, and monitoring the Care Management (CM) staff’s responsibilities and activities. This includes, but not limited to, ensuring proper staffing and coverage; monitoring and evaluating departmental operations to ensure optimal efficiency, productivity, and effectiveness; documenting and appropriately addressing excellence or deviations in work, departmental, and organizational expectations; and conducting intermittent and annual performance evaluations. This role assists in triaging identified issues/problems and forming resolution within the scope of work/licensure. The Supervisor is a subject matter expert (SME) in Care/Case/Utilization Management and supporting regulations, policies, protocols, and procedures. This position serves as a formal and informal instructor, and escalates issues/concerns to the appropriate person when outside of their scope. This position is responsible in assisting with and development and maintenance of a successful and cohesive unit, with high level of productivity and accuracy to achieve the department's overall performance metrics. The Supervisor ensures all functions of the UM department are operating in accordance with the organization's mission, values and strategic goals, which are focused on quality care delivery and continuous improvement; and are provided in a manner that is responsive and sensitive to the needs of L.A. Care's culturally diverse membership. The position supports the UM Manager/Director. This role also assists UM Educator/Manager/Director in identification of training needs including, but not limited to, collaborating in development of programs, training materials, competency checklist, and orientation checklists necessary to meet education and training needs of UM staff. The position supervises all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports. Duties Ensures adequate/appropriate distributions of workforce, assignments and time off requests. Participates in the hiring and termination process providing recommendations with appropriate supporting documentation. Monitors of staff's performance including productivity and compliance with regulatory requirements, compliance with policies. Identifies, communicates and coaches to improve staff performance. Develops tools, job aids, and workflows to optimize the process flow, performance and productivity of the UM team. Completes intermittent and annual staff evaluations. Serves as the primary resource for all business-related questions/issues raised by staff; escalates to appropriate leader/team when necessary. Recommends and implements process improvement measures to achieve department's performance measures outcomes and goals. Plans and oversees UM activities according to model of care, program description and policy and procedures to provide timely, quality care and services to members. Maintains all assigned reporting responsibilities, conducts regular audits to ensure compliance with community, industry and organizational standards including regulatory requirements. Serves as a super-user on electronic programs and systems used by the department. Assists in the development of programs, workflows, tools, training materials, orientation checklists, and competency checklist necessary to meet educational needs. Trains new staff, remediation of seasoned staff and cross training as needed in specified business lines. Serves as a leader and role model as well as technical and informational resource for staff and peers. Duties Continued Fosters a culture that encourages employee contribution to ensure that the department maintains an environment in which quality flourishes. Services as member/resource/liaison to the Interdisciplinary Care Team. Recommends resources to improve performance standards in terms of Utilization Management. Collaborates with peers and colleagues within the organization to address process improvements, member's needs, department and organizational enhancements and communicate development as appropriate. Participates on internal and external committees as delegated or assigned. Serves as a consultant to other departments or organizations as needed. Responsible for the daily workflow and leading the work of assigned staff. This role will mentor, coach, act as a resource and provide feedback on performance of assigned staff. Performs other duties as assigned. Education Required Associate's Degree in NursingEducation Preferred Bachelor's Degree in NursingExperience Required: Minimum of 7 years of acute/clinical care experience. Minimum of 2 years of experience in Case/Care/Utilization Management in an acute care or health plan setting. Minimum of 3 years leading process, program, or staff or supervisory experience. Equivalency: Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement. Skills Required: Knowledge of state, federal and regulatory requirements in Care/Case/Utilization Management. Strong verbal and written communication skills. Computer literacy with proficiency with Microsoft Word, Excel, etc. and ability to learn core departmental computer systems and software. Excellent organizational, time management, and interpersonal skills. Must be detailed-oriented, energetic, and an enthusiastic team player. Must be able to work independently. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California LicenseLicenses/Certifications Preferred Required Training Physical Requirements LightAdditional Information Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. L.A. Care offers a wide range of benefits including Paid Time Off (PTO) Tuition Reimbursement Retirement Plans Medical, Dental and Vision Wellness Program Volunteer Time Off (VTO)
RN Utilization Review Full-time
Munson Healthcare

Utilization Review Specialist (RN)

Munson Healthcare Traverse City, MI
Company Description More Than Just Care, It’s Community Imagine doing meaningful work in a place where people vacation. That’s life at Munson Healthcare - northern Michigan’s largest healthcare system, with eight award-winning community hospitals serving over half a million residents across 29 counties. If you want a career in healthcare and a lifestyle most people only dream about – with freshwater lakes, scenic trails, charming downtowns, a vibrant arts scene, and endless outdoor adventures - you might just be Munson Material. To us, that means teammates who live by our values of excellence, teamness, positivity, creativity, and a commitment to creating exceptional experiences for our patients and each other. Join a team that delivers outstanding care in one of the most beautiful regions in the country. Invested in You Grow: Tuition reimbursement, in-person and online development, and access to our career hub to help you advance. Thrive: Full benefits, paid holidays, generous PTO, employee discounts, and free individual retirement counseling. Be Well: Free wellness platform for you and your family, plus personalized support for personal or family challenges. Be Heard: Share your ideas and help shape the way we work through improvement huddles, employee surveys, and town hall meetings Job Description A Day In The Life The Utilization Review Specialist (RN) is responsible for ensuring appropriate utilization of healthcare services across the continuum of care. This role evaluates patient admissions, continued stays, and transitions of care to ensure compliance with regulatory requirements, payer guidelines, and evidence-based standards of practice. Working collaboratively with physicians, case managers, nursing staff, payers, and interdisciplinary teams, the Utilization Review Specialist promotes high-quality, cost-effective patient care while supporting optimal reimbursement and organizational performance. The position requires strong clinical judgment, critical thinking, communication skills, and knowledge of utilization management principles. KEY AREAS OF REPSONSIBILITY Admission Reviews available documentation to assess all admissions for appropriate status and services according to patient condition and diagnosis. Applies standard guidelines to determine appropriateness for inpatient level of care or observation services based on documented condition plan of treatment and care. Supports physician decision-making by coaching on appropriateness of inpatient or observation status. Confers with admitting physician if documentation does not support hospital level of care to offer alternatives. Refers cases to the Physician Advisor when documentation is inadequate to support acute level of care and remains unresolved after discussing with referring/attending physician. Understands and applies federal law regarding the use of Hospital Initiated Notice of Non-Coverage (HINN) and Ambulatory Benefit Notice (ABN). Monitors insurer compliance with contractual obligations. Maintains proficiency in the use of electronic review applications including CERMe and EMR and enters information correctly, consistently and timely. Maintains proficiency in the use of hospital information systems to access information and record data. Continuing Stay Actively participate in daily huddles, patient care conferences, and hospitalist/nurses hand-off reports to maintain knowledge about the patient’s clinical status and progression of care. Consults with case manager and/or physician advisor as necessary to resolve progression-of-care barriers through appropriate administrative and medical channels. Identify potentially unnecessary services and care delivery settings and recommend alternatives when appropriate. Collaborates with community physicians and hospitalists to influence transition from one level of care to another. Notifies insurers and third party administrators of clinical review information. Maintains documentation on each patient to include specific criteria that support appropriate level of care and continued stay. Performs status changes as necessary Refers cases to the Physician Advisor when treatment plan documentation does not support acute level of care. Monitors timeliness of PA response. Identify and record episodes of preventable delays or avoidable days due to failure of progression-of-care processes. Promote physicians’ use of evidence based protocols and/or order sets to influence high quality and cost effective care. Transition Collaborate with clinical team to confirm benefit eligibility for post-acute services. Apply Interqual/Milliman discharge screens to assess patient’s readiness for a lower level of care. Updates all involved parties regarding potential, threatened or actual denials due to lack of medical necessity or barriers to the progression of care. Participates in reviewing 30-day Readmissions as directed by program manager. Reviews request for direct admissions and transfers for appropriate level of care. Coordinates with ED Case Manager to recommend alternate placement from the ED when patients do not qualify for Outpatient Observation or Inpatient status Program Support Serves as a resource person to physicians, case managers, physician offices, and billing office for coverage and compliance issues. Works closely with decision support personnel to review resource utilization data and trends to identify outliers who may benefit from real time coaching to improve outcomes. Encourage healthcare team members in collaborative problem solving regarding appropriate use of resources. Assists in developing and revising policies to support utilization management activities, including criteria and guidelines for appropriate use of services, clinical practice guidelines and treatment protocols. Recognizes and responds appropriately to risk factors. Keeps current on all regulatory changes that affect medical necessity or reimbursement of acute care services and shares that information with program colleagues and hospital associates at information meetings. May represent Utilization Management on various committees, professional organizations, physician or and community groups Establish and maintain effective professional working relationships with patients, families, interdisciplinary team members, payers and external case managers Qualifications Requirements Current licensure as a Registered Nurse (RN) in the State of Michigan. Minimum of three years clinical experience required. Strong clinical assessment, critical thinking, and decision-making skills. Effective verbal and written communication skills. Proficiency in Microsoft Office, Outlook, and related computer applications. Ability to independently organize workload, manage competing priorities, and meet deadlines. Demonstrated attention to detail and problem-solving abilities. Preferred Previous utilization review, utilization management, or case management experience within a hospital or insurance setting. Knowledge of managed care, Medicare, Medicaid, HMOs, and reimbursement methodologies. Experience with discharge planning and transitions of care. EHR Cerner exprience. Additional Information Schedule: Typically M-F 2PM -10:30PM with a weekend rotation every 4/5 weekend. Rotating holiday work as needed. Locations: MMC ED and Copper Ridge. Once established this position will be 50/50 hybrid & onsite. Training Schedule: Onsite M-F 8AM -4:30PM for the first 8 weeks (estimated). Munson Healthcare requires all employees be vaccinated or have lab confirmed immunity for Measles, Mumps, Rubella and Varicella. MHC also requires all employees to receive a flu vaccine during the flu season in the year that they are hired and annually thereafter, or receive an approved medical or religious exemption.
RN Utilization Review Telehealth
L.A. Care Health Plan

