Utilization Review Nurse Jobs

RN Utilization Review Full-time
Texoma Medical Center

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

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

Utilization Management RN Lead

Bryan Health
Summary GENERAL SUMMARY: Conducts day-to-day activities for the clinical, financial and utilization coordination of the patient’s hospital experience. Proactively consults with the interdisciplinary team which includes, but is not limited to, hospital patient care staff, physicians, patient support, and family to ensure the patient’s hospital stay meets medical necessity and insurance authorizations are obtained to facilitate the financial well-being of the patient and hospital. Acts as the contact for the Utilization Management (UM) staff for day-to-day questions and guidance. Shares meeting responsibilities with the manager representing UM in meetings inside and outside the department. Serves as the Subject Matter Expert (SME) for the whole department both inside and outside the department. Assists with scheduling, assigning workflow, and various employee instructions both educational and corrective. PRINCIPAL JOB FUNCTIONS: 1. *Commits to the mission, vision, beliefs and consistently demonstrates our core values. 2. *Acts as manager when manager is unavailable. 3. *Serves as the subject matter expert for the Utilization Management department for utilization review activities, including concurrent and retrospective reviews as required. 4. *In conjunction with the manager, assists in streamlining operations and maximization of UM tools. 5. *In conjunction with the manager, attends Operational and Revenue Cycle meetings as needed representing the Utilization Management department, and attends the UM Committee meeting. 6. *Acts as the day-to-day contact for the Utilization Department staff to approve last-minute requests for time off, assists with assignments, schedules, and helps manager with employee situations. 7. *Performs duties as a Utilization Management RN by determining the medical necessity of requests by performing first level reviews and using approved evidence-based guidelines/criteria. 8. Takes UM-RN staff shifts as needed by performing utilization review activities, including concurrent and retrospective reviews as required. 9. *Collaborates with the patient’s provider and other healthcare team members in managing the patient’s length of stay and determining the continuing medical necessity of continued stays. 10. *Refers cases to reviewing physician when the treatment request does not meet criteria per appropriate algorithm. 11. *Participates in concurrent and retrospective denials and appeals process by researching issues surrounding the denial, participating in all levels of the appeal and process follow-up. 12. *Serves as an internal and external resource regarding appropriate level of care; admission status/classification; Medicare/Medicaid rules, regulations, and policies; third party and managed care contracts; discharge planning; and length of stay. 13. Ensures appropriate resource utilization relevant to the financial, regulatory, and clinical aspects of care; proposes alternative treatment to ensure a cost effective and efficient plan of care. 14. *Maintains awareness of financial reimbursement methodology, utilization management, payer/reimbursement practices and regulations and participates in resource stewardship. 15. *Promotes quality improvement initiatives and health care outcomes based on currently accepted clinical practice guidelines and total quality improvement initiatives. 16. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise. 17. Participates in meetings, committees and department projects as assigned. 18. Performs other related projects and duties as assigned. (Essential Job functions are marked with an asterisk “*.” Refer to the Job Description Guide for the definition of essential and non-essential job functions.) Attach Addendum for positions with slightly distinct roles or work-specific differences as needed. REQUIRED KNOWLEDGE, SKILLS AND ABILITIES: 1. Maintains clinical competency as required for the unit including but not limited to age-specific competencies relative to patient’s growth and developmental needs, annual skill competency verification and mandatory education and competencies. 2. Knowledge of governmental and third-party payer regulations and requirements related to patient hospitalization and acute rehabilitation admission, stay and discharge activities (i.e. CMS). 3. Knowledge of computer hardware equipment and software applications relevant to work functions. 4. Skills in conflict diffusion and resolution. 5. Ability to communicate effectively both verbally and in writing. 6. Ability to perform crucial conversations with desired outcomes. 7. Ability to establish and maintain effective working relationships with all levels of personnel and medical staff. 8. Ability to problem solve and engage independent critical thinking skills. 9. Ability to maintain confidentiality relevant to sensitive information. 10. Ability to prioritize work demands and work with minimal supervision. 11. Ability to maintain regular and punctual attendance. EDUCATION AND EXPERIENCE: Current Registered Nurse licensure from the State of Nebraska or approved compact state of residence as defined by the Nebraska Nurse Practice Act required. Minimum of Five (5) years utilization management experience required. OTHER CREDENTIALS / CERTIFICATIONS: Basic Life Support (CPR) certification required. Bryan Health recognizes American Heart Association (for healthcare professionals), American Red Cross (for healthcare professionals) and the Military Training Network. PHYSICAL REQUIREMENTS: (Physical Requirements are based on federal criteria and assigned by Human Resources upon review of the Principal Job Functions.) (DOT) – Characterized as sedentary work requiring exertion up to 10 pounds of force occasionally and/or a negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects, including the human body.
RN Utilization Review Other
ERP International

