Utilization Review Nurse Jobs

RN Utilization Review Full-time
UF Health

RN, Utilization Management | Utilization Management

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

Utilization Review Nurse: Emergency Dept

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

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

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

ED Case Management Utilization RN, Per Diem Day 10/hr Shift

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

Utilization Review, RN Flex

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

Preservice Review Nurse - PST time zone - Remote

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

Secondary Review Nurse - Indiana

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

Secondary Review Nurse - Indiana

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

Utilization/Clinical Review RN - PRN

Children's Healthcare of Atlanta Atlanta, GA
Note: If you are CURRENTLY employed at Children's and/or have an active badge or network access, STOP here. Submit your application via Workday using the Career App (Find Jobs). Work Shift Day Work Day(s) Variable Shift Start Time 8:00 AM Shift End Time 5:00 AM Worker Sub-Type PRN Children’s is one of the nation’s leading children’s hospitals. No matter the role, every member of our team is an essential part of our mission to make kids better today and healthier tomorrow. We’re committed to putting you first, and that commitment is at the heart of our company culture: People first. Children always. Find your next career opportunity and make a difference doing what you love at Children’s. Job Description Participates as a member of a multidisciplinary team in completing pre-screening assessments of prospective patients. Ensures completion of appropriate clinical review of all applicable patients as stated in system utilization management plan. Oversees Clinical Review Specialist as indicated. Maintains necessary documentation and communication with internal and external customers. This role is PRN to work (6) 8-hour days per month with 1 day being Saturday. If available, open to offering more days. Training/Orientation will be 3 days/week for 6-8 weeks. This role will be remote, including most training but monthly meetings/trainings will require being onsite at the Support Center in Atlanta. Experience 3 years of experience in a healthcare setting; pediatrics highly preferred Preferred Qualifications Bachelor of Science in Nursing 2 years of experience in hospital or insurance related utilization review Previous experience with MCG and/or InterQual systems Education Graduation from an accredited school of nursing Certification Summary Licensure as a Registered Nurse in the single State of Georgia or Multi-State through the Enhanced Nurse Licensure Compact Knowledge, Skills, and Abilities Working knowledge of financial aspects of third-party payors and reimbursement Effective decision-making/problem-solving skills Demonstration of creativity in problem-solving Must possess above-average computer skills Must be able to successfully pass the Basic Windows Skill Assessment at 80% or higher rating within 30 days of employment Job Responsibilities Provides clinical information to insurance companies as needed for completion of pre-certification process as noted in Children's Healthcare of Atlanta utilization management plan. Evaluates all patients, including critical care, for appropriateness of admission type and setting, utilizing a combination of clinical information, screening criteria, and third-party information within 24 hours or next business day. Initiates and facilitates physician communications relative to utilization review process when indicated without prompting and follows up to ensure completion, including peer-to-peer reviews, securing admission orders, and reporting quality issues. Reviews concurrently all inpatients, including critical care, every three days or sooner if payor requests, including information regarding patient's medical condition, intensity of services being utilized, treatment plan, and established review criteria. Ensures all pertinent information is documented into various systems for utilization review process. Gathers and reviews relevant medical information and documents utilization review process outcome based on system accepted utilization criteria on the accepted current review forms and in computer systems. Supports organizational efforts to ensure accurate capture of admission status and level of care using Epic and escalating cases for status change where necessary. Refers denied cases to appropriate personnel and provides assistance and/or clinical support to aid in appeal process. Serves as resource to Case Management for facilitation of patients moving to appropriate level of care and notifying when patients no longer meet medical necessity to aid in discharge planning. Meets productivity (10-12 reviews/day) and quality assurance (95%) standards and demonstrates utilization review proficiency with the successful completion and passing of McKesson Interrater Reliability testing. Attends all required onsite, telephonic, and mandatory department meetings. Participates in department activities to help promote utilization review process, aids in denial prevention, and serves as resource to peers and team members. Children’s Healthcare of Atlanta is an equal opportunity employer committed to providing equal employment opportunities to all qualified applicants and employees without regard to race, color, sex, religion, national origin, citizenship, age, veteran status, disability or any other characteristic covered by applicable law. Primary Location Address 1575 Northeast Expy NE Job Family Nursing-Non Bedside
RN Utilization Review Per Diem
Yale New Haven Health