Utilization Management Nurse Specialist RN II

L.A. Care Health Plan 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 Nurse Specialist RN II facilitates, coordinates, and approves medically necessary referrals that meet established criteria. Assures timely and accurate determination and notification of referrals and reconsiderations based on the referral determination status. Generates approval, modification and denial communications, to include member and provider notification of referral determination. Actively monitors for admissions in any inpatient setting. Performs telephonic and/or onsite admission and concurrent review, and collaborates with onsite staff, physicians, providers, member/family interaction to develop and implement a successful discharge plan. Works with the UM Manager and Physician Advisor on case reviews for pre-service, concurrent, post-service and retrospective claims medical review. Monitors and oversees the collection and transfer of data (medical records) and referral requests by Providers. Acts as a department resource for medical service requests /referral management and processes. Receives incoming calls from providers, professionally handles complex calls, researches to identify timely and accurate resolution steps. Follows up with caller to provide response or resolution steps. Answers all inquiries in a professional and courteous manner. Duties Promote and support team engagements, programs and activities to create and ensure a positive and productive workplace environment. Perform telephonic and/or onsite admission and concurrent review, and collaborates with onsite staff, physicians, providers, the member and significant others to develop and implement a successful discharge plan. Process, finalize and facilitate inbound requests that are received from providers. Generate appropriate member and provider communication for all determinations within the required timelines as defined by the most current department policy. Facilitate/review requests for Higher level of care or skilled nursing/discharge planning needs. Research for appropriate facilities, specialty providers and ancillary providers to utilize for all lines of business. Identification of potential areas of improvement within the provider network. Identify and initiate referrals for appropriate members to the various L.A. Care programs/processes and external community based programs or Linked and Carve Out Services (e.g. DDS/CCS/MH). Potential quality of care/potential fraud issues are identified and documented per L.A. Care policy. High risk/high cost cases and reports are maintained and referred to the Physician Advisor/UM Director. Document in platform/system of record. Utilize designated software system to document reviews and/or notes. Receive incoming calls from providers, professionally handle complex calls, research to identify timely and accurate resolution steps. Follow up with caller to provide response or resolution steps. Answer all inquiries in a professional and courteous manner. Perform other duties as assigned. Duties Continued Education Required Associate's Degree in NursingEducation Preferred Bachelor's Degree in NursingExperience Required: At least 5 years of varied RN clinical experience in an acute hospital setting. At least 2 years of Utilization Management/Case Management experience in a hospital or HMO setting . Preferred: Managed Care experience performing UM and CM at a medical group or management services organization. Experience with Managed Medi-Cal, Medicare, and commercial lines of business. Skills Required: Must be computer literate, with expertise in Outlook, Word, Excel, PowerPoint. Effectively utilizes computer and appropriate software and interacts as needed with L.A. Care Information System. Knowledge of personal computer, keyboarding, and appropriate software to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment. Prepare clear, comprehensive written and oral reports and materials. Provision of excellent customer service required due to frequent communication with providers and other members of the interdisciplinary team Excellent time management and priority-setting skills. Maintains strict member confidentiality and complies with all HIPAA requirements. Strong verbal and written communication skills. Preferred: Knowledge of National Committee for Quality Assurance (NCQA) requirements for Utilization Management or Care Management (CM). Knowledge of Department of Health Care Services (DHCS) or Centers for Medicare and Medicaid Services(CMS) requirements for health plan compliance with UM or CM. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California LicenseLicenses/Certifications Preferred Certified Case Manager (CCM)Required Training Physical Requirements LightAdditional Information May work on occasional weekends and some holidays depending on business needs. 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 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 Position Overview 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: Retirement Savings and Investment Plan Disability Benefits – Short Term Disability (STD) Sick Time Off Employee Assistance 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.
RN Utilization Review Full-time
Kern Medical

Utilization Review Nurse - Part Time - Shift

Kern Medical Bakersfield, CA
$43.51 - $68.56 / hour
Kern Medical has been a community cornerstone since its founding in 1867. Today, we are an acute care teaching center with 222 beds, offering the only advanced trauma care between Fresno and Los Angeles. Kern Medical offers a range of primary, specialty, and multi-specialty services including high-risk pregnancy care, inpatient psychiatric services integrated with county mental health programs, and a growing network of outpatient clinics providing personalized patient-centered wellness care. Kern Medical cares for 15,500 inpatients and 125,000 clinic patients a year. Career Opportunities within Kern Medical include many benefits such as: New Hire Bonus : $6,000.00 New Hire Premium : +6% of base rate of pay, matched up to 6% if contributed to Deferred Compensation Plan. A Comprehensive Benefits Package : includes Holidays, Paid Time Off, Retirement, Medical, Dental, Vision and Life Insurance. Position: Utilization Review Nurse - Case Management Compensation: The estimated pay for this position is $43.5114 to $68.5608 per hour . The rates shown include a 6% premium pay (base= $-$ plus 6%). This reflects only a portion of the total compensation package for this position. Additional compensation may be available for this role through differentials, incentives, and bonuses. In addition, this position may be eligible for participation and company contributions into the Kern County Employees’ Retirement Plan. Distinguishing Characteristics: Positions in this classification are assigned to the Utilization Review division of Kern Medical Center. Incumbents perform clinically oriented medical chart reviews and other administrative tasks to meet the requirements of the medical center's utilization review plan, state and federal regulations, insurance company requirements for reimbursement and facility accreditation standards. The Utilization Review Nurse classification ranges from less experienced nurses, who will perform administrative tasks concerning Utilization Review and Discharge planning activities, to experienced nurses who will apply full working knowledge of applicable regulations and to develop knowledge of outside agencies and services to develop appropriate discharge plans. Essential Functions: Obtains and evaluates medical records for in-patient admissions to determine if required documentation is present. Obtains appropriate records as required by payor agencies and initiates Physician Advisories as necessary for unwarranted admissions. Conducts on-going reviews and discusses care changes with attending physicians and others. Formulates and documents discharge plans. Provides on-going consultation and coordination with multiple services within the hospital to ensure efficient use of hospital resources Identifies pay source problems and provides intervention for appropriate referrals Coordinates with admitting office to avoid inappropriate admissions. Coordinates with clinic areas in scheduling specialized tests with other health care providers, assessing pay source and authorizing payment under Medically Indigent Adult program as necessary. Reviews and approves surgery schedule to ensure elective procedures are authorized. Coordinates with correctional facilities to determine appropriate use of elective procedures, durable medical goods and other services. Answer questions from providers regarding reimbursement, prior authorization and other documentation requirements. Learns the documentation requirements of payor sources to maximize reimbursement to the hospital Initiates and completes Disease Related Groups (DRG's) for Medicare payment; answers questions from providers regarding reimbursement, prior authorization and other documentation requirements. Teaches providers the documentation requirements of payor sources to maximize reimbursement to the hospital. May assist in training of other Utilization Review Nurses. Keeps informed of patient disease processes and treatment modalities. Other Functions: Performs other job related duties as required. Employment Standards: Possession of a valid license as a Registered Nurse in the State of California AND Two (2) years of experience or its equivalent as a registered nurse in an acute care hospital, at least one of which was on a medical/surgical ward or unit. OR Possession of a valid license as a Registered Nurse in the State of California and two (2) years of experience as a Case Manager in an alternate medical setting such as a clinic or physician’s office performing utilization or discharge planning. Incumbents may be required to possess and maintain specific certificates competency based on unit specific requirements as a condition of employment. Appointees not possessing the American Heart Association Provider Basic Life Support (BLS) card at time of hire must successfully complete appropriate training and qualify for the RQI Provider certification within 60 days of employment. As a continued condition of employment, employee must maintain RQI Provider certification and competency. Knowledge of: Payor source documentation requirements and governmental regulations affecting reimbursement; knowledge of acute care nursing principles, methods and commonly used procedures; knowledge of common patient disease processes and the usual methods for treating them; knowledge of medical terminology, hospital routine and commonly used equipment; knowledge of acute hospital organization and the interrelationships of various clinical and diagnostic services; Ability to: Effectively evaluate the medical records of hospital admissions regarding continuing stay necessity, appropriateness of setting, delivered care, use of ancillary services and discharge plans; ability to assess and judge the clinical performance of physicians and other health professionals; ability to communicate documentation needs in an effective and tactful manner that promotes cooperation; ability to gather and analyze data and prepare reports and recommendations based thereon; ability to get along with physicians, other health providers, outside payor sources and the general public. Supplemental: A background check may be conducted for this classification. All Kern County employees are designated "Disaster Service Workers" through state and local laws (CA Government Code Sec.3100-3109 and Ordinance Code Title 2-Administration, Ch. 2.66 Emergency Services). As Disaster Service Workers, all County employees are expected to remain at work, or to report for work as soon as practicable, following a significant emergency or disaster. If position responsibilities require driving a personal vehicle, then possession of a current valid California Driver’s License and adherence to the Kern County Hospital Authority Vehicle Use and Driving Standard Policy (ENG-EC-119) is required. If position responsibilities require driving a vehicle owned, leased or rented by Kern Medical, then possession of a current valid California Driver’s license, a signed authorization for Release of Drivers Record Information and adherence to the Kern County Hospital Authority Vehicle Use and Driving Standard Policy (ENG-EC-119) is required.
RN Utilization Review Full-time
Ascension

