Utilization Review Nurse Jobs

RN Utilization Review Full-time
TidalHealth

Registered Nurse (RN)- Utilization Review

TidalHealth Salisbury, MD
Why work at TidalHealth? Looking for a rewarding place to work? Choose TidalHealth. U.S. News & World Report, a global authority in hospital rankings and consumer advice, has named TidalHealth Peninsula Regional and TidalHealth Nanticoke as 2022-2023 High Performing hospitals for 11 challenging and elective health conditions; the highest award a hospital can earn for U.S. News’ Best Hospitals Procedures & Conditions ratings. Located just 30 minutes from the beach, TidalHealth offers the widest array of specialty and subspecialty services such as neurosurgery, cardiothoracic surgery, joint replacement, emergency/trauma care, comprehensive cancer care, wound care and clinical trials and research. Take advantage of our tuition assistance and scholarship programs to grow both personally and professionally. Utilization Review RN Position Summary The Utilization Review – RN is a registered nurse who is responsible for facilitating appropriate lengths of stay and reimbursement for all hospital admissions in accordance with its goals and objectives. Acts as the key information and education resource for the interdisciplinary team. Works to develop organization-wide approaches to problem solving. Analyzes current systems and variances to identify opportunities for improvement. Works to promote quality of care through collaboration with all service team members, patients, and families. Works with the leadership team to align the goals and visions. It is essential for RN to have general knowledge of payor industry, resource management and evidence-based clinical practice. Theoretical knowledge of the nursing and case management processes. Utilization Review RN Position Requirements Current and valid license to practice as a RN BSN preferred Accreditation preferred 3 or more years of strong clinical experience Interqual or Milliman criteria preferred Excellent interpersonal communication and negotiation skills Strong analytical, data management and PC skills Current working knowledge of discharge planning, utilization management, case management, performance improvement and managed care reimbursement Ability to work independently and exercise sound judgment in interactions with patients, families, providers and payo rs. Utilization Review RN Benefits At TidalHealth, team members working at least 36 hours per pay period based on 12-hour shift schedules or at least 37.5 hours for non 12-hour shift schedules and part-time team members working at least 30 hours or more on weekends only are eligible for benefits. Benefits include medical, prescription, vision, dental, flexible spending accounts, disability insurance plans, life insurance, paid time off plans, retirement plans, tuition assistance, employee assistance, and access to on-site childcare and a credit union.
RN Utilization Review Full-time
The Christ Hospital Health Network