RN-Utilization Coordinator-Geriatric Psychiatry-Per Diem

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

Care Review Clinician- Utilization Review (RN/LPN- Mississippi based- REMOTE)

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

Utilization Management Claims Review Nurse RN II

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

(RN)Healthcare Services Supervisor- Inpatient UM/UR (CA License Required)- REMOTE

Molina Healthcare Long Beach, CA
$76,425 - $149,028 / year
JOB DESCRIPTION Job Summary Leads and supervises multidisciplinary team of healthcare services professionals in some or all of the following functions: care management, utilization management, behavioral health, care transitions, long-term services and supports (LTSS), and/or other special programs. Ensures members reach desired outcomes through integrated delivery and coordination of care across the continuum, and contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Assists in implementing health management, care management, utilization management, behavioral health and other program activities in accordance with regulatory, contract standards and accreditation compliance. • Functions as a “hands-on” supervisor, assisting with assessing and evaluation of systems, day-to-day operations and efficiency of operations/services. • Assists in the coordination of orienting and training staff to ensure maximum efficiency and productivity, program implementation, and service excellence. • Trains and supports team members to ensure high-risk, complex members are adequately supported. • Assists with staff performance appraisals, ongoing monitoring of performance, and application of protocols and guidelines. • Collaborates with and keeps healthcare services leadership apprised of operational issues, staffing, resources, system and program needs. • Assists with coordination and reporting of department statistics and ongoing client reports, as assigned. • Local travel may be required (based upon state/contractual requirements). Required Qualifications • At least 5 years health care experience, and at least 2 years of managed care experienced in one or more of the following areas: utilization management, care management, care transitions, behavioral health, long-term services and supports (LTSS), or equivalent combination of relevant education and experience. r equivalent combination of relevant education and experience. • Registered Nurse (RN), Licensed Vocational Nurse (LVN), Licensed Practical Nurse (LPN), Licensed Clinical Social Worker (LCSW), Licensed Marriage and Family Therapist (LMFT), Licensed Professional Clinical Counselor (LPCC), or Licensed Master of Social Work (LMSW). Clinical licensure and/or certification required ONLY if required by state contract, regulation, business operating model, or state board licensing mandates. If licensed, license must be active and unrestricted in state of practice. • Ability to manage conflict and lead through change. • Operational and process improvement experience. • Strong written and verbal communication skills. • Working knowledge of Microsoft Office suite. • Ability to prioritize and manage multiple deadlines. • Excellent organizational, problem-solving and critical-thinking skills. Preferred Qualifications • CA Registered Nurse (RN). License must be active and unrestricted in state of practice. • Certified Case Manager (CCM), Certified Professional in Health Care Management certification (CPHM), Certified Professional in Health Care Quality (CPHQ) or other health care or management certification. • Medicaid/Medicare population experience. • Clinical experience. • Supervisory/leadership experience. MCG experience. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $76,425 - $149,028 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
RN Manager/Supervisor Utilization Review Full-time
Personal Touch Home Aides of New York

