Utilization Review Nurse Jobs

2 months ago

Utilization Review/Management Coordinator

UHS Grand Rapids, MI

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

Utilization Management Nurse Consultant

CVS Health MI

$29.10 - $62.32 / hour

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Regular business hours are 8:00 am-8:00 pm EST. Must be available to work any 8 hour shift within this timeframe with start times ranging from 8:00 am-11:30am EST. About Us American Health Holding, Inc. (AHH), a division of Aetna/CVS Health, is a URAC-accredited medical management organization founded in 1993. We provide flexible, cost-effective care management solutions that promote high-quality healthcare for members. Position Summary Join our Utilization Management team as a Nurse Consultant, where you'll apply clinical judgment and evidence-based criteria to review inpatient and outpatient services. You'll collaborate with providers, authorize care, and escalate cases when needed, all while navigating multiple systems and maintaining accurate documentation. This role suits nurses who thrive in fast-paced environments, are highly organized, and comfortable with computer-based work. Key Responsibilities Apply critical thinking and evidence-based clinical criteria to evaluate outpatient and inpatient services requiring precertification and concurrent review. Conduct clinical reviews via phone and electronic documentation, collaborating with healthcare providers to gather necessary information. Use established guidelines to authorize services or escalate to Medical Directors as needed. Navigate multiple computer systems efficiently while maintaining accurate documentation. Thrive in a fast-paced, high-volume environment with strong organizational, multitasking, and prioritization skills. Perform sedentary work that primarily involves extended periods of sitting, as well as frequent talking, listening, and use of a computer. Flexibility to provide coverage for other Utilization Management (UM) Nurses across various UM specialty teams as needed, ensuring continuity of care and operational support. Participate in occasional on-call rotations, including some weekends and holidays, per URAC and client requirements. Remote Work Expectations This is a 100% remote role; candidates must have a dedicated workspace free of interruptions. Dependents must have separate care arrangements during work hours, as continuous care responsibilities during shift times are not permitted. Required Qualifications Active unrestricted state Registered Nurse licensure in state of residence required. Minimum 5 years of relevant experience in Nursing. At least 1 year of Utilization Management experience in concurrent review or prior authorization. Strong decision-making skills and clinical judgment in independent scenarios. Proficient with phone systems, clinical documentation tools, and navigating multiple digital platforms. Commitment to attend a mandatory 3-week training (Monday–Friday, 8:30am–5:00pm EST) with 100% participation. Preferred Qualifications 1+ year of experience in a managed care organization (MCO). Experience in a high-volume clinical call center or prior remote work environment. Education Associate's degree in nursing (RN) required, BSN preferred. Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $29.10 - $62.32 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan . No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits This job does not have an application deadline, as CVS Health accepts applications on an ongoing basis. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