Registered Nurse - Utilization Manager

ERP International Nellis Air Force Base, NV
Overview ERP International is seeking a full time Registered Nurse (RN) Utilization Manager at Mike O’Callaghan Military Medical Center, Nellis AFB, Las Vegas, NV. Be the Best! Join our team of exceptional health care professionals across the nation. Come discover the immense pride and job satisfaction ERP Employees experience in providing care for our Military Members, their Families and Retired Military Veterans! ERP International is honored to have been named one of The Washington Post’s 2025 Top Workplaces ! Connect With Us! Apply online today and discover more about this exceptional employment opportunity. www.erpinternational.com * Excellent Compensation & Exceptional Comprehensive Benefits! * No Weekends! No Holidays! No Call! * Paid Vacation, Paid Sick Time, Paid Federal Holidays! * Medical/Dental/Vision, STD/LTD/Life Insurance, Health Savings Account and more available! * Annual CME Stipend and License/Certification Reimbursement! * Matching 401K! About ERP International, LLC: ERP is a nationally respected provider of health, science, and technology solutions supporting clients in the government and commercial sectors. We provide comprehensive enterprise information technology, strategic sourcing, and management solutions to DoD and federal civilian agencies in 40 states. Founded in 2006, ERP is headquartered in Laurel, MD and maintains satellite offices in Montgomery, AL and San Antonio, TX - plus project locations nationwide. ERP is an Equal Opportunity Employer - Disability and Veteran. Responsibilities Work Schedule: Monday - Friday, 8 to 10 hour shifts, between 7am and 6pm No Call, No Weekends, No Holidays! Job Specific Position Duties: • Provides Utilization Management activities and functions by using MTF specific Quality Improvement processes to identify areas for review from data, suspected problem areas, and input from departments/services within the facility. Identifies gaps between desired and actual program outcomes and develops an action plan to fix gaps. Determines effectiveness of the plan and continually evaluates the impact of implementation. Incorporates applicable utilization review tasks to ensure patients receive the appropriate level of care with the right care, at the right time, in the right place, with the right provider, at the right cost. Collaborates with staff, facility departments and outside agencies to determine the best, most cost-efficient care. Provides cross coverage for those medical management clinical services both inpatient and outpatient which overlap across medical management disciplines to include discharge planning and referrals for case management.• Utilization management duties incorporate discharge planning to ensure that hospital stays meet the requirements and that a safe discharge guides placement of those patients who are unable to be discharged to home due to need for extended care services.• Mandatory knowledge and skills:• Must have knowledge of medical privacy and confidentiality (Health Insurance Portability and Accountability Act [HIPAA]), accreditation standards of Accreditation Association for Ambulatory Health Care (AAAHC), the Joint Commission (TJC), and VA DoD Clinical Practice Guidelines (CPGs). • Must have a working knowledge of computer applications/software to include Microsoft Office programs (Outlook, Excel, PowerPoint, Publisher and Access, Skype), Tiger Connect and internet familiarity is required.• Must have a working knowledge of Ambulatory Procedure Grouping (APGs), Diagnostic Related Grouping (DRGs), International Classification of Diseases-Current Version (ICD), and Current Procedural Terminology-Current Version (CPT) coding; and McKesson (InterQual) and/or Milliman Care Guidelines.• Must have experience in Patient Advocacy, Patient Privacy, and Customer Relations.• Must be able to perform prospective, concurrent, and retrospective reviews to justify medical necessity for requested medical care and to aid in collection and recovery from multiple insurance carriers, including but not limited to Tricare, Medicare, Medicaid, and Health Net Federal Services.• Must be able to collect clinical data from inpatient and outpatient sources; provide documentation for appeals or grievance resolution; apply critical thinking skills and expertise in resolving complicated healthcare, social, interpersonal, and financial patient situations; apply problem-solving techniques to articulate medical requirements to patients, families/care givers, medical and non-medical staff in a professional and courteous way.• Communication. Demonstrate ability to utilize verbal and written communication to work as a member of a team employing team building concepts in both multi -and inter-disciplinary setting to maintain medical and utilization management goals. Must be able to provide oral reports/briefings to leadership on utilization management data and make recommendations regarding needed corrections to maximize revenue while decreasing costs associated with admissions; utilize customer service skills via phone, secure messaging and in person contacts to promote positive staff and patient interactions.• Must be able to interpret data to ensure compliance with requirements for length of stay, obtain needed pre-authorizations and referrals to assist with post hospitalization safe discharge of patients.• Working knowledge of the military health care system including TRICARE/ Health Net health benefits (is preferred).• Develops and implements a comprehensive Utilization Management plan/program in accordance with the facility’s goals and strategic objectives.• Performs data/metrics collection on identified program areas; analyzes and trends results, including over- and under- utilization of healthcare resources. Identifies areas for improvement and cost containment. Reports utilization patterns/trends and provides feedback in a timely manner.• Analyzes medical referrals/appointments and general hospital procedures and regulations by monitoring specialty care referrals for appropriateness, covered benefits, and authorized surgery/medical procedures, laboratory, radiology, pharmacy and durable medical equipment.• Performs medical necessity review for planned inpatient and outpatient surgery; and performs concurrent review to include length of stay (LOS) for the facility’s inpatients using appropriate criteria.• Reviews previous and present medical care practices for patterns; trends incidents of under-or over-utilization of resources incidental to providing medical care.• Acts as referral approval authority for designated referrals per local/AF/DoD/national guidelines and standards. Refers all first-level review failures to the Chief of Medical Staff (SGH) or other POC for further review and disposition.• Verifies eligibility of beneficiaries using Defense Eligibility Enrollment Reporting System (DEERS). Obtains pertinent information from patients/callers and updates data in MHS GENESIS, local referral database, and other office automation software programs as appropriate and directed.• Ensures and monitors specialty care referrals for appropriateness, medical necessity, and if the appointment, diagnostic testing, or procedure requested is a covered benefit according to appropriate health plan. Collaborates, coordinates with TOPA and Referral Management Director when needed in accordance with TRICARE Operations manual.• Receives and makes patient telephone calls, written, or e-mail correspondence regarding specialty clinic appointments and referrals following MTF-specific processes.• Monitors routinely referral management MHS GENESIS queue to ensure patients referrals are appointed and closed out per MTF guidelines.• Ensures Line of Duty paperwork is on file prior to authorization for all reserve and guard member referrals.• Keeps abreast of MTF and local market services and capabilities. Updates capability report as needed/directed.• Conducts referral reconciliation report as directed, identifying all open referrals and provides notification to appropriate personnel for resolution.• Monitors active duty, reserve/guard admissions, including all eligible beneficiaries, to civilian hospitals and notifies Clinical Nurse Case Manager and Patient Administration Element as required.• Serve as a liaison with headquarters (99th ABW) TRICARE regional offices, Manage Care Support Team, MTF staff and professional organizations concerning Utilization Management practices.• Collaborates with staff/departments, including, but not limited to: Executive Management, Resource Management, Medical Records, Patient Administration, Group Practice Managers, Health Care Integrator Consultants, Medical Management team, SGH (Chief of Medical Staff), Coders/Coding Auditors, Medical Management, Referral Management, TRICARE Operations, patient care teams, Quality Improvement, and the Managed Care Support Contractors.• Coordinates and participates in interdisciplinary team meetings, designated facility meetings, discharge planning meetings/rounds and Care Coordination meetings. Shares knowledge and experiences gained from own clinical practice and education relevant to nursing and utilization management.• Participates in the orientation, education, and training of other staff. May serve on committees, work groups, and task forces at the facility. Provides relevant and timely information to these groups and assists with decision-making and process improvement. Participates in customer service initiatives, performance and quality improvement measures and medical readiness activities designed to enhance health services.• Must maintain a level of productivity and quality consistent with: complexity of the assignment; facility policies and guidelines; established principles, ethics and standards of practice of professional nursing; the Case Management Society of America (CMSA); American Accreditation Healthcare Commission/Utilization Review Accreditation Commission (URAC);Comprehensive Accreditation Manual for Hospitals (CAMH); Health Services Inspection (HSI); and other applicable DoD and Service specific guidance and policies. Must also comply with the Equal Employment Opportunity (EEO) Program, infection control and safety policies and procedures. • Adheres to applicable local MTF/AF/DoD, DHA, VA instructions, policies and guidelines.• Completes medical record documentation and coding, and designated tracking logs and data reporting as required by local MTF/AF/DoD, DHA, VA instructions, policies and guidance.• Completes all required electronic medical record training, MTF- specific orientation and training programs, and any AF/DoD mandated Utilization Management training. Includes (but is not limited to) all training on the use of utilization management data base applications (i.e. Defense Health Agency (DHA),,Military Health System Population Health Portal (MHSPHP) CarePoint 4G , AFMS , TOPA applications to obtain necessary data for Preventative Healthcare Screening, Healthcare Effectiveness Data and Information Set (HEDIS).• Ensures a safe work environment, employee safe work habits and patient safety IAW regulatory agencies, infection control policies, and process improvement initiatives. Promote and contribute quality performance, performance improvement programs, and nursing practice in a setting that supports professional practice and sets a positive example; identify and deliver excellence in the delivery of nursing services and care to patients/residents; introduces and disseminates best practices in nursing services. Proactively identifies process issues that could lead to negative patient outcomes and/or delays in discharge placement and participates in the appropriate safety reporting processes for the facility. Qualifications Minimum Qualifications: * Degree/Education: Shall be a graduate from a baccalaureate degree program in nursing with a BSN, accredited by a national nursing accrediting agency recognized by the US Department of Education, the Commission on Collegiate Nursing Education (CCNE), or Accreditation Commission for Education in Nursing (ACEN). * Experience: Must have at least 3 years of total nursing experience in a direct patient care clinical inpatient and outpatient setting. Must have utilization management experience for 2 years in recent consecutive months including case management care and discharge planning for patients ranging in age from 0-95 years and including children, families, seniors, and groups. * Licensure/Certification: Active, unrestricted Registered Nursing license to practice nursing in a State, District of Columbia, the Commonwealth of Puerto Rico, or a territory of the United States. Certification (preferred) or eligible in a relevant specialty, such as Certified Managed Care Nurse through the American Board of Managed Care Nursing or the American Association of Managed Care Nurses or Certified Informatics Nursing, Ambulatory Care Nursing, Medical-Surgical Nursing or Nursing Case Management through the American Nurses Credentialing Center. * Life Support Certification: BLS from American Red Cross or American Health Association. * Security: Must possess ability to pass a Government background check/security clearance. Pay Scale: $34.26 - $60 to be determined based on employment options, qualifications, experience, and location ** $2,000 Sign-On Bonus **
RN Utilization Review Full-time
University of Rochester Medical Center