(RN) Quality Review Manager- Registered Nurse

Personal Touch Home Aides of New York New York, NY
$90,000 - $105,000 / hour
(RN) Quality Review Manager- Registered Nurse Brooklyn, NY This a full time , in-person position based out of Brooklyn, NY . RN new grads are welcome . Pay: $90, 000- $105, 000/ annually About Us : With over 50 years of dedicated service to our communities, Personal Touch has been a trusted provider of home care. Our priority lies in ensuring exemplary patient care while fostering a supportive and empowering workplace culture for all team members. We are currently seeking compassionate and skilled nurses to join our team and continue our legacy of providing personalized and attentive care to patients in the comfort of their own home. Why Choose Us: At Personal-Touch Home Care, we are committed to creating a rewarding and fulfilling experience for our team members. Our established history and reputation provide a stable and trusted foundation for your career. Join us in positively impacting the lives of our patients and their families. As a member of our team, you will enjoy a wide range of benefits that enhance your overall well-being and support your career growth. They include: Employee Recognition Programs: We acknowledge and celebrate your contributions. Comprehensive Health Benefits: We offer an inclusive package with Medical, Dental, Vision, Accident, and Long-Term Disability Coverage to ensure access to quality medical care while promoting overall wellness. Generous Paid Time Off: We provide generous paid time off to ensure you can recharge and return to work refreshed, leading to greater productivity and job satisfaction. We support a healthy work-life balance. Retirement Benefits: We offer a 401k plan to secure your financial future and help you save for retirement. Life Insurance: We offer company paid life insurance providing peace of mind and financial protection for you and your loved ones. Opportunities for Professional Growth and Development: Empowering you to thrive and grow. Employee Assistance Program: Supporting the well-being of you and your family. Perks Program: Exclusive deals and offers on products, services, and experiences you need and love Job Details Overview: As a RN Clinical Manager/ Quality Review Manager , you will play a pivotal role in coordinating and managing patient care to ensure the highest standards are met. This position involves supervising clinical personnel and ensuring the delivery of quality home care services. Responsibilities: Receive case referrals and assess patient needs to assign appropriate clinicians. Review and evaluate each case, providing guidance to clinicians for effective performance. Instruct and guide clinicians to promote quality care delivery, being available to assist as needed. Review patient clinical information, including diagnosis, medications, and procedures. Assist in establishing therapeutic goals and developing care plans. Attend case conference meetings to facilitate care coordination. Conduct concurrent chart and record reviews and communicate findings to appropriate personnel. Assist in screening, interviewing, and orienting new personnel. Assist in planning and implementing in-service and continuing education programs. Contribute to the formulation, revision, and implementation of policies and procedures. Perform direct patient care duties as needed. Maintain compliance with professional standards and principles. 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. #NYRN
RN Utilization Review Full-time
Molina Healthcare

(RN)Care Review Clinician - Utilization Review (KY based- REMOTE)

Molina Healthcare Louisville, KY
$25.08 - $51.49 / hour
JOB DESCRIPTION Job Summary Provides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines. • Analyzes clinical service requests from members or providers against evidence based clinical guidelines. • Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. • Conducts reviews to determine prior authorization/financial responsibility for Molina and its members. • Processes requests within required timelines. • Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner. • Requests additional information from members or providers as needed. • Makes appropriate referrals to other clinical programs. • Collaborates with multidisciplinary teams to promote the Molina care model. • Adheres to utilization management (UM) policies and procedures. Required Qualifications • At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience. • Registered Nurse (RN). License must be active and unrestricted in state of practice. • Ability to prioritize and manage multiple deadlines. • Excellent organizational, problem-solving and critical-thinking skills. • Strong written and verbal communication skills. • Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications • Certified Professional in Healthcare Management (CPHM). To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $25.08 - $51.49 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
RN Utilization Review Full-time
Molina Healthcare

Care Review Clinician - Utilization Review (KY RN license- REMOTE)

Molina Healthcare Louisville, KY
$25.08 - $51.49 / hour
JOB DESCRIPTION Job Summary Provides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines. • Analyzes clinical service requests from members or providers against evidence based clinical guidelines. • Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. • Conducts reviews to determine prior authorization/financial responsibility for Molina and its members. • Processes requests within required timelines. • Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner. • Requests additional information from members or providers as needed. • Makes appropriate referrals to other clinical programs. • Collaborates with multidisciplinary teams to promote the Molina care model. • Adheres to utilization management (UM) policies and procedures. Required Qualifications • At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience. • Registered Nurse (RN). License must be active and unrestricted in state of practice. • Ability to prioritize and manage multiple deadlines. • Excellent organizational, problem-solving and critical-thinking skills. • Strong written and verbal communication skills. • Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications • Certified Professional in Healthcare Management (CPHM). To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $25.08 - $51.49 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
RN Utilization Review Internship
Children's Hospital Colorado