Utilization Review Nurse-RN - Main Case Management - Full Time

The Christ Hospital Health Network Cincinnati, OH
Job Description To maintain high-quality, medically necessary, evidence-based care, and efficient treatment of all patients, regardless of payment source, by ensuring the patients receive the right care, at the right time, in the right place. Case Management Model: utilize an Integrated Case Management Model. Under this model the Case Managers will follow patients through the continuum while facilitating the functions of utilization review, utilization management, and cost containment. Track and trend denials and payor issues to provide feedback and education to payer relations and the case management department. Responsibilities Clinical review of 100% acute bedded patients admitted to Inpatient or Observation status at The Christ Hospital against medical necessity criteria (Interqual and MCG) for appropriateness of admission. Demonstrate understanding of evidenced based medical necessity criteria. Maintains efficient methods of ensuring the medical necessity and appropriateness of all hospital admissions. Identify/facilitate patient status from observation to inpatient as patient clinical condition warrants. Compliance with all Medicare regulatory requirements Work with external payers completing/securing authorization for all services provided. Monitors cases for appropriateness of continued stay, level of care and services, and quality of care using approved screening criteria. Communicate with physicians when alternatives to inpatient care are indicated by clinical review. Identify cases needed for second level of review- refers cases to the Physician Advisor that do not meet established guidelines for admission or continued stay. Consistent collaboration with the RN Case Manager to prevent extended length of stays and appropriate status determination. Identifies potential delays in service or treatment and refers to the appropriate individuals within the multidisciplinary patient care teams for action/resolution. Track and trends avoidable day information in Midas per process. Identifies problems related to the quality of patient care and refers such problems to the Performance Improvement Department. Adherence to department productivity standards. Initial, concurrent, and retro reviews should be completed timely including all necessary information for approval of claims. All reviews should contain information only pertinent to IS/SI (Intensity of Service/Severity of Illness). Compliance with documentation methods for monthly reporting and statistics for presentation to the Utilization Review Committee. Interfaces with patient registration and patient financial services etc. to collaborate on financial issues. Establish an effective rapport and relationship with third party payers to promote cost effective clinical outcomes. Assist in denial and appeal process Performs other duties as assigned, including but not limited to: Demonstrates professional responsibility required for a Utilization Review Nurse Complies with department and hospital policies at all times Maintains compliance with State/Federal Guidelines and standards Conforms to all requirements of Medicare Keep current on changing laws and requirements of Medicare Demonstrate a positive attitude at all times Qualifications KNOWLEDGE AND SKILLS: Please describe any specialized knowledge or skills, which are REQUIRED to perform the position duties. Do not personalize the job description, credentials, or knowledge and skills based on the current associate. List any special education required for this position. EDUCATION: Bachelor’s Degree. Graduate of an accredited school of nursing with current licensure OR actively enrolled in a BSN program with completion date within 3 years of hire date and a graduate of an accredited school of nursing with current licensure. YEARS OF EXPERIENCE: 3-5 years of medical/surgical nursing necessary and a minimum of 3 years of utilization review experience required. REQUIRED SKILLS AND KNOWLEDGE: Experience with case management, utilization review, and discharge planning that is related to the clinical or operational functional areas. Knowledge and application of a wide variety of advanced case management tools and methods. Knowledge of clinical and operations research methodology and design. Proficient in state of the art business trends, benchmarking, and case management tools and techniques. Ability to operate PC based software programs or automated database management systems. Expertise in meeting regulatory and accreditation requirements. Strong presentation, written and oral communication skills, with strong analytical and problem-solving skills as well as time/project management skills. Ability to work with a variety of disciplines and levels of staff across departments and the organization is required. LICENSES & CERTIFICATIONS: Licensed to practice in the State of Ohio Certified Case Management (CCM) or Accredited Case Management (ACM) preferred.
RN Utilization Review Full-time
Molina Healthcare

Care Review Clinician- Inpatient Utilization Review (RN-CA License)

Molina Healthcare Long Beach, CA
$30.37 - $59.21 / 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. 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: $30.37 - $59.21 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
RN Utilization Review Full-time
The Christ Hospital Health Network