RN, Utilization Management

University of Rochester Medical Center Rochester, NY
$80,923 - $105,208 / year
As a community, the University of Rochester is defined by a deep commitment to Meliora - Ever Better. Embedded in that ideal are the values we share: equity, leadership, integrity, openness, respect, and accountability. Together, we will set the highest standards for how we treat each other to ensure our community is welcoming to all and is a place where all can thrive. Job Location (Full Address): 601 Elmwood Ave, Rochester, New York, United States of America, 14642 Opening: Worker Subtype: Regular Time Type: Full time Scheduled Weekly Hours: 40 Department: 500009 Utilization Management Work Shift: UR - Day (United States of America) Range: UR URCD 215 Compensation Range: $80,923.00 - $105,208.00 The referenced pay range represents the minimum and maximum compensation for this job. Individual annual salaries/hourly rates will be set within the job's compensation range, and will be determined by considering factors including, but not limited to, market data, education, experience, qualifications, expertise of the individual, and internal equity considerations. Responsibilities: Works collaboratively with various departments across the entire health care system to review clinical documentation, utilizing evidence based criteria to support medical necessity and appropriate level of patient care for services provided. Reports outcome trends and patterns to UM leadership to help identify educational opportunities and performance improvement initiatives across the health care continuum. Adapts to process changes and assists with education efforts that support ongoing improvement. ESSENTIAL FUNCTIONS Determines level of care per regulatory requirements. Provides level of care notifications to patients and families as needed. Works collaboratively with payers to ensure authorization for dates of service. Collaborates with HIM, providers, Financial Counseling and Patient Financial Services. Monitors all UM hold bills and unplanned readmission reports. Conducts initial and concurrent reviews, utilizing evidence based criteria through Interqual. Supports discharge appeal process. Responsible for departmental denials and appeal activity. Documents according to regulatory guidelines and UM RN workflow protocols. Conducts clinical documentation improvement efforts through query process. Meets productivity expectations established by UM department. Provides and supports ongoing educational needs for all UM customers. Other duties as assigned. MINIMUM EDUCATION & EXPERIENCE Associate's degree in Nursing and 3 years of acute hospital experience required Bachelor's degree in Nursing (BSN) preferred Or equivalent combination of education and experience Utilization Management experience preferred KNOWLEDGE, SKILLS AND ABILITIES Database experience including: Interqual, Sharepoint, eRecord, ePARC, Cobius preferred LICENSES AND CERTIFICATIONS RN - Registered Nurse - State Licensure and/or Compact State Licensure NYS Registered Nurse license upon hire required The University of Rochester is committed to fostering, cultivating, and preserving an inclusive and welcoming culture to advance the University’s Mission to Learn, Discover, Heal, Create – and Make the World Ever Better. In support of our values and those of our society, the University is committed to not discriminating on the basis of age, color, disability, ethnicity, gender identity or expression, genetic information, marital status, military/veteran status, national origin, race, religion, creed, sex, sexual orientation, citizenship status, or any other characteristic protected by federal, state, or local law (Protected Characteristics). This commitment extends to non-discrimination in the administration of our policies, admissions, employment, access, and recruitment of candidates, for all persons consistent with our values and based on applicable law.
RN Utilization Review Full-time
Advocate Aurora Health

Utilization Review Nurse - Advocate Aurora Utilization Management FT

Advocate Aurora Health Oak Brook, IL
$35.50 - $53.25 / hour
Department: 11215 Advocate Aurora Health Corporate - Utilization Management Status: Full time Benefits Eligible: Yes Hou rs Per Week: 40 Schedule Details/Additional Information: Monday- Friday-8:30-5pm-Every 5th weekend required. One summer and one winter holiday required. Pay Range: $35.50 - $53.25 Major Responsibilities: Documents utilization review activity per department and medical center standards in a timely manner. Performs and documents accurate and timely concurrent and retrospective reviews based on approved established criteria. Communicates effectively with the healthcare team. Works closely with medical staff, hospital departments and ancillary services as part of Outcome Facilitation Team/Multidisciplinary Team in expediting care delivery to avoid delays in timely service provision and implementing and reporting utilization management (UM) activities, as applicable. Collaborates with managers, physicians, medical directors, advisory groups and treatment teams for issues related to physician practices and best practices for the patient’s plan of care. Refers cases to physician advisor as needed to ensure accurate status and compliance with regulatory guidelines. Remains knowledgeable in issues of healthcare regulations, reimbursement issues, impact on length of stay and community resources. Provides clinical updates to payers and/or external review organizations, collects data, coordinates denial activity, supports UM activity, and manages avoidable delays. Develops and maintains productive relationships with community-based agencies and networks by representing Aurora Health Care in a positive manner working collaboratively, internally and externally, to meet patient/family needs. Serves as an educator and expert resource to medical and hospital staff regarding admission status and acute care criteria, utilization management issues, and relevant regulatory requirements. Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served. Must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements relative to his/her age-specific needs, and to provide the care needed as described in the department's policies and procedures. Age-specific information is developed further in the departmental job standards. Licensure, Registration, and/or Certification Required: Registered Nurse license issued by the state in which the team member practices. Education Required: Bachelor's Degree in Nursing. Experience Required: Typically requires 3 years of experience in clinical nursing, utilization and/or quality management. Knowledge, Skills & Abilities Required: Must have working knowledge in the use of Microsoft Office (Excel, Outlook, PowerPoint and Word) or similar products. Knowledge of the components of quality and acute care patient care needs specifically related to the area/function in which care management will be performed. Demonstrates working knowledge of Utilization Review criteria as demonstrated by achieving 80% or greater on the annual InterRater Reliability (IRR) competency exam. Utilizes critical thinking skills to analyze and synthesize clinical scenarios as it relates to application of medical necessity criteria. Excellent analytical and interpersonal communication skills necessary to interact with families, patients, physicians, and third party payers. Ability to manage conflict appropriately, seeking a win-win outcome by communicating issues in accordance with the Aurora Service commitments. Promotes effective professional relationships with physicians and other professionals in a direct and positive manner. Takes responsibility self-development by seeking out opportunities for professional growth and development and being an active participant in department, hospital, and system initiatives. Physical Requirements and Working Conditions: Must be able to sit for approximately 50 percent of the workday; stand and walk for the equivalent of several blocks at a time. Must lift up to 10lbs. continuously and up to 20 lbs. frequently. Manual dexterity required for operation computer and calculator. Visual acuity required for facilitating review of written documents/computer screens, medical records, and to record information accurately. Clear verbal communications and hearing acuity required for receiving instructions and converse on standard telephone. Functional speech and hearing to allow for effective communication of instructions and conversation over the telephone. Exposed to normal office environment; including usual hazards related to operating electrical equipment. Operates all equipment necessary to perform the job. May be exposed to mechanical, electrical, chemical, and radiation hazards as well as blood and body fluids; therefore, personal protective equipment must be worn as necessary. This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties. Our Commitment to You: Advocate Health offers a comprehensive suite of Total Rewards: benefits and well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more – so you can live fully at and away from work, including: Compensation Base compensation listed within the listed pay range based on factors such as qualifications, skills, relevant experience, and/or training Premium pay such as shift, on call, and more based on a teammate's job Incentive pay for select positions Opportunity for annual increases based on performance Benefits and more Paid Time Off programs Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability Flexible Spending Accounts for eligible health care and dependent care expenses Family benefits such as adoption assistance and paid parental leave Defined contribution retirement plans with employer match and other financial wellness programs Educational Assistance Program Note: Eligibility for programs listed above may depend on your FTE or status (e.g., full-time, part-time, per diem, temporary, etc.); please ask a Recruiter for more information during an interview. About Advocate Health Advocate Health is the third-largest nonprofit, integrated health system in the United States, created from the combination of Advocate Aurora Health and Atrium Health. Providing care under the names Advocate Health Care in Illinois; Atrium Health in the Carolinas, Georgia and Alabama; and Aurora Health Care in Wisconsin, Advocate Health is a national leader in clinical innovation, health outcomes, consumer experience and value-based care. Headquartered in Charlotte, North Carolina, Advocate Health services nearly 6 million patients and is engaged in hundreds of clinical trials and research studies, with Wake Forest University School of Medicine serving as the academic core of the enterprise. It is nationally recognized for its expertise in cardiology, neurosciences, oncology, pediatrics and rehabilitation, as well as organ transplants, burn treatments and specialized musculoskeletal programs. Advocate Health employs 155,000 teammates across 69 hospitals and over 1,000 care locations, and offers one of the nation’s largest graduate medical education programs with over 2,000 residents and fellows across more than 200 programs. Committed to providing equitable care for all, Advocate Health provides more than $6 billion in annual community benefits.
RN Utilization Review Other
Prisma Health