Registered Nurse Utilization Review Flex

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

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

Utilization Management Registered Nurse

NaphCare, Inc. Hoover, AL
Overview NaphCare is hiring experienced Utilization Management Registered Nurse just like you at the Corporate Office located in Birmingham, AL. NaphCare is a family owned, healthcare technology company that has been delivering high quality healthcare to correctional facilities across the nation for over 35 years. Come join our team of over 5000 employees and growing! NaphCare pays well, offers outstanding benefits, and has an incredibly engaged corporate support team to make sure you have what you need to be truly excellent at what you do. NaphCare partners with correctional facilities to provide proactive, patient-focused healthcare. NaphCare Full Time Benefits: Prescriptions free of charge through our health plan Health, dental & vision insurance that starts day one ! We offer low cost benefits to our employees and their families Employment Assistance Program (EAP) services 401K and Roth with company contribution that starts day one! Tuition Assistance Referral bonuses On-site education Free Continuing Education! Term life insurance at no cost to the employee Generous paid time off & paid holidays NaphCare has a partnership with NetCE that provides CEU/CME for our staff. NetCE uses a rigorous peer review process to ensure that all activities and content are up-to-date. This service streamlines continuing education for all NaphCare Employees to meet state specific requirements for maintaining licensing. With NaphCare, you'll play a critical role in our continuing mission to be the leading provider of quality healthcare in the correctional industry. If you want a career that will make a difference, choose the company that is different. We support your growth and internal promotion. Once hired, we encourage our employees to continue to seek opportunities for advancement and leadership. Responsibilities Responsibilities for Utilization Management Registered Nurse: Develop, implement, and administer the quality assurance and utilization review processes Monitor and report on the quality of all facets of the medical care provided to patients Perform utilization and concurrent review of patient cases Conduct detailed clinical chart assessments Gather clinical information to assess and expedite care needs Determine need, if any, for intervention, and discussing with physicians Reviews requests from providers regarding medical necessity of requested services for patients Reviews and audits patients' medical records as indicated to determine medical necessity Utilizes nationally recognized criteria to determine medical necessity of requested services Refers provider requests to Medical Director or designee when medical necessity of requested services does not meet recognized criteria Qualifications Qualifications for Utilization Management Registered Nurse: A current and unrestricted RN license in AL A minimum of 3 years’ experience in an acute care setting and 2 years’ experience in utilization review and/or case management Valid cpr card Excellent communication and interpersonal skills attention to detail and decision-making skills are essential BSN or ADN required. Some travel required. We know you may have questions before applying. To speak to a recruiter directly, email your questions and/or resume to CorporateHR@naphcare.com with the position and location you’re interested in. Equal Opportunity Employer: disability/veteran
RN Utilization Review Full-time
St. Joseph's Health

Utilization Management Registered Nurse

St. Joseph's Health Paterson, NJ
The Utilization Management Registered Nurse (UM RN) is responsible for evaluating the medical necessity, appropriateness, and efficiency of healthcare services in accordance with established criteria, regulatory requirements, and organizational role. The UM RN ensures optimal patient care delivery while supporting compliance, quality outcomes, and effective resource utilization. The role is responsible for the assessment of medical necessity, both for admission to the hospital as well as continued stay. This function ensures that services are not only appropriate but ensures that an authorization is obtained from the payer, if required, and that the documentation supports the care delivered in such a way that minimizes risks of denials.
LVN Utilization Review Full-time
Astrana Health

UM Review Nurse - LVN

Astrana Health Monterey Park, CA
$34 - $47 / hour
UM Review Nurse - LVN Department: HS - UM Employment Type: Full Time Location: 1600 Corporate Center Dr., Monterey Park, CA 91754 Reporting To: Phillip Vasquez Compensation: $34.00 - $47.00 / 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 UM 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 - $47.00 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 Full-time
Meadville Medical Center