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

The Christ Hospital Health Network Cincinnati, OH
Job Description To maintain high-quality, medically necessary, evidence-based care, and efficient treatment of all patients, regardless of payment source, by ensuring the patients receive the right care, at the right time, in the right place. Case Management Model: utilize an Integrated Case Management Model. Under this model the Case Managers will follow patients through the continuum while facilitating the functions of utilization review, utilization management, and cost containment. Track and trend denials and payor issues to provide feedback and education to payer relations and the case management department. Responsibilities Clinical review of 100% acute bedded patients admitted to Inpatient or Observation status at The Christ Hospital against medical necessity criteria (Interqual and MCG) for appropriateness of admission. Demonstrate understanding of evidenced based medical necessity criteria. Maintains efficient methods of ensuring the medical necessity and appropriateness of all hospital admissions. Identify/facilitate patient status from observation to inpatient as patient clinical condition warrants. Compliance with all Medicare regulatory requirements Work with external payers completing/securing authorization for all services provided. Monitors cases for appropriateness of continued stay, level of care and services, and quality of care using approved screening criteria. Communicate with physicians when alternatives to inpatient care are indicated by clinical review. Identify cases needed for second level of review- refers cases to the Physician Advisor that do not meet established guidelines for admission or continued stay. Consistent collaboration with the RN Case Manager to prevent extended length of stays and appropriate status determination. Identifies potential delays in service or treatment and refers to the appropriate individuals within the multidisciplinary patient care teams for action/resolution. Track and trends avoidable day information in Midas per process. Identifies problems related to the quality of patient care and refers such problems to the Performance Improvement Department. Adherence to department productivity standards. Initial, concurrent, and retro reviews should be completed timely including all necessary information for approval of claims. All reviews should contain information only pertinent to IS/SI (Intensity of Service/Severity of Illness). Compliance with documentation methods for monthly reporting and statistics for presentation to the Utilization Review Committee. Interfaces with patient registration and patient financial services etc. to collaborate on financial issues. Establish an effective rapport and relationship with third party payers to promote cost effective clinical outcomes. Assist in denial and appeal process Performs other duties as assigned, including but not limited to: Demonstrates professional responsibility required for a Utilization Review Nurse Complies with department and hospital policies at all times Maintains compliance with State/Federal Guidelines and standards Conforms to all requirements of Medicare Keep current on changing laws and requirements of Medicare Demonstrate a positive attitude at all times Qualifications KNOWLEDGE AND SKILLS: Please describe any specialized knowledge or skills, which are REQUIRED to perform the position duties. Do not personalize the job description, credentials, or knowledge and skills based on the current associate. List any special education required for this position. EDUCATION: Bachelor’s Degree. Graduate of an accredited school of nursing with current licensure OR actively enrolled in a BSN program with completion date within 3 years of hire date and a graduate of an accredited school of nursing with current licensure. YEARS OF EXPERIENCE: 3-5 years of medical/surgical nursing necessary and a minimum of 3 years of utilization review experience required. REQUIRED SKILLS AND KNOWLEDGE: Experience with case management, utilization review, and discharge planning that is related to the clinical or operational functional areas. Knowledge and application of a wide variety of advanced case management tools and methods. Knowledge of clinical and operations research methodology and design. Proficient in state of the art business trends, benchmarking, and case management tools and techniques. Ability to operate PC based software programs or automated database management systems. Expertise in meeting regulatory and accreditation requirements. Strong presentation, written and oral communication skills, with strong analytical and problem-solving skills as well as time/project management skills. Ability to work with a variety of disciplines and levels of staff across departments and the organization is required. LICENSES & CERTIFICATIONS: Licensed to practice in the State of Ohio Certified Case Management (CCM) or Accredited Case Management (ACM) preferred.
RN Utilization Review Full-time
OSF HealthCare

RN Utilization Management & Review Spec

OSF HealthCare Urbana, IL
Total Rewards "Your life - our Mission" OSF HealthCare is dedicated to provide Mission Partners with a comprehensive and market-competitive total rewards package that includes benefits, compensation, recognition and well-being offerings that focus on the whole person and engage with their current stage of life and career. Click here to learn more about benefits and the total rewards at OSF. Pay range for this position is $34.25 - $51.13/hour. Actual pay is based on years of licensure. This is a Salaried position. Overview POSITION SUMMARY: The Utilization Management and Review Specialist (UMR Specialist) evaluates patient care and activities against objective criteria in an effort to take a proactive approach in addressing appropriate admission status of each patient. In addition the UMR Specialist will identify utilization issues involving under or over utilization of services, resolves and/or refers utilization issues in accordance with established procedures. Reviews medical records to determine appropriateness and medical necessity of admission and hospital stay and use of ancillary services. Behavioral Health: This position supports the Behavioral health department at OSF Sacred Heart Medical Center-Urbana Qualifications REQUIRED QUALIFICATIONS: Education: Bachelor's Degree in Nursing must be obtained within 3 years of date of hire into role. Experience: 2 years of clinical experience in an acute care or managed care setting Licensure/Certifications: Current state license as Registered Nurse (IL) Other skills/knowledge: Working knowledge of clinical EMR system PREFERRED QUALIFICATIONS: Education: Bachelor's Degree in Nursing Other Skills/Knowledge: Working knowledge of Microsoft Office applications OSF HealthCare is an Equal Opportunity Employer.
RN Utilization Review Full-time
Molina Healthcare