Registered Nurse Utilization Review

Ascension Baltimore, MD
$84,094.40 - $120,120 / year
Your future role at a glance Location: Partially Remote, with onsite coverage required in Baltimore, MD. Facility: Ascension Saint Agnes Hospital Department: Utilization Management Schedule: Day-Shift | Full-Time | Monday-Friday 8:00AM-4:30PM | Weekend Rotation once per month. Salary range: $84,094.40- $120,120.00 per year Life at Ascension: Where purpose meets opportunity Ascension is a leading nonprofit Catholic health system with a culture and associate experience grounded in service, growth, care and connection. We empower our 97,000+ associates to bring their skills and expertise every day to reimagining healthcare, together. Recognized as one of the Best 150+ Places to Work in Healthcare and a Military-Friendly Gold Employer, you’ll find an inclusive and supportive environment where your contributions truly matter. Benefits that help you thrive Comprehensive health coverage: medical, dental, vision, prescription coverage and HSA/FSA options Financial security & retirement: employer-matched 403(b), planning and hardship resources, disability and life insurance Time to recharge: pro-rated paid time off (PTO) and holidays Career growth: Ascension-paid tuition (Vocare), reimbursement, ongoing professional development and online learning Emotional well-being: Employee Assistance Program , counseling and peer support, spiritual care and stress management resources Family support: parental leave, adoption assistance and family benefits Other benefits: optional legal and pet insurance, transportation savings and more How you’ll make an impact in this role Advocate for appropriate care by reviewing admissions and service requests to ensure every patient receives the right level of medical necessity at the right time. Guide complex patient journeys through expert case management and consultation, providing a roadmap for high-quality outcomes in even the most challenging clinical situations. Support the frontline care team by resolving documentation and reimbursement hurdles, ensuring the hospital can focus its resources on direct patient care. Coordinate seamless transitions by collaborating with the healthcare team to build safe, effective discharge plans that set patients up for success long after they leave our facility. Maintain clinical integrity by overseeing compliance with federal and payer regulations, protecting our patients and our organization from administrative risk. What minimum requirements you’ll need Licensure / Certification / Registration: Registered Nurse credentialed from the Maryland Board of Nursing obtained prior to hire date or job transfer date required. Education: Diploma from an accredited school/college of nursing OR Required professional licensure at time of hire. What additional preferences we're seeking Specialized Expertise: Proven experience in Utilization Management, Case Management, or Clinical Documentation Improvement within a healthcare setting. Equal employment opportunity employer Ascension provides Equal Employment Opportunities (EEO) to all associates and applicants for employment without regard to race, color, religion, sex/gender, sexual orientation, gender identity or expression, pregnancy, childbirth, and related medical conditions, lactation, breastfeeding, national origin, citizenship, age, disability, genetic information, veteran status, marital status, all as defined by applicable law, and any other legally protected status or characteristic in accordance with applicable federal, state and local laws. For further information, view the EEO Know Your Rights (English) poster or EEO Know Your Rights (Spanish) poster. Fraud prevention notice Prospective applicants should be vigilant against fraudulent job offers and interview requests. Scammers may use sophisticated tactics to impersonate Ascension employees. To ensure your safety, please remember: Ascension will never ask for payment or to provide banking or financial information as part of the job application or hiring process. Our legitimate email communications will always come from an @ascension.org email address; do not trust other domains, and an official offer will only be extended to candidates who have completed a job application through our authorized applicant tracking system. E-Verify statement Employer does not participate in E-Verify and therefore cannot employ STEM OPT candidates.
RN Utilization Review Per Diem
Kaiser Permanente

Case Manager Utilization RN, Per Diem Day

Kaiser Permanente Bellflower, CA
Job Summary: Works collaboratively with an MD to coordinate and screen for the appropriateness of admissions and Continued stays. Makes recommendations to the physicians for alternate levels of care when the patient does not meet the medical necessity for Inpatient hospitalization. Interacts with the family, patient and other disciplines to coordinate a safe and acceptable discharge plan. Functions as an indirect caregiver, patient advocate and manages patients in the most cost effective way without compromising quality. Transfers stable non-members to planned Health care facilities. Responsible for complying with AB 1203, Post Stabilization notification. Complies with other duties as described. Must be able to work collaboratively with the Multidisciplinary team, multitask and in a fast pace environment. Essential Responsibilities: Plans, develops, assesses and evaluates care provided to members. Collaborates with physicians, other members of the multidisciplinary health care team and patient/family in the development, implementation and documentation of appropriate, individualized plans of care to ensure continuity, quality and appropriate resource use. Recommends alternative levels of care and ensures compliance with federal, state and local requirements. Assesses high risk patients in need of post-hospital care planning. Develops and coordinates the implementation of a discharge plan to meet patients identified needs; communicates the plan to physicians, patient, family/caregivers, staff and appropriate community agencies. Reviews, monitors, evaluates and coordinates the patients hospital stay to assure that all appropriate and essential services are delivered timely and efficiently. Participates in the Bed Huddles and carries out recommendations congruent with the patients needs. Coordinates the interdisciplinary approach to providing continuity of care, including Utilization management, Transfer coordination, Discharge planning, and obtaining all authorizations/approvals as needed for outside services for patients/families. Conducts daily clinical reviews for utilization/quality management activities based on guidelines/standards for patients in a variety of settings, including outpatient, emergency room, inpatient and non-KFH facilities. Acts as a liaison between in-patient facility and referral facilities/agencies and provides case management to patients referred. Refers patients to community resources to meet post hospital needs. Coordinates transfer of patients to appropriate facilities; maintains and provides required documentation. Adheres to internal and external regulatory and accreditation requirements and compliance guidelines including but not limited to: TJC, DHS, HCFA, CMS, DMHC, NCQA and DOL. Educates members of the healthcare team concerning their roles and responsibilities in the discharge planning process and appropriate use of resources. Provides patients with education to assist with their discharge and help them cope with psychological problems related to acute and chronic illness. Per established protocols, reports any incidence of unusual occurrences related to quality, risk and/or patient safety which are identified during case review or other activities. Reviews, analyses and identifies utilization patterns and trends, problems or inappropriate utilization of resources and participates in the collection and analysis of data for special studies, projects, planning, or for routine utilization monitoring activities. Coordinates, participates and or facilitates care planning rounds and patient family conferences as needed. Participates in committees, teams or other work projects/duties as assigned.
RN Utilization Review Telehealth
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 NursingEducation Preferred Bachelor's Degree in NursingExperience 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 LicenseLicenses/Certifications Preferred Required Training Physical Requirements LightAdditional Information Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. L.A. Care offers a wide range of benefits including Paid Time Off (PTO) Tuition Reimbursement Retirement Plans Medical, Dental and Vision Wellness Program Volunteer Time Off (VTO)
RN Utilization Review Full-time
Havenwyck Hospital