Registered Nurse (RN) - Utilization Management, PRN, Days

Prisma Health Columbia, SC
Inspire health. Serve with compassion. Be the difference. Job Summary Screens patients to obtain clinical information and make timely contacts with insurers to provide clinical information to support physician referrals. In collaboration with physicians, leads the multidisciplinary team including clinical staff and payors to ensure efficient delivery of quality, cost-effective care. Essential Functions All team members are expected to be knowledgeable and compliant with Prisma Health's purpose: Inspire health. Serve with compassion. Be the difference. Uses established clinical guidelines for initial/admission and continued stay reviews for patients within assigned unit to ensure medical necessity, appropriate level of care and timely implementation of plan of care in accordance with hospital(s) Utilization Review Plan and CMS regulation. Maintains expert level knowledge of body systems and expected clinical outcomes for patient disease process. Maintains current knowledge of changes in state and federal regulatory requirements related to the provision of care management services in the acute care setting. Serves as a resource for patients and families with regard to their rights and responsibilities, when payment of care is denied or when care is no longer medically necessary. Includes, but not limited to, delivery of the regulatory documents as provided by CMS. Consults with interdisciplinary team, Physician Advisor and administrative leadership as necessary to resolve barriers regarding progression of care. Collaborates with physicians throughout hospitalization, develops an effective working relationship, and provides expertise regarding payor and regulatory guidelines. Promotes effective and efficient utilization of clinical resources, ensuring quality, cost effective care. Provides timely clinical reviews to third party payors. Responds to requests for additional information within 24 hours or next business day. Partners with RN Hospital Care Managers and SW Hospital Care Managers to resolve payer related barriers. Maintains care management knowledge to provide services in accordance with standards of practice as established by department and management. Performs other duties as assigned. Supervisory/Management Responsibility This is a non-management job that will report to a supervisor, manager, director, or executive. Minimum Requirements Education - Bachelor's degree in Nursing Experience - Two (2) years acute care nursing experience. One (1) year acute case management or utilization management experience preferred. Utilization management experience is preferred. In Lieu Of Employees in this title prior to 6/1/2025 are grandfathered into the job profile and are only required to have an AD N or Nursing Diploma. Required Certifications, Registrations, Licenses Holds a current RN compact/multistate license recognized by the NCSBN Compact State or is licensed to practice as an RN in the state the team member is working. Knowledge, Skills and Abilities Medical Necessity Criteria (Interqual, MCG) knowledge preferred. Work Shift Day (United States of America) Location Corporate - Columbia - Taylor at Marion Facility 7001 Corporate Department 70017535 Utilization Management Share your talent with us! Our vision is simple: to transform healthcare for the benefits of the communities we serve. The transformation of healthcare requires talented individuals in every role here at Prisma Health.
RN Utilization Review Full-time
PeaceHealth

Utilization Management Coordinator Non RN

PeaceHealth Springfield, OR
$31.60 - $47.40 / hour
Description Job Description PeaceHealth is seeking a Utilization Management Coordinator Non RN for a Full Time, 1.00 FTE, Day position. The salary range for this job opening at PeaceHealth is $31.60 – $47.40. The hiring rate is dependent upon several factors, including but not limited to education, training, work experience, terms of any applicable collective bargaining agreement, seniority, etc. Job Summary Coordination of the organization's clinical documentation and utilization management. Coordination of care across the continuum. Collaborates and coordinates communication and decisions across the health care team to achieve national standards for best practices, discharge planning, clinical documentation and utilization management functions. Coordinates discharge planning and implementation. Essential Functions Review medical records for determination and documentation of medical necessity for inpatient and/or observations status utilizing established criteria and methods. Identifies issues and variations in utilization and escalates to appropriate members of the health care team. Actively support measures that promote effective use of resources. Develops and coordinates discharge plans with input and involvement of health care team. Incorporates priorities and decisions made by patient. Implements discharge plans in partnership with staff RNs. Identifies patients at risk for encountering problems post hospitalization and collaborates with Social Services for referral to appropriate discipline team members and outside agencies to support optimum success. Advocates for Services and funding as appropriate and necessary to meet care plan goals. Identify, plan and arrange for appropriate services applying knowledge of services available in the community, state, and federal health regulations and admission, discharge and medical necessity criteria. Facilitates process to support patient’s ability to access and utilize resources that best meet their needs and eligibility criteria. Demonstrates knowledge of procedures which assure quality care and effective utilization of hospital services; applies this knowledge when coordinating discharge plans and reviewing medical records. Monitor the individual’s condition and responsiveness to their interventions. Performs other duties as assigned. Qualifications Education Bachelor's Degree Preferred: in related field or 5 years clinical experience in an acute care setting Experience Minimum of 1 year Preferred: Current practical experience in utilization management, risk management, quality improvement and Preferred: Experience in discharge planning and social services Credentials Preferred: Social Worker Licensure and Preferred: Certified Case Manager Skills Excellent verbal and written communication skills including sensitivity to other cultures and ethnicities. (Required) Excellent skills in conceptual thinking, listening, problem resolution and planning. (Required) Demonstrated leadership skills. (Required) Excellent organizational skills. (Required) Proficient computer skills including MS Office applications and electronic medical records. (Required) Knowledgeable about issues related to chronic illness, developmental disabilities, special needs, mental illness, grief and transition, substance abuse, domestic violence, child abuse and senior abuse. (Required) Good understanding and adherence to core social work values and ethics. (Required) Working Conditions Lifting Consistently operates computer and other office equipment. Exerting up to 10 pounds of force occasionally and/or negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects. Sedentary work. Environmental Conditions Predominantly operates in an office environment. Some time spent on site in medical/hospital setting. Mental/Visual Ability to communicate and exchange accurate information. The worker is required to have close visual acuity to perform an activity such as: preparing and analyzing data and figures; transcribing; viewing a computer terminal; extensive reading. PeaceHealth is committed to the overall wellbeing of our caregivers: physical, emotional, financial, social, and spiritual. We offer caregivers a competitive and comprehensive total rewards package. Some of the many benefits included in this package are full medical/dental/vision coverage; 403b retirement plan employer base and matching contributions; paid time off; employer-paid life and disability insurance with additional buyup coverage options; tuition and continuing education reimbursement; wellness benefits, and expanded EAP and mental health program. See how PeaceHealth is committed to For full consideration of your skills and abilities, please attach a current resume with your application. EEO Affirmative Action Employer/Vets/Disabled in accordance with applicable local, state or federal laws.
RN Utilization Review Telehealth Full-time
UnityPoint Health

Registered Nurse Utilization Management Specialist

UnityPoint Health West Des Moines, IA
Remote: Yes Area of Interest: Nursing FTE/Hours per pay period: .9 Department: Utilization Management Shift: Monday-Friday, 11:30am-8:00pm (one workday off per pay period) Job ID: 178312 Overview UnityPoint Health is seeking an RN Utilization Management Specialist to join our team! Under the direction of the Manager of Utilization Management, the RN Utilization Management Specialist serves a key role in coordinating the organization’s interdisciplinary effort to assess and promote appropriate utilization of health care resources, provision of high-quality health care, optimal clinical outcomes, and patient and provider satisfaction. The RN UM Specialist will work to track and minimize the inappropriate use of such resources, provides the Utilization Management function for patients admitted to UPH, and facilitates effective utilization of resources through ongoing interactions with physicians, third party payers and regulatory agencies. Location: Remote - applicants must reside within the UPH footprint of Iowa, Illinois, or Wisconsin Hours: Monday-Friday, 11:30am-8:00pm (one work day off per pay period) Why UnityPoint Health? At UnityPoint Health, you matter. We’re proud to be recognized as a Top Place to Work in Healthcare by Becker's Healthcare several years in a row for our commitment to our team members. Our competitive Total Rewards program offers benefits options focused on your needs and priorities, no matter what life stage you’re in. Here are just a few: Expect paid time off, parental leave, 401K matching and an employee recognition program. Dental, health and vision insurance, paid holidays, short and long-term disability and more. We even offer pet insurance for your four-legged family members. Early access to earned wages with Daily Pay, tuition reimbursement to help further your career and adoption assistance to help you grow your family. With a collective goal to champion a culture of belonging where everyone feels valued and respected, we honor the ways people are unique and embrace what brings us together. And, we believe equipping you with support and development opportunities is a vital part of delivering an exceptional employment experience. Join our team of experts and make a difference with UnityPoint Health. Responsibilities Performs utilization management reviews using established criteria to confirm medical necessity, appropriate level of care and efficient use of resources. Maximizes positive financial outcomes for patients and hospital by conducting timely initial and ongoing concurrent chart review for hospitalized patients to monitor appropriateness of treatment, resource utilization, quality of care. Applies utilization criteria using designated software to complete documentation related to utilization review activities in an accurate and timely manner for the purpose of providing information for other members of the healthcare team and to facilitate decision making. Requests secondary reviews with physician advisors as appropriate, if admission or continued stay criteria are not met, assuring appropriate and timely level of care status. Assesses patient status, including reviewing outpatient surgical and observation admissions for the appropriate level of care, and continuously monitors length of stay for appropriate and timely medical management. Applies accepted potentially avoidable day logic to reviews for accurate and timely data collection. Proactively monitors insurance approval status in partnership with the UM Administrative Coordinator. Provides education to staff and physicians regarding medical necessity, levels of care and appropriate utilization of resources as needed. Pursues denials at the affiliate level in a timely manner to secure payment of services. Serves as a resource to internal and external staff, providers, payers, and patients on issues related to utilization management. Maintains current knowledge of Utilization Review Methodology, software, criteria, and regulations governing various payment systems. Maintains current knowledge of the UPH Utilization Management Plan. Maintains current knowledge of CMS rules (e.g., Code 44, A – B Rebilling, HINN, etc.) and other regulatory agencies requirements to insure appropriate reimbursement. Coordinates and monitors appeals with internal and external physician advisors for Second Level Review as needed. Provides education to patients and families regarding the role of the Utilization Management Specialist and provides clarification when needed on level of care and their payer source regulatory requirements as needed. Qualifications Registered Nurse - licensed in Iowa. Will need to obtain RN in Illinois (proivded by UPH) Associates Degree or Diploma (RN) in Nursing required 2 years of nursing experience
RN Utilization Review Home Health Full-time
State of Arizona