REGISTERED NURSE-Utilization Management- Full Time- On Site

Meadville Medical Center Meadville, PA
$5,000 SIGN ON BONUS (for external candidates only) Utilization management (UM ) is the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of the applicable health benefits plan. Prior authorization that allow payers, particularly health insurance companies to manage the cost of health care benefits by assessing its appropriateness before it is provided using evidence-based criteria or guidelines. Strong utilization management process can reduce payment denials. Clinical documentation specialists is designed to improve the physician’s documentation in the patient’s medical record, supporting the appropriate severity of illness, expected risk of mortality and complexity of care of the patient. Clinical documentation is responsible for extensive collaboration with physician is, nursing staff, support staff, other patient caregiver and medical records coding staff. Employee insurance liaison Meadville Medical Center has self-funded insurance. One staff member is assigned to work with Human resources, Highmark Liaison, Medical director and employees. Set process is to call medical procedures out of network and employee needs to request a waiver from our current liaison. The liaison will review the requested procedure with our current medical director. If the request is approved the liaison of UM will notify the employee and out Highmark Liaison. Medical necessity rules will be reviewed, urgency and medical history. The decision will be called to the employee. If it is not favorable, this can be appealed to human resources If this process is not followed, and the employee gets a bill. The liaison will review what was performed. They will review with the medical director and make a decision to override the out of network rules. The liaison support HR represented as needed. Applicate: Curious and Detailed Oriented. Actively seek out new ideas, possibilities, and answers to the tough questions. Pays meticulous attention to detail. Committed to life-long learning UM Process Payors may use different criteria and may require their data set be applied for their population. Utilization management is a strategy for managing cost and quality under the latest CMS reimbursement Reviews precertification requests for medical necessity, referring to the Medical Director those that require additional expertise. Reviews Clinical information for concurrent reviews, extending the length of stay for inpatients as appropriate. Establishes effective rapport with other employees, professional support service staff, customers, clients, patient’s families and physicians. Use effective relationship management, coordination of services, resource management, education, patient advocacy and related interventions. CDS-Inpatients Advanced clinical expertise and extensive knowledge of complex disease processes with a broad clinical experience in an inpatient setting required Pursues a subsequent review of records every 3 days to support and assign a working DRG assignment upon discharge. Formulates queries when it is determined there is missing documentation, conflicting documentation or unclear documentation. Provides on-going education to physicians and essential healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the patient's record. Use of coding nomenclature demonstrated knowledge of ICD-10 classifications, and thorough understanding of the effect coded data has prospective payment, outcome models, utilization, and reimbursement. Participates in the analysis and trending of statistical data for specified patient population; identifies opportunity for improvement. Promotes a partnership with the inpatient-coding professionals to ensure the accuracy of principal diagnosis, procedures and completeness of supporting documentation to determine the working and final DRG, severity of illness and risk of mortality. Acts as a resource person for the interdisciplinary team in order to promote collaboration and coordination of patient care considering age specific, developmental, cultural, and spiritual needs of the patient. Overall department goals Promotes improved quality of care and/or life. Promotes cost effective medical outcomes. Prevents hospitalization when possible and appropriate. Promotes decreased lengths of observation stays or inpatient stays when appropriate. Provides for continuity of care. Assures appropriate levels of care are received by our patients. Participates in rounding on the nursing floors. Works with HIM on coding issues. Provides advice and counsel to precertification staff in physician offices or in house. Identifies appropriate alternative resources and demonstrate creativity in managing each case to fully utilize all available resources. Maintains accurate records of all communications and interventions. Other duties as assigned. MINIMUM EDUCATION, KNOWLEDGE, SKILLS, AND ABILITIES REQUIRED Proof of successful completion of education requirements for board certified registered nurse as defined by the state in which the employee is to practice as well as proof of such licensure in good standing. 5 years’ experience as a Registered Nurse is preferred. Ability to read analyze and interpret documents, reports, technical procedures, governmental regulations and correspondence BLS required. Certification for UM nurse and CDI specialists is encouraged.
RN Utilization Review Full-time
Molina Healthcare

(RN) Care Review Clinician- Utilization Review (Remote, MS based)