Care Review Clinician (RN)

Molina Healthcare Phoenix, AZ
$26.41 - $51.49 / hour
Job Summary Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service. This position will support the Arizona state Plan. We are seeking a candidate with an Arizona RN licensure. The ideal candidate will have experience with UM and prior authorization with both inpatient and outpatient. Candidates with a Behavioral Health background are highly preferred. Further details to be discussed during our interview process. Remote position, must reside in Arizona. Work hours: Monday - Friday 8:30am- 5:00pm Mountain Time with some weekends and holidays. KNOWLEDGE/SKILLS/ABILITIES Assesses inpatient services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and 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 inpatient reviews to determine financial responsibility for Molina Healthcare and its members. May also perform prior authorization reviews and/or related duties as needed. Processes requests within required timelines. Refers appropriate cases to Medical Directors and presents them in a consistent and efficient manner. Requests additional information from members or providers in consistent and efficient manner. Makes appropriate referrals to other clinical programs. Collaborates with multidisciplinary teams to promote Molina Care Model. Adheres to UM policies and procedures. Occasional travel to other Molina offices or hospitals as requested, may be required. This can vary based on the individual State Plan. 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: $26.41 - $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
Texas Health and Human Services

Utilization Review Nurse

Texas Health and Human Services San Antonio, TX
$4,801.16 - $7,761.50 / month
Join the Texas Health and Human Services Commission (HHSC) and be part of a team committed to creating a positive impact in the lives of fellow Texans. At HHSC, your contributions matter, and we support you at each stage of your life and work journey. Our comprehensive benefits package includes 100% paid employee health insurance for full-time eligible employees, a defined benefit pension plan, generous time off benefits, numerous opportunities for career advancement and more. Explore more details on the Benefits of Working at HHS webpage . Functional Title: Utilization Review Nurse Job Title: Nurse II Agency: Health & Human Services Comm Department: UR Wav & Comm Srvs Ran Mmt St Posting Number: 15113 Closing Date: 09/23/2026 Posting Audience: Internal and External Occupational Category: Healthcare Practitioners and Technical Salary Range: $4,801.16 - $7,761.50 Pay Frequency: Monthly Salary Group: TEXAS-B-22 Shift: Day Additional Shift: Days (First) Telework: Travel: Up to 75% Regular/Temporary: Regular Full Time/Part Time: Full time FLSA Exempt/Non-Exempt: Exempt Facility Location: Job Location City: SAN ANTONIO Job Location Address: 1067 BANDERA RD Other Locations: Weslaco MOS Codes: 290X,46AX,46FX,46NX,46PX,46SX,46YX,66B,66C,66E,66F,66G,66H,66N,66P,66R,66S,66T,66W Nurse II The Texas Health and Human Services Commission (HHSC) Medicaid CHIP Services (MCS) department seeks a highly qualified candidate to fill the position of Nurse II. MCS is driven by its mission to deliver quality, cost-effective services to Texans. This position makes a significant contribution to MCS’s mission by ensuring individuals served in our 1915(c) waiver programs and Community Attendant Services (CAS) receive the appropriate type and amount of service. The ideal candidate thrives in an environment that emphasizes teamwork to achieve goals, excellence through high professional standards and personal accountability, curiosity to continuously grow and learn, critical thinking for effective execution, and integrity to do things right even when what is right is not easy. Under the direct supervision of the Utilization Review Nurse