Claims Medical Review Nursing Consultant

State of Arizona Phoenix, AZ
AHCCCS Arizona Health Care Cost Containment System Accountability, Community, Innovation, Leadership, Passion, Quality, Respect, Courage, Teamwork The Arizona Health Care Cost Containment System (AHCCCS), Arizona’s Medicaid agency, is driven by its mission to deliver comprehensive, cost-effective health care to Arizonans in need. AHCCCS is a nationally acclaimed model among Medicaid programs and a recipient of multiple awards for excellence in workplace effectiveness and flexibility. AHCCCS employees are passionate about their work, committed to high performance, and dedicated to serving the citizens of Arizona. Among government agencies, AHCCCS is recognized for high employee engagement and satisfaction, supportive leadership, and flexible work environments, including remote work opportunities. With career paths for seasoned professionals in a variety of fields, entry-level positions, and internship opportunities, AHCCCS offers meaningful career opportunities in a competitive industry. Come join our dynamic and dedicated team. Claims Medical Review Nursing Consultant Division of Fee for Service Management (DFSM) Job Location: Address: 150 North 18th Avenue Phoenix, Arizona 85007 This position may offer the ability to work remotely within Arizona based upon the department's needs and continual meeting of expected performance measures. All AHCCCS Employees must reside within the state of Arizona. Posting Details: Starting salary at $71,032 and may be increased based on experience and qualifications. FLSA Status: Exempt Grade: 22 Closing Date: Open until filled Job Summary: The position is responsible for monitoring, evaluating and approving or denying payment of medical and/or behavioral healthcare services through prospective, concurrent, and retrospective review for the Fee for Service population. The position determines medical necessity based on standards of care, rules, regulations, policies and procedures governing the provision of covered services. The State of Arizona strives for a work culture that affords employees flexibility, autonomy, and trust. Across our many agencies, boards, and commissions, many State employees participate in the State’s Remote Work Program and are able to work remotely in their homes, in offices, and in hoteling spaces. All work, including remote work, should be performed within Arizona unless an exception is properly authorized in advance. Major duties and responsibilities include but are not limited to: • Performs medical claims review/adjudication using claims industry standards. Determines if a claim meets emergency criteria, medical necessity, and/or correct revenue code/CPT/HCPC coding. Also determines if the level of care and length of stay is appropriate for the AHCCCS recipient. • Prepares reports and analyzes savings and trends. Interacts with other departments/providers as needed. • Performs special projects including but not limited to research projects. Knowledge, Skills & Abilities (KSAs): Knowledge of: • Medical nursing practice, medical case management protocols, quality management and utilization review protocols as related to all populations including Maternal and Child Health services, preventive health, family planning, sterilization, and pregnancy termination, EPSDT, acute, LTC, chronic long-term elderly and physical disabled, developmentally disabled, behavioral/mental health, and Tribal • Healthcare delivery system nationally and locally • Managed care processes • Acute nursing processes including assessment, planning, intervention, and evaluation • InterQual Criteria • CCI • Coding: CPT, HCPCS, ICD-9 • Medical Claims Review • Statistical analysis • Computer data retrieval and input • Interpretation of governmental agencies • AHCCCS Rules and Regulations • Code of Federal Regulations Skill in: • Organizational skills that result in prioritization of multiple tasks • Interpretation of rules, laws and agency policy pertaining to the AHCCCS program • Good written and communication skills • Computer skills • Utilization Review skills • Medical Claims Review skills • Producing work products with limited supervision • Effectively collaborating with people in positions of all levels • Research and analysis • Team player and can work independently Ability to: • Interpret and apply medical and claims policies • Read and interpret medical documentation • Evaluate medical documentation for emergency criteria, medical necessity, correct CPT coding • Determine appropriate hospital levels of care and lengths of stay • Respond to inquiries for UR/CPT coding decisions • Maintain data for monthly reports • Work independently with minimal supervision Selective Preference(s): Minimum: Must maintain a current Arizona medical license (RN or higher) or Arizona Behavioral Health license (Associate or higher) and 3 years of relevant healthcare experience. May require a valid Arizona Driver License for travel-related duties. Preferred: Experience in Prior Authorization, Utilization Management, claims review, auditing, or managed care; knowledge of population served. Pre-Employment Requirements: • Successfully pass fingerprint background check, prior employment verifications and reference checks; employment is contingent upon completion of the above-mentioned process and the agency’s ability to reasonably accommodate any restrictions. • Travel may be required for State business. Employees who drive on state business must complete any required driver training (see Arizona Administrative Code R2-10-207.12.) If this position requires driving or the use of a vehicle as an essential function of the job to conduct State business, then the following requirements apply: Driver’s License Requirements. All newly hired State employees are subject to and must successfully complete the Electronic Employment Eligibility Verification Program (E-Verify). Benefits: Among the many benefits of a career with the State of Arizona, there are: • 10 paid holidays per year • Paid Vacation and Sick time off (13 and 12 days per year respectively) - start earning it your 1st day (prorated for part-time employees) • Paid Parental Leave-Up to 12 weeks per year paid leave for newborn or newly-placed foster/adopted child. Learn more about the Paid Parental Leave pilot program here. • Other Leaves - Bereavement, civic duty, and military. • A top-ranked retirement program with lifetime pension benefits • A robust and affordable insurance plan, including medical, dental, life, and disability insurance • Participation eligibility in the Public Service Loan Forgiveness Program (must meet qualifications) • RideShare and Public Transit Subsidy • A variety of learning and career development opportunities By providing the option of a full-time or part-time remote work schedule, employees enjoy improved work/life balance, report higher job satisfaction, and are more productive. Remote work is a management option and not an employee entitlement or right. An agency may terminate a remote work agreement at its discretion. Learn more about the Paid Parental Leave program here . For a complete list of benefits provided by The State of Arizona, please visit our benefits page Retirement: Lifetime Pension Benefit Program • Administered through the Arizona State Retirement System (ASRS) • Defined benefit plan that provides for life-long income upon retirement. • Required participation for Long-Term Disability (LTD) and ASRS Retirement plan. • Pre-taxed payroll contributions begin after a 27-week waiting period (prior contributions may waive the waiting period). Deferred Retirement Compensation Program • Voluntary participation. • Program administered through Nationwide. • Tax-deferred retirement investments through payroll deductions. Contact Us: Persons with a disability may request a reasonable accommodation such as a sign language interpreter or an alternative format by emailing careers@azahcccs.gov. Requests should be made as early as possible to allow time to arrange the accommodation. The State of Arizona is an Equal Opportunity/Reasonable Accommodation Employer.
RN Utilization Review Full-time
Bryan Health