Utilization Management Case Manager

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

Registered Nurse - Care Coordinator - Utilization Review

Parkland Health (TX) Dallas, TX
Location: Parkland Support Serv Bldg A Shift- Days 6:00am- 4:30pm (10hrs) Work Hours: Monday- Friday with rotating weekends **This position will hybrid- must be okay with coming onsite** Employment Type: Full Time Primary Purpose Establishes and maintains an efficient, cost effective care management process by determining patient financial and medical eligibility, medical necessity, and by developing, implementing and monitoring individual patient plans of care and communicating these plans to patients, families, and Parkland staff to ensure quality patient care throughout the healthcare continuum and compliance with program/Parkland policies and procedures. Responsible for the maintaining the knowledge and skill set related to utilization review, care coordination, performance improvement and professional licensure and certification. Minimum Specifications Education Must be a graduate of an accredited school of Nursing. Experience Must have two (2) years of hospital or community based patient care nursing, preferably in assigned clinical area. Equivalent Education and/or Experience Certification/Registration/Licensure Must have current, valid RN license or temporary RN license from the Texas Board of Nursing; or, valid Compact RN license. Must have current healthcare provider BLS for Healthcare Providers certification from one of the following: American Heart Association American Red Cross Military Training Network Required Tests for Placement Skills or Special Abilities Provides care to assigned patient population in accordance with the current State of Texas Nursing Practice Act, established protocols, multidisciplinary plan of care, and clinical area specific standards. Must be able to communicate and collaborate effectively with a diverse group of patients, families and healthcare staff. Must be able to demonstrate a working knowledge of specific patient populations, and be able to demonstrate knowledge of disease processes affecting this group. Must be able to demonstrate a working knowledge of PC operations and the ability to use word processing software in a Windows environment. Must be able to demonstrate a working knowledge of the laws and regulations governing Medicare, Medicaid and community-based funding sources. Must be self-directed and capable of priority setting and problem solving. Must be able to demonstrate patient centered/patient valued behaviors. Responsibilities Conducts assessment of patients on assigned Care Coordination team to develop a case management plan of care. Gathers information from patient, physicians, other pertinent members of the healthcare team. Determines funding sources for patients and potential eligibility if appropriate. Plans and develops specific objectives, goals and actions designed to meet the patient's needs as identified through the assessment process. Utilizes hospital approved review criteria to ensure appropriate bed status. Identifies at-risk populations using approved screening tool and follows established reporting procedures. Ensures appropriate admission status is documented. Collaborates with all members of the multidisciplinary team and the patient to implement the plan of care. Monitors the patient's progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective. Communicates all financial counseling as appropriate. Addresses and resolves system barriers impeding diagnostic or treatment progress. Proactively identifies and resolves delays and obstacles to discharge. Ensures/maintains plan consensus from patient/family, physician, and payer. Serves as patient advocate to secure coverage for needed community services. Mobilizes resources and coordinates the effort to the health care team to achieve a positive patient transition to appropriate next level of care. Communicates plan of care to patient and their family providing updates and reassesses the plan of care to determine effectiveness. Completes appropriate coordinator management documentation. Evaluates the plan of care at appropriate intervals to determine effectiveness in meeting outcomes and goals. Works with nursing and other disciplines to ensure that discharge needs, including teaching, are met. Collaborates with the healthcare team to identify 'best' practices for achieving patient outcomes. Develops reporting mechanisms to communicate outcomes to physicians and other members of the health care team. Responsible for Utilization Management activities for assigned patients. Applies approved utilization criteria to monitor appropriateness of admissions and continued stays, and documents findings based on department standards. Monitors length of stay (LOS) and ancillary resource use on an ongoing basis and takes action to achieve continuous improvement in both areas. Monitors and addresses outcome variances. Identifies causes of outcome variances and implements actions to improve the variances. Seeks the most efficient, cost effective ways to provide appropriate care. Supports cost containment efforts through the recommendation of performance improvement opportunities by the health care team. Communicates with Care Management team to facilitate covered-day reimbursement certification and/or authorization for assigned patients. Discusses payer criteria and issues on a case-by-case basis with clinical staff and follows up to resolve problems with payers as needed. Transitions patients through the health care system based upon individual and patient population needs. Directs liaison activities to appropriately integrate the patient into the health care continuum including procuring of services, health promotion and counseling, disease prevention, health education and screening, and community resource linkage. Engages in special projects and serves on committees, as assigned. Requisition ID: 989858
RN Utilization Review
Lexington Medical Center

Quality Review Specialist-RN

Lexington Medical Center West Columbia, SC
Quality Management - Acute Full TimeDay Shift 8:00-4:30 Lexington Health is a comprehensive network of care that includes six community medical and urgent care centers, nearly 80 physician practices, more than 9,000 health care professionals and Lexington Medical Center, a 607-bed teaching hospital in West Columbia, South Carolina. It was selected by Modern Healthcare as one of the Best Places to Work in Healthcare and was first in the state to achieve Magnet with Distinction status for excellence in nursing care. Consistently ranked as best in the Columbia Metro area by U.S. News & World Report, Lexington Health delivers more than 4,000 babies each year, performs more than 34,000 surgeries annually and is the region's third largest employer. Lexington Health also includes an accredited Cancer Center of Excellence, the state’s first HeartCARE Center, the largest skilled nursing facility in the Carolinas, and an Alzheimer’s care center. Its postgraduate medical education programs include family medicine and transitional year residencies, as well as an informatics fellowship.Job Summary The Quality Review Specialist-RN provides consultative services regarding quality assessment and trends to medical staff and to hospital ancillary department personnel. In this role, the employee will perform comprehensive retrospective reviews in a timely manner utilizing criteria developed and approved by the medical staff, hospital, and regulatory agents. Minimum Qualifications Minimum Education: High School Diploma or Equivalent Minimum Years of Experience: 4 Years of clinical or hospital experience; 2 Years of experience in quality or utilization review. Substitutable Education & Experience (Optional): None. Required Certifications/Licensure: Registered Nurse (RN) Required Training: None. Essential Functions Utilizes in-depth knowledge of clinical workflows, policies and procedures, patient care / clinical business processes, regulatory requirements, and best practices to: Risk Management- Perform daily review of new occurrence reports. Identify occurrences that require additional follow-up and reports these to the Director or designee in a timely manner. Ensure that occurrences are categorized correctly and all fields completed and correct. Verifies data accuracy with medical record if necessary. Ensure that occurrence reports are forwarded to all appropriate persons. Access other sources of data as needed for investigation and follow up. Serves as System Administrator for the occurrence reporting system. Primary liaison between Risk Management, Information Services, and system users. Manages access to the occurrence reporting system. Adds new locations and new users and provides new-user training. Assigns passwords. Removes users as needed. Provides new user training and ongoing user support, paying keen attention to user needs and opportunities to offer solutions and modify processes to improve efficiencies. Coordinates with vendor and Information Services to troubleshoot system as needed. Center for Best Practice & PN Quality- Assists with development, implementation, and evaluation of the hospital’s overall quality improvement program. Assist with coordination, preparation, and maintenance of performance improvement assessment and improvement activities. Responsible for data integrity and follows well defined processes for maintaining data integrity as well as manage assigned database. Assists in evaluation, analysis, maintenance and development of system functionality of the EHR to meet clinical objectives including participating in project plan development/tracking and workflow analysis. Duties & Responsibilities Provides accurate and timely routine statistical analyses and reports to designated parties. Identifies need for new reports and develops and creates reports. Generates user-friendly reports from other databases. Evaluates and analyzes data for trends, identifies areas of concern, and uses data display techniques to provide reports for various meetings and hospital committees. Prepares materials for meetings and assists with maintenance of performance improvement project records. Represents department on committees / teams as assigned. Participates and supports department goals, objectives and timelines, working with a sense of urgency and accuracy to ensure effective implementation. Successfully engages in multiple initiatives simultaneously and demonstrates flexibility in role and a willingness to help others. Attains an annual minimum of 12 hours of continuing education in topics related to role. May prepare materials for meetings and assists with maintenance of performance improvement project records. May represent department on committees / teams as assigned. Risk Management: Resolves problems and recommends solutions through research, inquiry, and data analysis, maintaining support call logs and tracking of issues. Compiles and maintains accurate statistics pertaining to occurrence data. Participates in and contributes to patient safety / risk reduction activities, including: Participates in and contributes to investigations of serious unanticipated events and "close-calls". Participates in and contributes to development, implementation and evaluation of corrective action plans. Supports a culture of safety by encouraging staff to speak up and report safety and quality issues. Center for Best Practice & PN Quality: Identifies opportunities for improvement and coordinates/participates in the development and implementation of action plans to make improvements- recommends changes to systems/processes that do not contribute to desired outcomes. Works collaboratively and communicates effectively with administration, IS, and clinical care teams through participation in the planning, development, and evaluation and maintenance of the Clinical Information system. Audits database contents for accuracy and validity. Acts as a resource person in quality assessment activities with hospital departments and committees. Works directly with hospital personnel to provide assistance and guidance in establishing criteria, reviewing medical records, etc. Requires efficient use of numerous software products (Word, Excel, PowerPoint, Outlook, etc.) Performs all other duties as assigned. We are committed to offering quality, cost-effective benefits choices for our benefit eligible employees and their families: Day ONE medical, dental and life insurance benefits Health care and dependent care flexible spending accounts (FSAs) Employees are eligible for enrollment into the 403(b) match plan day one. LHI matches dollar for dollar up to 6%. Employer paid life insurance – equal to 1x salary Employee may elect supplemental life insurance with low cost premiums up to 3x salary Adoption assistance LHI provides its full-time employees employer paid short-term disability and long-term disability coverage after 90 days of eligible employment Tuition reimbursement Student loan forgiveness Equal Opportunity EmployerIt is the policy of Lexington Health to provide equal opportunity of employment for all individuals, and to remain compliant with applicable state and federal laws and regulations. Lexington Health strives to provide a discrimination-free environment, and to recruit, select, on-board, and employ all employees without regard to race, color, religion, sex, age, disability, national origin, veteran status, or pregnancy, childbirth, or related medical conditions, including but not limited to, lactation. Lexington Health endeavors to upgrade and promote employees from within the hospital where possible and consistent with the employee’s desires and abilities and the hospital’s needs.
RN Outpatient Utilization Review Outpatient
Devoted Health