Manager, the utilization review (UR) nurse: reviews and evaluates individual's records, individual service plans (ISPs), patient assessments, documentation related to Title XIX and Title XX, and state plan Medicaid community services for aged and disabled persons and individuals with intellectual and developmental disabilities (IDD); and conducts face to face interviews with individuals enrolled in the Community Attendant Services (CAS), Community Living Assistance and Support Services (CLASS), Deaf Blind with Multiple Disabilities (DBMD), Home and Community-based Services (HCS), and Texas Home Living (TxHmL) programs to determine service justification. Based on the in-person, teleconference or telephone interview assessment, desk review and evaluation of services, the UR nurse uses program knowledge and nursing expertise to determine appropriateness and quality of services, cost effectiveness of the service plan, validates determinations of health service needs, and makes service authorization decisions. The UR nurse conducts a variety of quality assurance reviews, and quality improvement studies. The UR nurse evaluates assigned Level of Need (LON) determinations in the IDD waiver programs when assigned to do so. This position works collaboratively with other UR nurses and regional staff to implement an effective statewide UR program and to ensure UR policies and procedures are applied consistently. This position works under the general supervision of the UR Nurse Manager, with moderate latitude for use of initiative and independent judgment. Essential Job Functions: Attends work on a regular and predictable schedule in accordance with agency leave policy and performs other duties as assigned. Conducts desk reviews of required documentation for Health and Human Services Commission (HHSC), Medicaid Long Term Care Waiver Programs and Community Attendant Services (CAS). Participates in onsite, televideo, or telephonic interviews of the individuals identified in the random sample. Reviews, evaluates, and documents services provided to aged and disabled persons and persons with intellectual disability to validate service needs, service provision, determines appropriateness, quality, and cost effectiveness of services. (35%) Makes service authorization decisions on difficult, complicated, and/or targeted cases. (20%) Conducts a variety of quality assurance reviews and quality improvement studies and evaluates compliance with Medicaid program service requirements, state rules, regulations, policies, and procedures. (10%) Works collaboratively with other UR nurses through routine and ad hoc meetings to implement an effective statewide UR program and to ensure UR policies and procedures are applied consistently. (10%) Develops, provides resources and technical assistance to regional staff and providers. (10%) Testifies as the Subject Matter Expert (SME) in Medicaid fair hearings related to appealed service reductions or denials. (5%) Produces routine and specialized data and information for program reports. (5%) Works collaboratively across MCS to identify innovative and effective solutions for clients and staff (5%) Registrations, Licensure Requirements or Certifications: Must be licensed as a professional Registered Nurse (RN) in the state of Texas or a state that recognizes reciprocity through the Nurse Licensure Compact. Qualification as a Qualified Intellectual Disability Professional (QIDP) as defined in 42 Code of Federal Regulations 483.430(a) required. Must have a valid Texas Driver License. Knowledge Skills Abilities: Meets the criteria for designation as a Qualified Intellectual Disability Professional (QIDP) as defined in 42 Code of Federal Regulations 483.430(a) required. Knowledge of nursing health care laws, rules, standards, and regulations, medical diagnoses and procedures, community health and nursing care principles, quality management, utilization