Utilization Management RN

Bryan Health Lincoln, NE
Summary GENERAL SUMMARY: Conducts day-to-day activities for the clinical, financial and utilization coordination of the patient’s hospital experience. Proactively consults with the interdisciplinary team which includes, but is not limited to, hospital patient care staff, physicians, patient support and family to ensure the patient’s hospital stay meets medical necessity and insurance authorizations are obtained in order to facilitate the patient’s and hospitals financial well-being. 1 year of UM experience required. PRINCIPAL JOB FUNCTIONS: 1. *Commits to the mission, vision, beliefs and consistently demonstrates our core values. 2. *Performs utilization review activities, including concurrent and retrospective reviews as required. 3. *Determines the medical necessity of request by performing first level reviews, using approved evidence based guidelines/criteria. 4. *Collaborates with the patient’s provider and other healthcare team members in managing the patient’s length of stay and determining the continuing medical necessity of continued stays. 5. *Refers cases to reviewing physician when the treatment request does not meet criteria per appropriate algorithm. 6. *Participates in concurrent and retrospective denials and appeals process by researching issues surrounding the denial, participating in all levels of the appeal and process follow-up. 7. *Serves as an internal and external resource regarding appropriate level of care; admission status/classification; Medicare/Medicaid rules, regulations, and policies; 3rd party and managed care contracts; discharge planning; and length of stay. 8. Ensures appropriate resource utilization relevant to the financial, regulatory and clinical aspects of care; proposes alternative treatment to ensure a cost effective and efficient plan of care. 9. *Maintains awareness of financial reimbursement methodology, utilization management, payer/reimbursement practices and regulations and participates in resource stewardship. 10. *Promotes quality improvement initiatives and health care outcomes based on currently accepted clinical practice guidelines and total quality improvement initiatives. 11. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise. 12. Participates in meetings, committees and department projects as assigned. 13. Performs other related projects and duties as assigned. (Essential Job functions are marked with an asterisk “*”. Refer to the Job Description Guide for the definition of essential and non-essential job functions.) Attach Addendum for positions with slightly different roles or work-specific differences as needed. REQUIRED KNOWLEDGE, SKILLS AND ABILITIES: 1. Maintains clinical competency as required for the unit including but not limited to age-specific competencies relative to patient’s growth and developmental needs, annual skill competency verification and mandatory education and competencies. 2. Knowledge of governmental and third party payer regulations and requirements related to patient hospitalization and acute rehabilitation admission, stay and discharge activities, i.e., CMS, CARF, FIM (TM). 3. Knowledge of computer hardware equipment and software applications relevant to work functions. 4. Skill in conflict diffusion and resolution. 5. Ability to communicate effectively both verbally and in writing. 6. Ability to perform crucial conversations with desired outcomes. 7. Ability to establish and maintain effective working relationships with all levels of personnel and medical staff. 8. Ability to problem solve and engage independent critical thinking skills. 9. Ability to maintain confidentiality relevant to sensitive information. 10. Ability to prioritize work demands and work with minimal supervision. 11. Ability to perform crucial conversations with desired outcomes. 12. Ability to maintain regular and punctual attendance. EDUCATION AND EXPERIENCE: Current Registered Nurse licensure from the State of Nebraska or approved compact state of residence as defined by the Nebraska Nurse Practice Act. Minimum of two (2) years recent clinical experience required. Prior care coordination and/or utilization management experience preferred. OTHER CREDENTIALS / CERTIFICATIONS: Basic Life Support (CPR) certification required. Bryan Health recognizes American Heart Association (for healthcare professionals), American Red Cross (for healthcare professionals) and the Military Training Network. PHYSICAL REQUIREMENTS: (Physical Requirements are based on federal criteria and assigned by Human Resources upon review of the Principal Job Functions.) (DOT) – Characterized as sedentary work requiring exertion up to 10 pounds of force occasionally and/or a negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects, including the human body.
RN ER Utilization Review Full-time
Atlantic Health System

Utilization Reviewer (RN) - Emergency Department, Full Time, Days, 8 AM - 4 PM, Atlantic Health Overlook Medical Center

Atlantic Health System Morristown, NJ
$40 - $70.40 / hour
Job Description Utilization Reviewer (RN) – Emergency Department Atlantic Health System – Overlook 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
RN Utilization Review Outpatient Full-time
Baptist Health South Florida

Registered Nurse Utilization Review, Case Management, Part Time, 7A-7:30P

Baptist Health South Florida Miami, FL
$73,860.80 - $98,234.86 / year
Baptist Health is the region's largest not-for-profit healthcare organization, with 12 hospitals, over 29,000 employees, 4,500 physicians and 200 outpatient centers, urgent care facilities and physician practices across Miami-Dade, Monroe, Broward and Palm Beach counties. With internationally renowned centers of excellence in cancer, cardiovascular care, orthopedics and sports medicine, and neurosciences, Baptist Health is supported by philanthropy and driven by its faith-based mission of medical excellence. For 26 years, we've been named one of Fortune's 100 Best Companies to Work For, and in the 2025-2026 U.S. News & World Report Best Hospital Rankings, Baptist Health was the most awarded healthcare system in South Florida, earning 63 high-performing honors. What truly sets us apart is our people. At Baptist Health, we create personal connections with our colleagues that go beyond the workplace, and we form meaningful relationships with patients and their families that extend beyond delivering care. Many of us have walked in our patients' shoes ourselves and that shared experience fuels out commitment to compassion and quality. Our culture is rooted in purpose, and every team member plays a part in making a positive impact – because when it comes to caring for people, we're all in. At Baptist Health, we’re committed to supporting our employees at every stage of their journey, both personally and professionally. Our approach is rooted in a “grow our own” philosophy, designed to help our team members build meaningful, long-term careers with us, supported by benefits that make a real difference, including: Career growth and development opportunities , with clear pathways and ongoing support Comprehensive health and wellness resources that go beyond traditional benefits A wellness program that can help employees eliminate their medical plan deductible , reducing out-of-pocket healthcare costs Tuition reimbursement to support continued learning and advancement And so much more Together, these benefits and others reflect our commitment to caring for our people, so they can build fulfilling careers with us while making a meaningful impact every day. Description: The purpose of this position is to conduct initial, concurrent, retrospective chart review for clinical financial resource utilization. Coordinates with healthcare team for optimal/efficient patient outcomes, while decreasing length of stay (LOS) and avoid delays and denied days. They are accountable for a designated patient caseload and provides intervention, coordination to decrease avoidable delays, denial of reimbursement. Specific functions within this role include: Screens pre-admission, admission process using established criteria for all points of entry. Facilitates communication between payers, review agencies, healthcare team. Identify delays in treatment or inappropriate utilization and serves as a resource. Coordinates communication with physicians. Identify opportunities for expedited appeals and collaborates to resolve payer issues. Ensures/Maintains effective communication with Revenue Cycle Departments. Estimated salary range for this position is $73860.80 - $98234.86 / year depending on experience. Qualifications: Degrees: Associates. Licenses & Certifications: MCG Care Guidelines Specialist. Registered Nurse. Additional Qualifications: RNs hired prior to 2-2012 (10/1/2017 at Bethesda or 7/1/2019 at BRRH) with an Associates Degree in Nursing are not required to have a BSN to continue their non-leadership role as an RN. however, they are required to complete the BSN within 3 years of job entry date. MCG Specialist Certification ISC/HRC required within 12 months of job entry date. 3 years of Nursing experience preferred. Excellent written, interpersonal communication and negotiation skills. Strong critical thinking skills and the ability to perform clinical/chart review abstract information efficiently. Strong analytical, data management and computer skills. Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components. Current working knowledge of payer and managed care reimbursement preferred. Ability to work independently and exercise sound judgment in interactions with the health care team and patients/families. Knowledgeable in local, state, and federal legislation and regulations. Ability to tolerate high volume production standards. Minimum Required Experience: 3 Years EOE, including disability/vets
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
$40 - $70.40 / 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
RN Manager/Supervisor Utilization Review Telehealth Full-time
Centene

Supervisor, Utilization Management (RN)

Centene North Sacramento, CA
$75,300 - $135,400 / year
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. Position Purpose: Supervises Prior Authorization, Concurrent Review, and/or Retrospective Review Clinical Review team to ensure appropriate care to members. Supervises day-to-day activities of utilization management team. Monitors and tracks UM resources to ensure adherence to performance, compliance, quality, and efficiency standards Collaborates with utilization management team to resolve complex care member issues Maintains knowledge of regulations, accreditation standards, and industry best practices related to utilization management Works with utilization management team and senior management to identify opportunities for process and quality improvements within utilization management Educates and provides resources for utilization management team on key initiatives and to facilitate on-going communication between utilization management team, members, and providers Monitors prior authorization, concurrent review, and/or retrospective clinical review nurses and ensures compliance with applicable guidelines, policies, and procedures Works with the senior management to develop and implement UM policies, procedures, and guidelines that ensure appropriate and effective utilization of healthcare services Evaluates utilization management team performance and provides feedback regarding performance, goals, and career milestones Provides coaching and guidance to utilization management team to ensure adherence to quality and performance standards Assists with onboarding, hiring, and training utilization management team members Leads and champions change within scope of responsibility Performs other duties as assigned Complies with all policies and standards Education/Experience: Requires Graduate of an Accredited School Nursing or Bachelor's degree and 4+ years of related experience. Knowledge of utilization management principles preferred. License/Certification: RN - Registered Nurse - State Licensure and/or Compact State Licensure required CA RN LICENSE REQUIRED Pay Range: $75,300.00 - $135,400.00 per year Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
LVN Utilization Review Home Health Full-time
WelbeHealth