Capital Health Ashland, VA

Utilization Review RN

Capital Health is the region's leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advanced technology. Capital Health is a five-time Magnet-Recognized health system for nursing excellence and is comprised of 2 hospitals. Capital Health Medical Group is made up of more than 250 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region. Capital Health recognizes that attracting the best talent is key to our strategy and success as an organization. As a result, we aim for flexibility in structuring competitive compensation offers to ensure we can attract the best candidates. The listed pay range or pay rate reflects compensation for a full-time equivalent (1.0 FTE) position. Actual compensation may differ depending on assigned hours and position status (e.g., part-time). Pay Range: $39.40 - $59.19 Scheduled Weekly Hours: 40 Position Overview Performs chart review of identified patients to identify quality, timeliness and appropriateness of patient care. Conducts admission reviews for Medicare, Medicaid beneficiaries, as well as private insurers and self pay patients, based on appropriate guidelines. Uses these criteria guidelines to screen for appropriateness for inpatient level of care or observation services based on physician certification (physicians H&P, treatment plan, potential risks and basis for expectation of a 2 midnight stay). Refers cases as appropriate, to the UR physician advisor for review and determination. Gathers clinical information to conduct continued stay utilization review activities with payers on a daily basis. Performs concurrent and retrospective clinical reviews with various payers, utilizing the appropriate guidelines as demonstrated by compliance with all applicable regulations, policies and timelines. Adheres to CMS guidelines for utilization reviews as evidenced by utilization of the relevant guidelines and appropriate referrals to the physician advisor and the UR Committee. Identifies, develops and implements strategies to reduce length of stay and resource consumption. . Confers proactively with admitting physician to provide coaching on accurate level of care determinations at point of hospital entry. Keeps current on all regulatory changes that affect delivery or reimbursement of acute care services. Uses knowledge of national and local coverage determinations to appropriately advise physicians. Understands and applies federal law regarding the use of Hospital Initiated Notice of Non-Coverage (HINN) and Lifetime Reserve Days letters. Identifies and records consistently any information on any progression of care or patient flow barriers using the Avoidable Days tool in the Utilization software program. Consults with medical staff, care team and case managers as necessary to resolve immediate progression of care barriers through appropriate administrative and medical channels. Engages care team colleagues in collaborative problem solving regarding appropriate utilization of resources. Recognizes and responds appropriately to patient safety and risk factors. Represents Utilization Management at various committees, professional organizations an physician groups as needed. Promotes the use of evidence based protocols and or order sets to influence high quality and cost effective care. Identifies, develops and implements strategies to reduce lengths of stay and resource consumption in the patient population. Participates in performance improvement activities. Promotes medical documentation that accurately reflects findings and interventions, presence of complication or comorbidities, and patient's need for continued stay. Identifies and records episodes of preventable delays or avoidable days due to failure of progression of care processes. Maintains appropriate documentation in the Utilization software system on each patient to include specific information of all resource utilization activities. Participates actively in daily huddles, patient care conferences, and hospitalist or nurse handoff reports to maintain knowledge about intensity of services and the progression of care. Identifies potentially wasteful or misused resources and recommends alternatives if appropriate by analyzing clinical protocols. Maintains related continuing education credits = 15 per calendar year. MINIMUM REQUIREMENTS Education: Minimum of Associate's degree in Nursing. Graduate of an accredited school of nursing. CPHQ, CCM or CPUR preferred. Experience: Three years of clinical nursing or two years quality management, utilization review or discharge planning experience. Other Credentials: Registered Nurse - NJ Knowledge and Skills: Three years of clinical nursing or two years quality management, utilization review or discharge planning experience. CPHQ, CCM or CPUR preferred. Special Training: Basic computer skills including the working knowledge of Microsoft Office, UR software and EMR. Possesses familiarity with MCG guidelines. Mental, Behavioral and Emotional Abilities: Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form. Usual Work Day: 8 Hours PHYSICAL DEMANDS AND WORK ENVIRONMENT Frequent physical demands include: Sitting , Standing , Walking Occasional physical demands include: Climbing (e.g., stairs or ladders) , Carry objects , Push/Pull , Twisting , Bending , Reaching forward , Reaching overhead , Keyboard use/repetitive motion , Talk or Hear Continuous physical demands include: Lifting Floor to Waist 10 lbs. Lifting Waist Level and Above 5 lbs. Sensory Requirements include: Accurate Near Vision, Accurate Far Vision, Accurate Color Discrimination, Accurate Depth Perception, Accurate Hearing Anticipated Occupational Exposure Risks Include the following: N/A This position is eligible for the following benefits: Medical Plan Prescription drug coverage & In-House Employee Pharmacy Dental Plan Vision Plan Flexible Spending Account (FSA) - Healthcare FSA - Dependent Care FSA Retirement Savings and Investment Plan Basic Group Term Life and Accidental Death & Dismemberment (AD&D) Insurance Supplemental Group Term Life & Accidental Death & Dismemberment Insurance Disability Benefits – Long Term Disability (LTD) Disability Benefits – Short Term Disability (STD) Employee Assistance Program Commuter Transit Commuter Parking Supplemental Life Insurance - Voluntary Life Spouse - Voluntary Life Employee - Voluntary Life Child Voluntary Legal Services Voluntary Accident, Critical Illness and Hospital Indemnity Insurance Voluntary Identity Theft Insurance Voluntary Pet Insurance Paid Time-Off Program The pay range listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future. When determining base salary and/or rate, several factors may be considered including, but not limited to location, years of relevant experience, education, credentials, negotiated contracts, budget, market data, and internal equity. Bonus and/or incentive eligibility are determined by role and level. The salary applies specifically to the position being advertised and does not include potential bonuses, incentive compensation, differential pay or other forms of compensation, compensation allowance, or benefits health or welfare. Actual total compensation may vary based on factors such as experience, skills, qualifications, and other relevant criteria.