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

REGISTERED NURSE-Utilization Management- Full Time- On Site

Meadville Medical Center Meadville, PA
$5,000 SIGN ON BONUS (for external candidates only) Utilization management (UM ) is the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of the applicable health benefits plan. Prior authorization that allow payers, particularly health insurance companies to manage the cost of health care benefits by assessing its appropriateness before it is provided using evidence-based criteria or guidelines. Strong utilization management process can reduce payment denials. Clinical documentation specialists is designed to improve the physician’s documentation in the patient’s medical record, supporting the appropriate severity of illness, expected risk of mortality and complexity of care of the patient. Clinical documentation is responsible for extensive collaboration with physician is, nursing staff, support staff, other patient caregiver and medical records coding staff. Employee insurance liaison Meadville Medical Center has self-funded insurance. One staff member is assigned to work with Human resources, Highmark Liaison, Medical director and employees. Set process is to call medical procedures out of network and employee needs to request a waiver from our current liaison. The liaison will review the requested procedure with our current medical director. If the request is approved the liaison of UM will notify the employee and out Highmark Liaison. Medical necessity rules will be reviewed, urgency and medical history. The decision will be called to the employee. If it is not favorable, this can be appealed to human resources If this process is not followed, and the employee gets a bill. The liaison will review what was performed. They will review with the medical director and make a decision to override the out of network rules. The liaison support HR represented as needed. Applicate: Curious and Detailed Oriented. Actively seek out new ideas, possibilities, and answers to the tough questions. Pays meticulous attention to detail. Committed to life-long learning UM Process Payors may use different criteria and may require their data set be applied for their population. Utilization management is a strategy for managing cost and quality under the latest CMS reimbursement Reviews precertification requests for medical necessity, referring to the Medical Director those that require additional expertise. Reviews Clinical information for concurrent reviews, extending the length of stay for inpatients as appropriate. Establishes effective rapport with other employees, professional support service staff, customers, clients, patient’s families and physicians. Use effective relationship management, coordination of services, resource management, education, patient advocacy and related interventions. CDS-Inpatients Advanced clinical expertise and extensive knowledge of complex disease processes with a broad clinical experience in an inpatient setting required Pursues a subsequent review of records every 3 days to support and assign a working DRG assignment upon discharge. Formulates queries when it is determined there is missing documentation, conflicting documentation or unclear documentation. Provides on-going education to physicians and essential healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the patient's record. Use of coding nomenclature demonstrated knowledge of ICD-10 classifications, and thorough understanding of the effect coded data has prospective payment, outcome models, utilization, and reimbursement. Participates in the analysis and trending of statistical data for specified patient population; identifies opportunity for improvement. Promotes a partnership with the inpatient-coding professionals to ensure the accuracy of principal diagnosis, procedures and completeness of supporting documentation to determine the working and final DRG, severity of illness and risk of mortality. Acts as a resource person for the interdisciplinary team in order to promote collaboration and coordination of patient care considering age specific, developmental, cultural, and spiritual needs of the patient. Overall department goals Promotes improved quality of care and/or life. Promotes cost effective medical outcomes. Prevents hospitalization when possible and appropriate. Promotes decreased lengths of observation stays or inpatient stays when appropriate. Provides for continuity of care. Assures appropriate levels of care are received by our patients. Participates in rounding on the nursing floors. Works with HIM on coding issues. Provides advice and counsel to precertification staff in physician offices or in house. Identifies appropriate alternative resources and demonstrate creativity in managing each case to fully utilize all available resources. Maintains accurate records of all communications and interventions. Other duties as assigned. MINIMUM EDUCATION, KNOWLEDGE, SKILLS, AND ABILITIES REQUIRED Proof of successful completion of education requirements for board certified registered nurse as defined by the state in which the employee is to practice as well as proof of such licensure in good standing. 5 years’ experience as a Registered Nurse is preferred. Ability to read analyze and interpret documents, reports, technical procedures, governmental regulations and correspondence BLS required. Certification for UM nurse and CDI specialists is encouraged.