Clinical Guide: (UM) Utilization Management Nurse (Outpatient Prior Authorization)

Devoted Health
$82,680 - $96,460 / year
Job Description A bit about this role: As a Clinical Guide on our Outpatient Utilization Management team, you’ll have the opportunity to make a difference in the lives of our members. You’ll be responsible for clinical review of outpatient authorization requests — applying evidence-based medical necessity criteria, CMS and Medicare Advantage requirements, and health plan policy to determine whether requested services are appropriate. Your decisions help members get the right care in the right setting, and help them navigate the healthcare system with confidence. Our ideal Clinical Guide is detail-oriented, solutions-focused, and comfortable making well-documented clinical judgments at pace. You’re someone who can hold accuracy and volume at the same time, and who is energized rather than unsettled by evolving policies and workflows. Schedule: This is a full-time, remote position working five 8-hour days, 40 hours per week. We are hiring for the following schedules: Monday – Friday, 10:00 AM – 7:00 PM ET Monday – Friday, 11:00 AM – 8:00 PM ET Sunday – Thursday, 10:00 AM – 7:00 PM ET We’ll ask about your schedule preference during the process and will do our best to match it. Because we’re filling a limited number of openings on each schedule, availability changes as roles are filled — so we ask that candidates be open to more than one schedule where possible. Your responsibilities and impact will include: Conduct timely, comprehensive clinical review of outpatient authorization requests, applying evidence-based medical necessity criteria, CMS and Medicare Advantage requirements, and health plan policies. Review requests across multiple authorization categories — including outpatient procedures, imaging, therapy, DME, and home health — each with its own criteria and resources. Determine the appropriateness of requested services and the appropriate setting of care, recommending clinically appropriate alternatives where relevant. Refer cases that do not meet criteria to the Medical Director for secondary review; prepare clinical summaries and support peer-to-peer discussions. Communicate with providers and internal teams to obtain additional clinical documentation and resolve open questions. Meet CMS turnaround time standards while maintaining accuracy across a high volume of requests. Maintain accurate, defensible documentation of every determination, in line with CMS regulations, Medicare Advantage requirements, and internal compliance standards. Apply clinical judgment on complex cases — gathering additional information and escalating when appropriate. Identify, document, and communicate potential quality assurance or risk management issues. Explain complex clinical and coverage information clearly to providers and internal partners. Required skills and experience: An unrestricted RN license with a minimum of 4 years of RN experience. Minimum 3 years of utilization management, utilization review, or prior authorization experience within a health plan, hospital, or post-acute setting. Knowledge and understanding of CMS guidelines and Medicare Advantage requirements. Experience escalating cases that do not meet criteria, including preparing clinical summaries for physician review. Comfort in a fast-paced environment with daily turnaround standards and frequently changing policies, criteria, and workflows. The ability to comfortably multi-task — you’ll be listening, talking, and typing at the same time. Desired skills and experience: Outpatient prior authorization experience — home health and DME a significant plus. Proficiency with technology, including Google Workspace and AI tools. The ability to break down complex information and adjust your approach to different audiences. Transparency in your work — what’s going well and what isn’t. A desire to change the healthcare experience: you love to serve and make a difference. #LI-DS1 #LI-Remote Salary Range: $82,680-$96,460 / year The pay range listed for this position is the range the organization reasonably and in good faith expects to pay for this position at the time of the posting. Once the interview process begins, your talent partner will provide additional information on the compensation for the role, along with additional information on our total rewards package. The actual base salary offered will depend on a variety of factors, including the qualifications of the individual applicant for the position, years of relevant experience, specific and unique skills, level of education attained, certifications or other professional licenses held, and the location in which the applicant lives and/or from which they will be performing the job. Our Total Rewards package includes: Employer sponsored health, dental and vision plan with low or no premium Generous paid time off $100 monthly mobile or internet stipend Stock options for all employees Bonus eligibility for all roles excluding Director and above; Commission eligibility for Sales roles Parental leave program 401K program And more.... *Our total rewards package is for full time employees only. Intern and Contract positions are not eligible. Founded in 2017, Devoted Health is on a mission to dramatically improve the health and well-being of older Americans by caring for everyone like they are family, and that includes our employees. Our robust and seamlessly integrated care platform merges advanced data and AI access with world-class clinical and service experiences to create a member experience that is unlike the industry norm. To continue building upon our mission, we want to bring together those who share our values, embrace change and advancement, and are enthusiastic about where we're going — all the while bringing their own unique qualities, experiences, and expertise, in hopes of further changing the healthcare experience. Devoted is an equal opportunity employer. We are committed to a safe and supportive work environment in which all employees have the opportunity to participate and contribute to the success of the business. We value diversity and collaboration. Individuals are respected for their skills, experience, and unique perspectives. This commitment is embodied in Devoted’s Code of Conduct, our company values and the way we do business. As an Equal Opportunity Employer, the Company does not discriminate on the basis of race, color, religion, sex, pregnancy status, marital status, national origin, disability, age, sexual orientation, veteran status, genetic information, gender identity, gender expression, or any other factor prohibited by law. Our management team is dedicated to this policy with respect to recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, employee activities and general treatment during employment.
RN Utilization Review Telehealth
Devoted Health

Clinical Guide Part A: (UM) Utilization Management Nurse

Devoted Health
$82,680 - $96,460 / year
Job Description A bit about this role: The Clinical Guide Part A will be part of the Utilization Management team, responsible for inpatient, behavioral health, and/or post-acute authorization review in alignment with CMS and Medicare Advantage regulations. Reviews medical records to evaluate the medical necessity and appropriateness of requested inpatient and/or post-acute services in accordance with established clinical criteria and CMS guidelines. Schedule: This is a full-time, remote position working five 8-hour days. We are hiring for several schedules: Tuesday – Saturday, 9:00 AM – 6:00 PM ET Sunday – Thursday, 9:00 AM – 6:00 PM ET Monday – Friday, 11:00 AM – 8:00 PM ET Monday – Friday, 9:00 AM – 6:00 PM ET We'll ask about your schedule preference during the process and will do our best to match it. Because we are filling a limited number of openings on each schedule, availability changes as roles are filled — so we ask that candidates be open to more than one schedule where possible. Most schedules include one weekend day. Weekend and later-day coverage is a core part of how our Utilization Management team meets CMS turnaround requirements. Your Responsibilities and Impact will include: Review Medical Records: Conduct prospective (pre-service), concurrent, and retrospective utilization review to evaluate medical necessity, appropriate level of care (Inpatient vs. Observation), and post-acute services in accordance with established clinical criteria and CMS guidelines. Evaluate Treatment Plans: Assess the appropriateness, timing, and setting of requested services, ensuring alignment with medical necessity criteria and Medicare Advantage requirements. Recommend alternative levels of care when clinically appropriate. Inpatient & Behavioral Health Review: Perform initial, concurrent, and discharge reviews for inpatient and behavioral health admissions. Ensure admission status accuracy and regulatory compliance with CMS timeliness (TAT) standards. Post-Acute Review: Conduct initial authorization and concurrent review for post-acute services (SNF, LTACH, ARU, Home Health), evaluating ongoing medical necessity and appropriate length of stay. Issue NOMNC when coverage criteria are no longer met. Medical Director Collaboration: Refer cases that do not meet criteria to the Medical Director for secondary review and final determination. Prepare clinical summaries and coordinate peer-to-peer (P2P) discussions. Manage authorization reopen requests as appropriate. Resource Stewardship: Monitor utilization of inpatient and post-acute services to promote appropriate resource use while maintaining high-quality, member-centered care. Regulatory & Documentation Compliance: Maintain accurate, defensible documentation of all determinations. Ensure adherence to CMS regulations, Medicare Advantage requirements, and internal compliance standards. Required skills and experience: Unrestricted RN license with a minimum of 4 years of clinical experience 3+ years in utilization review, utilization management, case management, discharge planning, care coordination, or clinical appeals — in a health plan, hospital, or post-acute setting Familiarity with CMS regulations and Medicare Advantage requirements, or comparable payer coverage experience Experience escalating cases that don't meet criteria, including preparing clinical summaries for physician review Ability to work one of the posted schedules, including a weekend day for most schedules; flexibility across more than one schedule preferred. Able to work in a fast paced environment that is constantly evolving. Desired skills and experience: Experience with AI/LLM Certified in InterQual #LI-DS1 #LI-Remote Salary Range: $82,680-$96,460 / year The pay range listed for this position is the range the organization reasonably and in good faith expects to pay for this position at the time of the posting. Once the interview process begins, your talent partner will provide additional information on the compensation for the role, along with additional information on our total rewards package. The actual base salary offered will depend on a variety of factors, including the qualifications of the individual applicant for the position, years of relevant experience, specific and unique skills, level of education attained, certifications or other professional licenses held, and the location in which the applicant lives and/or from which they will be performing the job. Our Total Rewards package includes: Employer sponsored health, dental and vision plan with low or no premium Generous paid time off $100 monthly mobile or internet stipend Stock options for all employees Bonus eligibility for all roles excluding Director and above; Commission eligibility for Sales roles Parental leave program 401K program And more.... *Our total rewards package is for full time employees only. Intern and Contract positions are not eligible. Founded in 2017, Devoted Health is on a mission to dramatically improve the health and well-being of older Americans by caring for everyone like they are family, and that includes our employees. Our robust and seamlessly integrated care platform merges advanced data and AI access with world-class clinical and service experiences to create a member experience that is unlike the industry norm. To continue building upon our mission, we want to bring together those who share our values, embrace change and advancement, and are enthusiastic about where we're going — all the while bringing their own unique qualities, experiences, and expertise, in hopes of further changing the healthcare experience. Devoted is an equal opportunity employer. We are committed to a safe and supportive work environment in which all employees have the opportunity to participate and contribute to the success of the business. We value diversity and collaboration. Individuals are respected for their skills, experience, and unique perspectives. This commitment is embodied in Devoted’s Code of Conduct, our company values and the way we do business. As an Equal Opportunity Employer, the Company does not discriminate on the basis of race, color, religion, sex, pregnancy status, marital status, national origin, disability, age, sexual orientation, veteran status, genetic information, gender identity, gender expression, or any other factor prohibited by law. Our management team is dedicated to this policy with respect to recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, employee activities and general treatment during employment.
RN Utilization Review Telehealth
Devoted Health