St. Luke's University Health Network Allentown, PA

RN DRG Downgrades Appeals Review Specialist

St. Luke's is proud of the skills, experience and compassion of its employees. The employees of St. Luke's are our most valuable asset! Individually and together, our employees are dedicated to satisfying the mission of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care. The RN DRG Downgrades Appeals Review Specialist is responsible for the retrospective clinical review and defense of inpatient DRG downgrades, clinical validation denials, and medical necessity determinations issued by governmental and commercial payers. JOB DUTIES AND RESPONSIBILITIES: Conduct retrospective clinical record reviews to evaluate DRG downgrades, clinical validation denials, and medical necessity determinations. Analyze documentation in conjunction with MS-DRG logic and ICD-10-CM/PCS coding guidelines to determine appeal opportunity. Develop and submit defensible first- and second-level appeal letters using clinical evidence, regulatory guidance, coding standards, and payer policy. Collaborate with Physician Advisors, Coding leadership, and CDI to support higher-level appeals (e.g., IRO, ALJ, payer conferences). Identify denial trends and provide structured feedback to Coding and CDI leadership to reduce future payer vulnerability. Participate in payer audit response processes (RAC, QIO, MIC, commercial auditors) and assist in preparation for formal appeal proceedings. Maintain accurate documentation within EPIC, payer audit platforms, and internal tracking tools to support reporting and performance monitoring. Review denial data and appeal outcomes to assist leadership in assessing revenue impact, case resolution trends, and operational improvement opportunities. Maintain current knowledge of MS-DRG methodology, ICD-10-CM/PCS coding guidelines, clinical validation standards, federal and commercial payer policies, and medical necessity criteria. Serve as a clinical resource regarding documentation specificity and disease process validation as it relates to reimbursement defense. PHYSICAL AND SENSORY REQUIREMENTS: Sitting, standing and light lifting. Repetitive arm/finger use retrieving/viewing computerized patient medical record and abstracting of patient information. Corrected vision and hearing to within normal range. Hearing as it relates to normal conversation. Works inside with adequate lighting, comfortable temperature and ventilation. EDUCATION: Registered Nurse required. BSN preferred. Active RN license required. CDI certification (CDIP, CCDS) preferred. TRAINING AND EXPERIENCE: Minimum five (5) years RN experience in adult inpatient acute care (medical/surgical or critical care). Strongly preferred: Clinical Documentation Improvement (CDI) experience. Strongly preferred: DRG downgrade or clinical validation denial experience. Strongly preferred: Utilization review or payer medical review experience. Familiarity with MS-DRG reimbursement methodology. Demonstrated understanding of disease pathophysiology and documentation specificity requirements. Working knowledge of ICD-10-CM/PCS fundamentals. Understanding of payer audit and appeal processes. Experience with EPIC and encoder tools (e.g., 3M) preferred. Please complete your application using your full legal name and current home address. Be sure to include employment history for the past seven (7) years, including your present employer. Additionally, you are encouraged to upload a current resume, including all work history, education, and/or certifications and licenses, if applicable. It is highly recommended that you create a profile at the conclusion of submitting your first application. Thank you for your interest in St. Luke's!! St. Luke's University Health Network is an Equal Opportunity Employer.

Utilization Management Nurse Consultant

CVS Health KS

$26.01 - $56.14 / hour

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours. Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function. Typical office working environment with productivity and quality expectations. Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor. Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment. Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding. Effective communication skills, both verbal and written Required Qualifications - 2+ years of experience as a Registered Nurse in adult acute care/critical care setting - Must have active current and unrestricted RN licensure in state of residence - Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours Preferred Qualifications - 2+ years of clinical experience required in med surg or specialty area - Managed Care experience preferred, especially Utilization Management - Preference for those residing in Central Time zones Education Associates Degree required BSN preferred Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $26.01 - $56.14 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan . No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 03/27/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

JPS Health Network Fort Worth, TX

Nurse Case Manager - Inpatient

Description: The Nurse Case Manager - Inpatient is responsible for coordinating the care and service of assigned patients with physicians, nurses, social workers and other members of the healthcare team to facilitate the progression of care from hospital admission through discharge. The Nurse Case Manager- Inpatient is also responsible for ensuring that the patient is placed in the appropriate level of care while monitoring the utilization of healthcare resources and discharge planning to achieve the desired clinical, financial, and resource utilization outcomes. Typical Duties: Provides an assessment for all observation status patients prior to observation placement. The patient is to be assessed throughout the shift to determine discharge readiness or the need to convert to an inpatient status by using the approved medical appropriateness criteria and all third-party payer regulatory requirement. Performs initial status review and level of care placement on all patients in an inpatient status using approved medical appropriate criteria in addition to third-party payer regulatory requirements. Conducts an initial clinical assessment on assigned patients as well as discharge planning assessment prior to admission, at the time of admission, or at discharge. Meets directly with the patient, family, and/or representative to assess needs and develop an individualized discharge plan based on the patient’s medical diagnosis, treatment plan, financial resources, and psychosocial issues, etc. Reassesses the discharge plan throughout the patient’s hospitalization with input from the healthcare team and patient, family, and/or representative and modifying as needed. Collaborates with the multi-disciplinary care team to ensure all needed clinical information is provided to the appropriate entities for the assigned level of care and supports the concurrent appeal process for any reduction in level of care or denial as requested. Maintains active communication with the patient, family, and/or representative, physicians, nursing and other members of the multi-disciplinary care team to effect timely, appropriate patient management; documents each component of the case management process and related activities. Identifies appropriate services not related to admission and assists in arrangement of services on an outpatient basis. Leads the Unit’s daily interdisciplinary rounds to ensure a comprehensive plan of care is developed, including identification of patient needs, assignment of tasks to resolve clinical issues, review of discharge barriers, and identification of discharge planning options. Generates referrals to the Case Management Physician Advisor according to departmental policies. Serves as an educational resource for physician, nursing staff and others concerning case management strategies essential in meeting the organization’s quality, utilization, financial and customer satisfaction objectives. Performs other related job duties as assigned.