management, health care needs and services for elderly and disabled. Thorough knowledge of ID and other developmental disability related conditions, HCS, TxHmL, CLASS, DBMD, CAS, and ICF/ID program rules, service array and billing guidelines, local authority functions and waiver service system. Written and verbal communication skills necessary to consult, teach, and provide clear and concise directions and reports. Awareness of federal and state laws relating to long term care and other Medicaid and non-Medicaid services and programs. Knowledge of program planning, implementation and evaluation, and continuous quality improvement. Ability to communicate effectively, both orally and in writing. Ability to interpret statistical information. Ability to multi-task, handle stress and meet deadlines. Ability to work collaboratively across MCS to accomplish objectives. A keen attention to detail and the ability to implement creative solutions to problems. Able to balance team and individual responsibilities. Written and verbal communication skills necessary to consult, teach, and provide clear and concise directions and reports. Ability to: explain and interpret applicable health laws, rules, standards, and regulations; recognize patterns of medical necessity treatment, fraud, abuse, and neglect; use a personal computer, copier, Microsoft Office suite and Outlook e-mail; travel throughout the state as necessary. Initial Screening Criteria: Two-year experience working as a Registered Nurse (RN). Graduation from an accredited four-year college or university with major course work in nursing preferred, or from an accredited nursing program. BSN preferred, experience and education may be substituted for one another. Must meet the federal definition of a Qualified Intellectual and Developmental Disability Professional as defined in 42 Code of Federal Regulations 483.430(a). Must have at least one year of experience working directly with persons with intellectual disability or other developmental disabilities. Must be able to travel 75% of the time. Experience in utilization review, or quality assurance activities in long term services and supports for the aged and disabled preferred. Review our Tips for Success when applying for jobs at DFPS, DSHS and HHSC . Active Duty, Military, Reservists, Guardsmen, and Veterans : Military occupation(s) that relate to the initial selection criteria and registration or licensure requirements for this position may include, but not limited to those listed in this posting. All active-duty military, reservists, guardsmen, and veterans are encouraged to apply if qualified to fill this position. For more information please see the Texas State Auditor’s Job Descriptions, Military Crosswalk and Military Crosswalk Guide at Texas State Auditor's Office - Job Descriptions . ADA Accommodations: In compliance with the Americans with Disabilities Act (ADA), HHSC and DSHS agencies will provide reasonable accommodation during the hiring and selection process for qualified individuals with a disability. If you need assistance completing the on-line application, contact the HHS Employee Service Center at 1-888-894-4747. If you are contacted for an interview and need accommodation to participate in the interview process, please notify the person scheduling the interview. Pre-Employment Checks and Work Eligibility: Depending on the program area and position requirements, applicants selected for hire may be required to pass background and other due diligence checks. HHSC uses E-Verify. You must bring your I-9 documentation with you on your first day of work. Download the I-9 Form Telework Disclaimer: This position may be eligible for telework. Please note, all HHS positions are subject to state and agency telework policies in addition to the discretion of the direct supervisor and business needs.
LPN Utilization Review Full-time
Guthrie