Utilization Management LVN

WelbeHealth Los Angeles, CA
$35.87 - $47.36 / hour
At WelbeHealth, we are transforming the reality of senior care by providing an all-inclusive healthcare option to the most vulnerable senior population, while functioning as both a care provider and care plan to we serve. Our Health Plan Services team plays a critical role in our participants’ journeys, and our Utilization Management team ensures that we provide timely, quality, compliant, and cost-effective care to our participants. The Utilization Management LVN is accountable for the review and audit of authorization requests to ensure services meet standard medical guidelines. Essential Job Duties: Chart audits of items including but not limited to consult summaries, imaging results, and procedure summaries to determine if additional follow up services are requested Oversee departmental clinical inboxes, email inboxes, and fax queues to ensure appropriate handling of documents and authorization requests Identify, document, and correct inconsistencies and gaps in participants’ charts with authorizations in the UM system Review prior authorization requests for medical necessity and alignment with participants’ care plans, including routine office visits, procedures, and DME Job Requirements: Minimum of one (1) year of chart auditing or UM review experience Knowledgeable in areas of Medicare and Medicaid UM regulations Unencumbered LVN licensure Benefits of Working at WelbeHealth: Apply your expertise in new ways as we rapidly expand. You will have the opportunity to design the way we work in the context of an encouraging and loving environment where every person feels uniquely cared for. Medical insurance coverage (Medical, Dental, Vision) Work/life balance - we mean it! 17 days of personal time off (PTO), 12 holidays observed annually, and sick time 401K savings + match Advancement opportunities - we’ve got a track record of hiring and promoting from within, meaning you can create your own path! And additional benefits Compensation consists of base salary plus bonus. WelbeHealth offers a competitive total rewards package that includes a 401(k) match, comprehensive healthcare coverage, and a broad range of additional benefits. Actual compensation will be determined based on experience and relevant qualifications. Compensation Offering $35.87 — $47.36 USD COVID-19 Vaccination Policy At WelbeHealth, our mission is to unlock the full potential of our vulnerable seniors. In this spirit, please note that we have a vaccination policy for all our employees and proof of vaccination, or a vaccine declination form will be required prior to employment. WelbeHealth maintains required infection control and PPE standards and has requirements relevant to all team members regarding vaccinations. Our Commitment to Diversity, Equity and Inclusion At WelbeHealth, we embrace and cherish the diversity of our team members, and we're committed to building a culture of inclusion and belonging. We're proud to be an equal opportunity employer. People seeking employment at WelbeHealth are considered without regard to race, color, religion, sex, gender, gender identity, gender expression, sexual orientation, marital or veteran status, age, national origin, ancestry, citizenship, physical or mental disability, medical condition, genetic information or characteristics (or those of a family member), pregnancy or other status protected by applicable law. Beware of Scams Please ensure your application is being submitted through a WelbeHealth sponsored site only. Our emails will come from @welbehealth.com email addresses. You will never be asked to purchase your own employment equipment. You can report suspected scam activity to fraud.report@welbehealth.com
RN Utilization Review Telehealth Full-time
Astrana Health

UM Review Nurse

Astrana Health Monterey Park, CA
$34 - $42 / hour
UM Review Nurse Department: HS - UM Employment Type: Full Time Location: 1600 Corporate Center Dr., Monterey Park, CA 91754 Reporting To: Sandra Castellon Compensation: $34.00 - $42.00 / hour Description Astrana Health is looking for a CA-licensed Utilization Review Nurse to assist our Health Services Department. In this position, you will utilize your clinical judgement to approve or deny outpatient medical services for patients based on Medical Necessity Criteria, respective to various Health Plans. This position requires open availability between Monday through Sunday, 8 A - 8 P. You would be scheduled for 5 shifts per week. This is a remote position for CA-licensed nurses. Candidates must live in California. We are seeking nurses with at least one year of outpatient Utilization Management experience in a fast-paced setting. Our Values: Put Patients First Empower Entrepreneurial Provider and Care Teams Operate with Integrity & Excellence Be Innovative Work As One Team What You'll Do Complete prior authorization/retrospective review of elective inpatient admissions, outpatient procedures, post-homecare services, and durable medical equipment Refer cases to Medical Directors as needed/appropriate Maintain knowledge of state and federal regulations and accreditation standards Comply with internal policies and procedures Perform any other job duties as requested Qualifications Active and unrestricted LVN license in CA. 1+ years of outpatient UM experience Experience with Microsoft applications such as Word, Excel, and Outlook You’ll be Great for this Role If: Two (2) years of health plan, IPA or MSO experience Strong interpersonal skills Ability to collaborate with co-workers, senior leadership, and other management Experience educating and training staff Environmental Job Requirements and Working Conditions This is a remote position. Our office is located at 1600 Corporate Center Drive in Monterey Park, CA. Candidates who live within a 30 mile radius of the office may be expected to work hybrid. Typical business hours are Monday - Friday from 8:30 AM to 5 PM, however, this position requires open availability between 8 AM - 8 PM PST, M-Su. Your schedule will be compromised of 5 shifts per week. Nurses rotate weekend and holiday coverage. Overtime is required in this position. The national target pay range for this role is $34.00 - $42.00 per hour. Actual compensation will be based on job level, geographic location (current or future), experience, and other job-related factors. Astrana Health is proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based on race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. All employment is decided based on qualifications, merit, and business need. If you require assistance in applying for open positions due to a disability, please email us at humanresourcesdept@astranahealth.com to request an accommodation. Additional Information: The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.
RN Utilization Review Telehealth Full-time
Centene

Clinical Review Nurse-Concurrent Review

Centene New York, NY
$27.02 - $48.55 / hour
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. ***Applicants must have and maintain active New York State (NYS) RN licensure to be considered. The standard fully remote work schedule is Monday through Friday, 8:30 a.m. to 5:00 p.m. with the potential for weekend and/or holiday coverage based on business needs.*** Position Purpose: Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member. Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines Reviews member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities Collaborates with care management on referral of members as appropriate Performs other duties as assigned. Complies with all policies and standards Education/Experience: Requires graduation from an accredited school of nursing or a Bachelor’s degree in Nursing (BSN), along with 2–4 years of related nursing experience. A minimum of 2 years of acute care experience is required. Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. License/Certification: LPN - Licensed Practical Nurse - State Licensure required NYS RN Licensure Strongly Preferred Pay Range: $27.02 - $48.55 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
RN Outpatient Utilization Review Outpatient Full-time
IU Health

Registered Nurse – Outpatient – Urology – Ambulatory Referral Review

IU Health Indianapolis, IN
Overview Part and Full-time roles are eligible for a $30,000 sign-on bonus — apply today to learn more! We are seeking an individual with a minimum of one year of RN experience for this role. Are you an upcoming nurse graduate or recent nurse graduate? Please apply through our pipeline requisition here: https://iuhealth.org/applyrn . This pipeline requisition allows the IU Health Talent Acquisition team to pair upcoming & recent nurse graduates with the best opportunities available to them based on their unique skillset and interests. Thanks for your interest in joining the team! IU Health is seeking expert RN's who will have the opportunity to collaborate with the brightest minds in medicine. At IU Health, you will develop in significant ways, advancing healthcare for all! Being an IU Health nurse means building a professional nursing career designed with competitive benefits, a culture that accepts your outstanding strengths, and supports your personal and professional goals. If you are seeking an organization where you can engage expertly, develop clinical expertise, embrace learning, cultivate new relationships, and fuel your spirit of inquiry, apply today! Position Overview: Join our dynamic healthcare team as a Registered Nurse specializing in Ambulatory Referral Review, supporting the Urology service line. This innovative role leverages your clinical expertise to coordinate and manage patient care referrals from an off-site, system-wide call center. Working Monday through Friday during the day shift with flexible hours, this remote/hybrid position offers a balanced work environment with comprehensive training to ensure your success. Work Environment: This position is primarily remote, with initial hybrid training to ensure seamless onboarding and integration into the team. Key Responsibilities: Utilize the nursing process (assessment, diagnosis, outcome identification, planning, implementation, and evaluation) to review inbound patient care referrals efficiently and accurately. Analyze electronic health records, test results, and clinical documentation in accordance with specialty care protocols and scheduling workflows. Assess patient acuity and prioritize scheduling based on clinical needs. Collaborate closely with specialty physicians and interdisciplinary teams to ensure patients receive timely, appropriate care. Maintain adherence to organizational policies, ensuring quality and compliance in referral management. Qualifications: Associate's Degree is required. Bachelor's Degree is preferred. Requires 0-3 years of relevant experience. 2+ years of Urology experience preferred. Requires that the RN has graduated from a nationally accredited nursing program. Requires an active Registered Nurse (RN) license in the state of Indiana or an active Nurse Licensure Compact (NLC) RN license. Requires basic life support (BLS) certification through the AHA annually. Other advanced life support certifications may be required per unit/department specialty according to patient care policies. Requires the ability to assess patients without face-to-face interaction. Why Join Us? Be part of a forward-thinking healthcare organization dedicated to delivering patient-centered care. This role offers an excellent opportunity to utilize your nursing skills in a specialized, fast-paced environment while enjoying the flexibility of remote work.
RN Utilization Review Full-time
New York State