Clinical Guide Part A: (UM) Utilization Management Nurse

Devoted Health
$82,680 - $96,460 / year
Job Description A bit about this role: The Clinical Guide Part A will be part of the Utilization Management team, responsible for inpatient, behavioral health, and/or post-acute authorization review in alignment with CMS and Medicare Advantage regulations. Reviews medical records to evaluate the medical necessity and appropriateness of requested inpatient and/or post-acute services in accordance with established clinical criteria and CMS guidelines. Schedule: This is a full-time, remote position working five 8-hour days. We are hiring for several schedules: Tuesday – Saturday, 9:00 AM – 6:00 PM ET Sunday – Thursday, 9:00 AM – 6:00 PM ET Monday – Friday, 11:00 AM – 8:00 PM ET Monday – Friday, 9:00 AM – 6:00 PM ET We'll ask about your schedule preference during the process and will do our best to match it. Because we are filling a limited number of openings on each schedule, availability changes as roles are filled — so we ask that candidates be open to more than one schedule where possible. Most schedules include one weekend day. Weekend and later-day coverage is a core part of how our Utilization Management team meets CMS turnaround requirements. Your Responsibilities and Impact will include: Review Medical Records: Conduct prospective (pre-service), concurrent, and retrospective utilization review to evaluate medical necessity, appropriate level of care (Inpatient vs. Observation), and post-acute services in accordance with established clinical criteria and CMS guidelines. Evaluate Treatment Plans: Assess the appropriateness, timing, and setting of requested services, ensuring alignment with medical necessity criteria and Medicare Advantage requirements. Recommend alternative levels of care when clinically appropriate. Inpatient & Behavioral Health Review: Perform initial, concurrent, and discharge reviews for inpatient and behavioral health admissions. Ensure admission status accuracy and regulatory compliance with CMS timeliness (TAT) standards. Post-Acute Review: Conduct initial authorization and concurrent review for post-acute services (SNF, LTACH, ARU, Home Health), evaluating ongoing medical necessity and appropriate length of stay. Issue NOMNC when coverage criteria are no longer met. Medical Director Collaboration: Refer cases that do not meet criteria to the Medical Director for secondary review and final determination. Prepare clinical summaries and coordinate peer-to-peer (P2P) discussions. Manage authorization reopen requests as appropriate. Resource Stewardship: Monitor utilization of inpatient and post-acute services to promote appropriate resource use while maintaining high-quality, member-centered care. Regulatory & Documentation Compliance: Maintain accurate, defensible documentation of all determinations. Ensure adherence to CMS regulations, Medicare Advantage requirements, and internal compliance standards. Required skills and experience: Unrestricted RN license with a minimum of 4 years of clinical experience 3+ years in utilization review, utilization management, case management, discharge planning, care coordination, or clinical appeals — in a health plan, hospital, or post-acute setting Familiarity with CMS regulations and Medicare Advantage requirements, or comparable payer coverage experience Experience escalating cases that don't meet criteria, including preparing clinical summaries for physician review Ability to work one of the posted schedules, including a weekend day for most schedules; flexibility across more than one schedule preferred. Able to work in a fast paced environment that is constantly evolving. Desired skills and experience: Experience with AI/LLM Certified in InterQual #LI-DS1 #LI-Remote Salary Range: $82,680-$96,460 / year The pay range listed for this position is the range the organization reasonably and in good faith expects to pay for this position at the time of the posting. Once the interview process begins, your talent partner will provide additional information on the compensation for the role, along with additional information on our total rewards package. The actual base salary offered will depend on a variety of factors, including the qualifications of the individual applicant for the position, years of relevant experience, specific and unique skills, level of education attained, certifications or other professional licenses held, and the location in which the applicant lives and/or from which they will be performing the job. Our Total Rewards package includes: Employer sponsored health, dental and vision plan with low or no premium Generous paid time off $100 monthly mobile or internet stipend Stock options for all employees Bonus eligibility for all roles excluding Director and above; Commission eligibility for Sales roles Parental leave program 401K program And more.... *Our total rewards package is for full time employees only. Intern and Contract positions are not eligible. Founded in 2017, Devoted Health is on a mission to dramatically improve the health and well-being of older Americans by caring for everyone like they are family, and that includes our employees. Our robust and seamlessly integrated care platform merges advanced data and AI access with world-class clinical and service experiences to create a member experience that is unlike the industry norm. To continue building upon our mission, we want to bring together those who share our values, embrace change and advancement, and are enthusiastic about where we're going — all the while bringing their own unique qualities, experiences, and expertise, in hopes of further changing the healthcare experience. Devoted is an equal opportunity employer. We are committed to a safe and supportive work environment in which all employees have the opportunity to participate and contribute to the success of the business. We value diversity and collaboration. Individuals are respected for their skills, experience, and unique perspectives. This commitment is embodied in Devoted’s Code of Conduct, our company values and the way we do business. As an Equal Opportunity Employer, the Company does not discriminate on the basis of race, color, religion, sex, pregnancy status, marital status, national origin, disability, age, sexual orientation, veteran status, genetic information, gender identity, gender expression, or any other factor prohibited by law. Our management team is dedicated to this policy with respect to recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, employee activities and general treatment during employment.
RN Outpatient Utilization Review Outpatient
Devoted Health

Clinical Guide: (UM) Utilization Management Nurse (Outpatient Prior Authorization)