Per Diem

Cook Children's Health Care System Fort Worth, TX

UTILIZATION MANAGMENT (UM) COORDINATOR - PRN

UHS Franklin, TN

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

UM/ECM - RN Reviewer HP

Location: Calmont Operations Building Department: Utilization Shift: First Shift (United States of America) Standard Weekly Hours: 40 Summary: Responsible for the coordination and efficient utilization of health care resources for Cook Childrens Health Plan (CCHP) members. Works with the Department Manager and Team Lead to assure the timely provision of quality care throughout the continuum of care. The Registered Nurse Utilization Management/Episodic Case Manager (UM/ECM - RN) Reviewer facilitates clinically appropriate and fiscally responsible care through communication with the providers and health plan medical directors. The UM/ECM - RN Reviewer assesses and identifies the members clinical information and determines, in conjunction with the Medical Director, medical necessity and appropriateness of requested services. Utilizes Medical Management Committee (MMC) approved clinical criteria to authorize requested services for the member. The UM/ECM - RN Reviewer communicates with providers of care/services to facilitate appropriate care transitions. The UM/ECM - RN Reviewer assures adherence to regulatory/contractually required timeliness standards for authorization request processing, associated communications and notice of adverse determinations are met for CCHP. Additional Information: Responsible for the coordination and efficient utilization of health care resources for Cook Childrens Health Plan (CCHP) members. Works with the Department Manager and Team Lead to assure the timely provision of quality care throughout the continuum of care. The Registered Nurse Utilization Management/Episodic Case Manager (UM/ECM - RN) Reviewer facilitates clinically appropriate and fiscally responsible care through communication with the providers and health plan medical directors. The UM/ECM - RN Reviewer assesses and identifies the members clinical information and determines, in conjunction with the Medical Director, medical necessity and appropriateness of requested services. Utilizes Medical Management Committee (MMC) approved clinical criteria to authorize requested services for the member. The UM/ECM - RN Reviewer communicates with providers of care/services to facilitate appropriate care transitions. The UM/ECM - RN Reviewer assures adherence to regulatory/contractually required timeliness standards for authorization request processing, associated communications and notice of adverse determinations are met for CCHP. Qualifications: Registered Nurse, BSN preferred. Minimum of five (5) years clinical experience. 2 years utilization management or case management experience required. Strong skills in the following area s: Oral and written communication. Critical thinking. Organization and time management. Customer service. Certification/Licensure: Current unrestricted Registered Nurse licensure in the State of Texas. About Us: Cook Children's Health Plan Cook Children's Health Plan provides vital coverage to nearly 120,000 people in low-income families who qualify for government-sponsored programs in our six county service region. Cook Children's Health Plan provides health coverage for CHIP, CHIP Perinatal, STAR (Medicaid) and STAR Kids Members in the Tarrant county service area. The counties we serve includes Tarrant, Johnson, Denton, Parker, Hood and Wise. Cook Children’s is an equal opportunity employer. As such, Cook Children’s offers equal employment opportunities without regard to race, color, religion, sex, age, national origin, physical or mental disability, pregnancy, protected veteran status, genetic information, or any other protected class in accordance with applicable federal laws. These opportunities include terms, conditions and privileges of employment, including but not limited to hiring, job placement, training, compensation, discipline, advancement and termination.

Utilization Review Manager

UHS Grand Rapids, MI

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

Gainwell Technologies LLC Arkansas City, AR

5 months ago

Utilization Review Nurse- Remote

$65,000 - $78,000 / year

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