Registered Nurse 3 - Utilization

New York State Albany, NY
$47 - $53 / hour
Description Duties Description To be discussed at time of interview. Qualifications Minimum Qualifications Possession of a license and current registration as a registered professional nurse in New York State; and three years of post-licensure clinical nursing experience of which one year was in utilization review and/or discharge planning. Substitution: a bachelor's degree in nursing can substitute for one year of post-licensure clinical nursing experience; and a master's degree in nursing can substitute for two years of post-licensure clinical nursing experience. Additional Comments Please include a copy of your NYS Registration License when submitting a resume
RN Utilization Review Full-time
Hillcrest HealthCare System

Registered Nurse / RN Peer Review Coordinator

Hillcrest HealthCare System Tulsa, OK
Join our team as a day shift, full-time, Peer Review Coordinator RN in Tulsa, OK. Why Join Us? Thrive in a People-First Environment and Make Healthcare Better Thrive: We empower our team with career growth opportunities, tuition assistance, and resources that support your wellness, education, and financial well-being. People-First: We prioritize your well-being with paid time off, comprehensive health benefits, and a supportive, inclusive culture where you are valued and cared for. Make Healthcare Better: We use advanced technology to support our team and enhance patient care. Get to Know Your Team: Hillcrest Medical Center is a 656-bed hospital that includes The Alexander Burn Center, The Peggy V. Helmerich Women’s Health Center, Kaiser Rehabilitation Center, the latest technology for the treatment of cancer, and the Oklahoma Heart Institute. The Peer Review Coordinator will manage the peer review process from acceptance of cases for peer review, facilitating first level screening if applicable, preparation of case review documents, and documentation of peer review results, production of reports and maintenance of the peer review database. Job Requirements: Minimum of five years in an acute hospital setting Oklahoma RN licensure Preferred Job Requirements: CPHQ
RN Utilization Review Full-time
Confluence Health

Nurse Utilization RN

Confluence Health Wenatchee, WA
$44.64 - $71.24 / hour
Salary Range $44.64 - $71.24 Overview Located in the heart of Washington, we enjoy open skies, snow-capped mountains, and the lakes and rivers of the high desert. We are the proud home of orchards, farms, and small communities. Confluence Health actively supports the communities we serve and their quality of life through our community support program and through our individual efforts as involved community members. Full Time Employees of Confluence Health receive a wide range of benefits in addition to compensation. Medical, Dental & Vision Insurance Flexible Spending Accounts & Health Saving Accounts Paid Time Off Generous Retirement Plans Life Insurance Long-Term Disability Gym Membership Discount Tuition Reimbursement Employee Assistance Program Adoption Assistance Shift Differential For more information on our Benefits & Perks, click here! Summary Performs utilization review in accordance with all state mandated regulations. Maintains compliance with regulation changes affecting utilization management. Reviews patients records and evaluates patient progress. Performs continuing review on medical records and identification and need of on-going hospitalization. Obtains and reviews necessary medical reports and subsequent treatment plan requests. Conducts reviews and validates physician's orders, reports progress and unusual occurrences on patients. Ensures appropriate and cost-effective healthcare services to patients. Documents review information in computer. Monitors all Outpatient in a Bed & Inpatient surgeries for correct status. Reviews the insurance prior authorizations for correct status. Uses the Medicare Inpatient Only list of surgery CPT codes for correct status/class to ensure reimbursement for surgeries. Reviews all denials from insurance companies for correct status/class. Pursues peer to peer discussions between our hospitalists and insurance MD, reconsideration, appeal, administrative rate, or change in status/class. Position Reports To: Director of Utilization Management Essential Functions Prepares and organizes initial and continued stay utilization reviews. Complete admission review per MCG guidelines. Coordinates provider certification of Medicare inpatient hospital stays as required in the Medicare Benefit Manual, Final Rule etc. Utilizes clinical information located in the patient record to support patient status decisions and recommendations. Documents this information in MCG. Collaborates with other departments regarding review results. Issues MOON letters to patients per Medicare guidelines to notify them of their Observation status and billing of Medicare Part B. Communicates to care management staff when payers deny the patient stay. Complies with Medicare and other regulations for second level review by the UR Committee, notification of patient, physician, and hospital of particular status changes. Follows the A/B Rebill flow maps as indicated. Ensures written notification to the patient, physician, and hospital when the final outcome of a second level review is A/B Rebill. Notifies patient accounts to hold submission of a bill when a case has been sent for second level review and the patient has been discharged. Notifies patient accounts to submit the bill when the results of the second level review is known, along with the results. Participates in tracking and monitoring second level reviews as directed. Adheres to Workflows and Process Maps specific to UM functions. Follows process flow maps and established workflows. Participates in standard work. Assist in identifying processes and procedure improvements to positively affect work flows. Issues Notices of Non-coverage according to policy and procedure. Complies with the various private contracts regarding review, pre-authorization, phone calls, deliver non-coverage letters as required and/or appeal denials. Provides Clinical information to payers as requested and per contract. Facilitates concurrent Peer to Peer discussions between providers when a payer denies all or part of a hospital stay when the denial occurs prior to discharge. Communicates the results of Peer to Peer discussions, if known, with business office and patient accounts. Tracks all discussions with payers in the appropriate billing system, according to facility. Assist with the process following an appeal of discharge, as outlined in the Important Message from Medicare. Provide requested clinical information to the QIO following a patient’s appeal of the discharge decision. Deliver a HINN-12 notification following a decision from the QIO to uphold a decision to discharge, according to procedure. Performs other duties as assigned. Demonstrate Standards of Behavior and adhere to the Code of Conduct in all aspects of job performance at all times. Qualifications Required: Associate's Degree in Nursing. Three (3) years experience in an acute care setting as a Health Care Professional with demonstrated expertise in specific clinical area. Current licensure in the state of Washington (RCW 18.88) or licensure through Multistate Nurse Licensure Compact (SSB 5499). Demonstrated skills in the areas of negotiation, communication (verbal and written), conflict, interdisciplinary collaboration, management, creative problem solving, and critical thinking. Knowledge of healthcare financing, community and organizational resources, patient care processes, and data analysis. Excellent verbal and written communication skills. Demonstrates flexibility via an ability to adapt to changing priorities and regulations. Must possess basic computer skills related to Windows navigation, email communication. Desired : Bachelor's Degree in Nursing (BSN) or related field. Accreditation in ACMA. Physical/Sensory Demands O = Occasional, represents 1 to 25% or up to 30 minutes in a 2 hour workday. F = Frequent, represents 26 to 50% or up to 1 hour of a 2 hour workday. C = Continuous, represents 51% to 100% or up to 2 hours of a 2 hour workday. Physical/Sensory Demands For This Position: Walking - O Sitting/Standing - C Reaching: Shoulder Height - O Reaching: Above shoulder height - O Reaching: Below shoulder height - O Climbing - O Pulling/Pushing: 25 pounds or less - O Pulling/Pushing: 25 pounds to 50 pounds - O Pulling/Pushing: Over 50 pounds - O Lifting: 25 pounds or less - O Lifting: 25 pounds to 50 pounds - O Lifting: Over 50 pounds - O Carrying: 25 pounds or less - O Carrying: 25 pounds to 50 pounds - O Carrying: Over 50 pounds - O Crawling/Kneeling - O Bending/Stooping/Crouching - F Twisting/Turning - O Repetitive Movement - C Working Conditions: Work is performed in a hybrid setting with remote work as well as in an office environment. Involves frequent contact with staff, leadership and practitioners. Work may be stressful at times. Job Classification: FLSA: Non-Exempt Hourly/Salary: Hourly Physical Exposures For This Position: Unprotected Heights - No Heat - No Cold - No Mechanical Hazards - No Hazardous Substances - No Blood Borne Pathogens Exposure Potential - No Lighting - Yes Noise - Yes Ionizing/Non-Ionizing Radiation – No Infectious Diseases - No
RN Manager/Supervisor Utilization Review Home Health Full-time
Personal Touch Home Aides of New York

(RN) Quality Review Manager- Registered Nurse

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

Utilization Management Claims Review Nurse RN II

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

Utilization Management Clinical Quality Nurse Reviewer RN II

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

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

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