Devoted Health
$82,680 - $96,460 / year
Job Description A bit about this role: As a Clinical Guide on our Outpatient Utilization Management team, you’ll have the opportunity to make a difference in the lives of our members. You’ll be responsible for clinical review of outpatient authorization requests — applying evidence-based medical necessity criteria, CMS and Medicare Advantage requirements, and health plan policy to determine whether requested services are appropriate. Your decisions help members get the right care in the right setting, and help them navigate the healthcare system with confidence. Our ideal Clinical Guide is detail-oriented, solutions-focused, and comfortable making well-documented clinical judgments at pace. You’re someone who can hold accuracy and volume at the same time, and who is energized rather than unsettled by evolving policies and workflows. Schedule: This is a full-time, remote position working five 8-hour days, 40 hours per week. We are hiring for the following schedules: Monday – Friday, 10:00 AM – 7:00 PM ET Monday – Friday, 11:00 AM – 8:00 PM ET Sunday – Thursday, 10:00 AM – 7:00 PM ET We’ll ask about your schedule preference during the process and will do our best to match it. Because we’re filling a limited number of openings on each schedule, availability changes as roles are filled — so we ask that candidates be open to more than one schedule where possible. Your responsibilities and impact will include: Conduct timely, comprehensive clinical review of outpatient authorization requests, applying evidence-based medical necessity criteria, CMS and Medicare Advantage requirements, and health plan policies. Review requests across multiple authorization categories — including outpatient procedures, imaging, therapy, DME, and home health — each with its own criteria and resources. Determine the appropriateness of requested services and the appropriate setting of care, recommending clinically appropriate alternatives where relevant. Refer cases that do not meet criteria to the Medical Director for secondary review; prepare clinical summaries and support peer-to-peer discussions. Communicate with providers and internal teams to obtain additional clinical documentation and resolve open questions. Meet CMS turnaround time standards while maintaining accuracy across a high volume of requests. Maintain accurate, defensible documentation of every determination, in line with CMS regulations, Medicare Advantage requirements, and internal compliance standards. Apply clinical judgment on complex cases — gathering additional information and escalating when appropriate. Identify, document, and communicate potential quality assurance or risk management issues. Explain complex clinical and coverage information clearly to providers and internal partners. Required skills and experience: An unrestricted RN license with a minimum of 4 years of RN experience. Minimum 3 years of utilization management, utilization review, or prior authorization experience within a health plan, hospital, or post-acute setting. Knowledge and understanding of CMS guidelines and Medicare Advantage requirements. Experience escalating cases that do not meet criteria, including preparing clinical summaries for physician review. Comfort in a fast-paced environment with daily turnaround standards and frequently changing policies, criteria, and workflows. The ability to comfortably multi-task — you’ll be listening, talking, and typing at the same time. Desired skills and experience: Outpatient prior authorization experience — home health and DME a significant plus. Proficiency with technology, including Google Workspace and AI tools. The ability to break down complex information and adjust your approach to different audiences. Transparency in your work — what’s going well and what isn’t. A desire to change the healthcare experience: you love to serve and make a difference. #LI-DS1 #LI-Remote Salary Range: $82,680-$96,460 / year The pay range listed for this position is the range the organization reasonably and in good faith expects to pay for this position at the time of the posting. Once the interview process begins, your talent partner will provide additional information on the compensation for the role, along with additional information on our total rewards package. The actual base salary offered will depend on a variety of factors, including the qualifications of the individual applicant for the position, years of relevant experience, specific and unique skills, level of education attained, certifications or other professional licenses held, and the location in which the applicant lives and/or from which they will be performing the job. Our Total Rewards package includes: Employer sponsored health, dental and vision plan with low or no premium Generous paid time off $100 monthly mobile or internet stipend Stock options for all employees Bonus eligibility for all roles excluding Director and above; Commission eligibility for Sales roles Parental leave program 401K program And more.... *Our total rewards package is for full time employees only. Intern and Contract positions are not eligible. Founded in 2017, Devoted Health is on a mission to dramatically improve the health and well-being of older Americans by caring for everyone like they are family, and that includes our employees. Our robust and seamlessly integrated care platform merges advanced data and AI access with world-class clinical and service experiences to create a member experience that is unlike the industry norm. To continue building upon our mission, we want to bring together those who share our values, embrace change and advancement, and are enthusiastic about where we're going — all the while bringing their own unique qualities, experiences, and expertise, in hopes of further changing the healthcare experience. Devoted is an equal opportunity employer. We are committed to a safe and supportive work environment in which all employees have the opportunity to participate and contribute to the success of the business. We value diversity and collaboration. Individuals are respected for their skills, experience, and unique perspectives. This commitment is embodied in Devoted’s Code of Conduct, our company values and the way we do business. As an Equal Opportunity Employer, the Company does not discriminate on the basis of race, color, religion, sex, pregnancy status, marital status, national origin, disability, age, sexual orientation, veteran status, genetic information, gender identity, gender expression, or any other factor prohibited by law. Our management team is dedicated to this policy with respect to recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, employee activities and general treatment during employment.
RN Utilization Review Full-time
Atlantic Health System

Utilization Reviewer (RN)- Full Time Days 8 AM - 4 PM, Atlantic Health Newton/Hackettstown/Chilton Medical Center

Atlantic Health System Morristown, NJ
$41.79 - $73.56 / hour
Job Description Utilization Reviewer (RN) – Emergency Department Atlantic Health System – Newton, Hackettstown & Chilton Medical Center Full-Time | Days | Monday-Friday | 8:00 AM – 4:00 PM Atlantic Health System is seeking a Full-Time Utilization Reviewer RN to support Emergency Department operations at Overlook Medical Center. The Utilization Reviewer is responsible for conducting real-time medical necessity reviews and level-of-care determinations for patients presenting to the Emergency Department. This role serves as a key liaison between clinical teams and utilization management to ensure appropriate patient status assignment, regulatory compliance, and optimal patient throughput. Responsibilities Perform concurrent medical necessity reviews for Emergency Department patients utilizing MCG and/or InterQual criteria. Evaluate admission, observation, and level-of-care determinations in accordance with CMS, payer, and organizational guidelines. Collaborate with Emergency Department physicians, hospitalists, physician advisors, and care management teams to support timely patient placement decisions. Provide education and guidance regarding CMS Observation Rules, Two-Midnight Rule, and documentation requirements. Identify potential denial risks and compliance concerns and escalate as appropriate. Communicate patient status determinations and pertinent clinical information to inpatient Utilization Review staff for continuity of care. Participate in departmental quality initiatives, data collection, reporting, and performance improvement activities related to utilization management and patient throughput. Maintain current knowledge of regulatory and payer requirements impacting utilization review practices. Required QUALIFICATIONS Graduate of an accredited School of Nursing. Current New Jersey Registered Nurse (RN) License in good standing. Strong clinical assessment and critical thinking skills. Excellent communication and interdisciplinary collaboration abilities. Preferred Bachelor of Science in Nursing (BSN). Previous Case Management, Utilization Review, or Care Coordination experience. Experience utilizing MCG and/or InterQual criteria. Knowledge of CMS regulations, Observation Status requirements, and Utilization Management principles. Prior Emergency Department, Acute Care, Case Management, or Clinical Documentation experience. About Us At Atlantic Health, our promise to our communities is; Anyone who enters one of our facilities will receive the highest quality care delivered at the right time, at the right place, and at the right cost. This commitment is also echoed in the respect, development and opportunities we give to our more than 22,000 team members. Headquarters in Morristown, New Jersey, we are one of the leading non-profit health care systems in the nation. Our facilities and sites of care include: Atlantic Health Morristown Medical Center, Morristown, NJ Atlantic Health Overlook Medical Center, Summit, NJ Atlantic Health Newton Medical Center, Newton, NJ Atlantic Health Chilton Medical Center, Pompton Plains, NJ Atlantic Health Hackettstown Medical Center, Hackettstown, NJ Atlantic Health Goryeb Children's Hospital, Morristown, NJ Atlantic Health CentraState Healthcare System, Freehold, NJ Atlantic Medical Group Atlantic Visiting Nurse Atlantic Mobile Health Atlantic Rehabilitation We have more than 900 community-based healthcare providers affiliated through Atlantic Medical Group. We Have Received Awards And Recognition For The Services We Have Provided To Our Patients, Team Members And Communities. Below Are Just a Few Of Our Accolades Chosen for 17 years by Fortune as one of the magazine’s “100 Best Companies to Work For." Atlantic Health Morristown and Atlantic Health Overlook Named by Newsweek as two of the “World’s Best Hospitals” in 2026. Atlantic Health Morristown and Atlantic Health Overlook ranked within the top three hospitals in New Jersey by U.S. News & World Report’s 2025-2026 Best Hospital rankings. Atlantic Health scored four “A” grades by The Leapfrog Group in its Fall 2025 Hospital Safety Grades, performance measures reflecting errors, accidents, injuries and injections, as well as systems hospitals have in place to prevent harm. Atlantic Health Morristown and Atlantic Health Overlook are New Jersey's only hospitals to be named among America's 50 Best hospitals by Healthgrades in 2026. Named by Becker's Healthcare as one of the "165 Top Places to Work in Healthcare – 2026. Atlantic Health Morristown, Atlantic Health Overlook, Atlantic Health Chilton and Atlantic Health Newton all Forbes Top Hospitals for 2026. Named by Newsweek as one of America’s Greatest Workplaces for Inclusion & Diversity 2025. Atlantic Health rated LEVEL 9 - 2025 CHIME Digital Health Most Wired. Summary Atlantic Health offers a competitive and comprehensive Total Rewards package that supports the health, financial security, and well-being of all team members. Offerings vary based on role level (Team Member, Director, Executive). Below is a general summary, with role-specific enhancements highlighted: Team Member Benefits Medical, Dental, Vision, Prescription Coverage (22.5 hours per week or above for full-time and part-time team members) Life & AD&D Insurance. Short-Term and Long-Term Disability (with options to supplement) 403(b) Retirement Plan: Employer match, additional non-elective contribution PTO & Paid Sick Leave Tuition Assistance, Advancement & Academic Advising Parental, Adoption, Surrogacy Leave Backup and On-Site Childcare Well-Being Rewards Employee Assistance Program (EAP) Fertility Benefits, Healthy Pregnancy Program Flexible Spending & Commuter Accounts Pet, Home & Auto, Identity Theft and Legal Insurance ____________________________________________ Note: In Compliance with the NJ Pay Transparency Act (effective Sunday, June 1, 2025), all job postings will include the hourly wage or salary (or a range), as well as this summary of benefits. Final compensation and benefit eligibility may vary by role and employment status and will be confirmed at the time of offer. EEO STATEMENT Atlantic Health, Inc. is an equal employment opportunity employer and federal contractor or subcontractor and therefore abides by applicable laws to protect applicants and employees from discrimination in hiring, promotion, discharge, pay, fringe benefits, job training, classification, referral, and other aspects of employment, on the basis of race, color, religion, sex (including pregnancy, gender identity and sexual orientation), national origin, citizenship status, disability, age, genetics, or veteran
LPN Utilization Review Home Health Full-time
Molina Healthcare

Facility Site Review Nurse (LVN/LPN)- Remote in CA

Molina Healthcare Long Beach, CA
$30.37 - $55 / hour
Job Description Job Summary Provides support for clinical facility site reviews. Under the supervision of leadership, uses clinical judgement within appropriate scope to independently conduct reviews and other monitoring activities for primary care providers, specialty care providers, skilled nursing facilities, sub-acute facilities, intermediate care facilities for developmentally disabled and community-based adult services sites, and other network providers. Completes reviews in alignment with local/state/federal requirements and internal Molina policies and procedures. Leverages survey review data to develop reports, document review outcomes, and identify opportunities for ongoing program improvement. Contributes to overarching strategy to provide quality and cost-effective member care. Job Duties • Conducts onsite, virtual and/or desktop reviews, including but not limited to the following: Physical Accessibility Review Survey (PARS), CR5/ member grievance reviews, Healthcare Delivery Organization (HDO)/credentialing reviews, initial health appointment medical record reviews, quality grant program reviews, and Quality Assurance Performance Improvement (QAPI) reviews. • Completes all aspects of facility site reviews using appropriate assessment tool and established regulations/policies and procedures. • Reviews and audits provider quality programs, processes, and policies. • Documents discussions and correspondence in facility site review (FSR) files as appropriate. • Documents review outcomes and other details in designated database, develops reports, and ensures proper document collection throughout the review process. • Communicates and coordinates information and findings from site visits between FSR leadership, internal and external staff and customers. • Assists with quality interventions program documentation and updates, reports, presentations, etc. • Represents as a Molina liaison to address provider questions and concerns. • Collaborates directly with providers to provide education, resources and tools to assist in achieving and maintaining compliance with local, state, and federal requirements. • Provides tools and resources to promote and facilitate access to preventive and other important health services. • Supports the development of facility site review policies, procedures and processes. • Identifies and supports ongoing program improvement opportunities and initiatives. • Provides technical assistance to providers, medical groups, and internal partners to enable delivery of accessibility information to Molina members. • Participates in PARS trainings, internal/departmental/collaborative meetings, workgroups and completes required compliance trainings to maintain necessary knowledge and skills. • Maintains confidentiality and compliance with Health Insurance Portability and Accountability Act (HIPAA) standards. • Collaborates with leadership to establish individual and team goals. • Completes special assignments and projects as assigned. Job Qualifications REQUIRED QUALIFICATIONS: • At least 2 years of related clinical/quality review experience, or equivalent combination of relevant education and experience. • Active and unrestricted Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) in state of practice. This position requires same-day out-of-office travel 50- 75% of the time, depending on location. (on average the nurses are in the field 3-4 days per week) This position may require multiple days’ out of town overnight travel 0 - 30% of the time, depending upon location. • Valid and unrestricted driver's license, reliable transportation, and adequate auto insurance for job related travel requirements. • Ability to work within a variety of settings and adjust style as needed - working with diverse populations, various personalities and situations. • Responsiveness in all forms of communication, and ability to remain calm in high-pressure situations. • Critical thinking skills. • Proactive, detail oriented, and organized. • Ability to work cross-functionally across a highly matrixed organization. • Effective verbal and written communication skills. • Microsoft Office suite and applicable software programs proficiency. PREFERRED QUALIFICATIONS: • Managed care experience. • Quality improvement and/or auditing experience. • Successful completion of PARS training and/or PARS certification. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $30.37 - $55 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
RN Utilization Review Full-time
UF Health

RN, Utilization Management| Day |Full Time

UF Health The Villages, FL
Overview Make an impact by supporting the right care at the right time through utilization management excellence. 💻 Work Style: Onsite 📍 Location: Gainesville, FL 🕒 FTE: Full-Time (1.0FTE) ⏰ Schedule: ( Days-TBD) 8:00 PM – 6:30PM 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 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 Utilization Review Telehealth Full-time
Mass General Brigham

Utilization Management Nurse, Out of Network

Mass General Brigham Assembly Square, MA
$90,000 - $107,000 / year
Site: Mass General Brigham Health Plan Holding Company, Inc. Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham. Job Summary Given equity, this position will pay somewhere between $90,000 to $107,000 annually. Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham, we are at the forefront of transformation with one of the world’s leading integrated healthcare systems. Together, we are providing our members with innovative solutions centered on their health needs to expand access to seamless and affordable care and coverage. Our work centers on creating an exceptional member experience – a commitment that starts with our employees. Working with some of the most accomplished professionals in healthcare today, our employees have opportunities to learn and contribute expertise within a welcoming and supportive environment that embraces their unique and varied backgrounds, experiences, and skills. We are pleased to offer competitive salaries and a benefits package with flexible work options, career growth opportunities, and much more. The UM Nurse will support network adequacy review and authorization activities for members enrolled in ACO, HMO, and EPO products who require planned inpatient or outpatient services from out-of-network providers. Utilizing clinical knowledge, the UM Nurse will review prior authorization requests, assess medical necessity and benefit coverage, render approval decisions within scope, determine when physician review is required, and complete determinations following physician review. The ideal candidate will have prior authorization experience in a managed care setting and possess strong commercial health plan knowledge. Essential Functions: • Expertise in clinical review for prospective, concurrent, retrospective utilization management reviews utilizing Interqual ®, company policies and procedures, and other resources as determined by review, including physician reviews as needed for all lines of business as per departmental needs • Review authorization requests for medical services, including making initial eligibility and coverage determinations, screening for medical necessity appropriateness, determining if additional information is required, and referral to correct programs within Mass General Brigham Health Plan as needed. • Manage incoming requests for procedures and services including patient medical records and related clinical information. • Strong working knowledge of commercial, self-insured, fully insured, and limited network plans. • Adherence to program, departmental, and organizational performance metrics, including productivity. • Excellent verbal and written communication skills. • Excellent problem-solving and customer service skills. • Would need to be available for “on call” for a minimum of once per month with the possibility of that increasing depending on staff availability; Approximately 6 months after hire. • Must be self-directed and highly motivated with an ability to multitask. • Develop and maintain effective working relationships with internal and external customers • Hold self and others accountable to meet commitments. • Sound decision-making and time management skills. • Proactive in areas of professional development, personally and for the department. • Persist in accomplishing objectives to consistently achieve results despite any obstacles and setbacks that arise. • Build strong relationships and infrastructures that designate Mass General Brigham Health Plan as a people-first organization. • Proficient with Microsoft Word, Excel, Outlook, McKesson InterQual ®, Outlook, SharePoint, PC based operating system, and web-based phone system. Qualifications Education Associate's Degree Nursing required or Bachelor's Degree Nursing preferred Licenses and Credentials Massachusetts Registered Nurse (RN) license required ​ Experience At least 2-3 years of utilization review experience is highly preferred Experience using Interqual or Milliman is highly preferred At least 1-2 years of experience in a payer setting is highly preferred At least 1-2 years of experience in an acute care setting is highly preferred Knowledge, Skills, and Abilities Demonstrate Mass General Brigham Health Plan’s core brand principles of always listening, challenging conventions, and providing value Strong aptitude for technology-based solutions. Embrace opportunities to take the complexity out of how we work and what we deliver. Listen to our constituents, learn, and act quickly in our ongoing pursuit of meaningful innovation Current in healthcare trends. Ability to inject energy, when and where it’s needed. Exercise self-awareness; monitor impact on others; be receptive to and seek out feedback; use self-discipline to adjust to feedback. Be accountable for delivering high-quality work. Act with a clear sense of ownership. Bring fresh ideas forward by actively listening to and working with employees and the people we serve. Communicate respectfully and professionally with colleagues Strong EQ; exercises self-awareness; monitors impact on others; is receptive to and seeks out feedback; uses self-discipline to adjust to feedback. Knowledge, Skills, and Abilities Demonstrate Mass General Brigham Health Plan’s core brand principles of always listening, challenging conventions, and providing value Strong aptitude for technology-based solutions. Embrace opportunities to take the complexity out of how we work and what we deliver. Listen to our constituents, learn, and act quickly in our ongoing pursuit of meaningful innovation Current in healthcare trends. Ability to inject energy, when and where it’s needed. Exercise self-awareness; monitor impact on others; be receptive to and seek out feedback; use self-discipline to adjust to feedback. Be accountable for delivering high-quality work. Act with a clear sense of ownership. Bring fresh ideas forward by actively listening to and working with employees and the people we serve. Communicate respectfully and professionally with colleagues Strong EQ; exercises self-awareness; monitors impact on others; is receptive to and seeks out feedback; uses self-discipline to adjust to feedback. Additional Job Details (if applicable) Working Conditions Would need to be available for “on call” for a minimum of once per month with the possibility of that increasing depending on staff availability; Approximately 6 months after hire. This is a remote role with occasional onsite team meetings in Somerville, MA. Monday through Friday, eastern business hours required Remote workdays require a stable, secure, quiet, and HIPAA-compliant workspace. This will be confirmed via Microsoft Teams video for all employees Given equity, this position will pay somewhere between $90,000 to $107,000 annually. Remote Type Remote Work Location 399 Revolution Drive Scheduled Weekly Hours 40 Employee Type Regular Work Shift Day (United States of America) Pay Range $58,656.00 - $142,448.80/Annual Grade 98TEMP At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package. EEO Statement: 8925 Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran’s Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642. Mass General Brigham Competency Framework At Mass General Brigham, our competency framework defines what effective leadership “looks like” by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.