LPN Licensed Practical Nurse - Utilization Mgmt Reviewer (Case Mgmnt) - Full Time

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

Utilization Review RN

Swedish Health Services Seattle, WA
$52.26 - $81.13 / hour
Description The Utilization Review (UR) Nurse has a strong clinical background blended with a well-developed knowledge and skills in Utilization Management (UM), medical necessity and patient status determination. This individual supports the UM program by developing and maintaining effective, efficient processes for determining the appropriate admission status based on regulatory and reimbursement requirements of commercial and government payers. Providence caregivers are not simply valued – they’re invaluable. Join our team at Swedish Shared Services and thrive in our culture of patient-focused, whole-person care built on understanding, commitment, and mutual respect. Your voice matters here, because we know that to inspire and retain the best people, we must empower them. Required Qualifications Bachelor's Degree in Nursing degree (BSN) from an accredited school of nursing. Upon hire: Washington Registered Nurse License 3 years of Registered nursing experience in the clinical setting. Preferred Qualifications Upon hire: ACM or CCM certification 1 year of Case management experience. Why Join Providence? Our best-in-class benefits are uniquely designed to support you and your family in staying well, growing professionally and achieving financial security. We take care of you, so you can focus on delivering our mission of improving the health and wellbeing of each patient we serve. About Providence At Providence, our strength lies in Our Promise of “Know me, care for me, ease my way.” Working at our family of organizations means that regardless of your role, we’ll walk alongside you in your career, supporting you so you can support others. We provide best-in-class benefits and we foster an inclusive workplace where diversity is valued, and everyone is essential, heard and respected. Together, our 120,000 caregivers (all employees) serve in over 50 hospitals, over 1,000 clinics and a full range of health and social services across Alaska, California, Montana, New Mexico, Oregon, Texas and Washington. As a comprehensive health care organization, we are serving more people, advancing best practices and continuing our more than 100-year tradition of serving the poor and vulnerable. Posted are the minimum and the maximum wage rates on the wage range for this position. The successful candidate's placement on the wage range for this position will be determined based upon relevant job experience and other applicable factors. These amounts are the base pay range; additional compensation may be available for this role, such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities. Providence offers a comprehensive benefits package including a retirement 401(k) Savings Plan with employer matching, health care benefits (medical, dental, vision), life insurance, disability insurance, time off benefits (paid parental leave, vacations, holidays, health issues), voluntary benefits, well-being resources and much more. Learn more at providence.jobs/benefits. Applicants in the Unincorporated County of Los Angeles: Qualified applications with arrest or conviction records will be considered for employment in accordance with the Unincorporated Los Angeles County Fair Chance Ordinance for Employers and the California Fair Chance Act. About The Team Providence Swedish is the largest not-for-profit health care system in the greater Puget Sound area. It is comprised of eight hospital campuses (Ballard, Edmonds, Everett, Centralia, Cherry Hill (Seattle), First Hill (Seattle), Issaquah and Olympia); emergency rooms and specialty centers in Redmond (East King County) and the Mill Creek area in Everett; and Providence Swedish Medical Group, a network of 190+ primary care and specialty care locations throughout the Puget Sound. Whether through physician clinics, education, research and innovation or other outreach, we’re dedicated to improving the wellbeing of rural and urban communities by expanding access to quality health care for all. Providence is proud to be an Equal Opportunity Employer. We are committed to the principle that every workforce member has the right to work in surroundings that are free from all forms of unlawful discrimination and harassment on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law. We believe diversity makes us stronger, so we are dedicated to shaping an inclusive workforce, learning from each other, and creating equal opportunities for advancement. For any concerns with this posting relating to the posting requirements in RCW 49.58.110(1), please click here where you can access an email link to submit your concern. Requsition ID: 426352 Company: Swedish Jobs Job Category: Health Information Management Job Function: Revenue Cycle Job Schedule: Full time Job Shift: Day Career Track: Nursing Department: 3900 SS CASE MANAGEMENT Address: WA Seattle 217 Broadway E Work Location: Swedish Capital Hill-Seattle Workplace Type: On-site Pay Range: $52.26 - $81.13 The amounts listed are the base pay range; additional compensation may be available for this role, such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities.
RN Utilization Review Full-time
Capital Health

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

Capital Health Hopewell, VA
$39.40 - $51.47 / hour
Capital Health is the region's leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advanced technology. Capital Health is a dynamic health care resource accredited by the DNV that includes two hospitals, an outpatient center, satellite ED, and an expansive network of primary and specialty care. Capital Health Medical Group is made up of more than 600 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region. Capital Health recognizes that attracting the best talent is key to our strategy and success as an organization. As a result, we aim for flexibility in structuring competitive compensation offers to ensure we can attract the best candidates. The listed pay range or pay rate reflects compensation for a full-time equivalent (1.0 FTE) position. Actual compensation may differ depending on assigned hours and position status (e.g., part-time). Pay Range: $39.40 - $51.47 Scheduled Weekly Hours: 40 Position Overview Performs chart review of identified patients to identify quality, timeliness and appropriateness of patient care. Conducts admission reviews for Medicare, Medicaid beneficiaries, as well as private insurers and self pay patients, based on appropriate guidelines. Uses these criteria guidelines to screen for appropriateness for inpatient level of care or observation services based on physician certification (physicians H&P, treatment plan, potential risks and basis for expectation of a 2 midnight stay). Refers cases as appropriate, to the UR physician advisor for review and determination. Gathers clinical information to conduct continued stay utilization review activities with payers on a daily basis. Performs concurrent and retrospective clinical reviews with various payers, utilizing the appropriate guidelines as demonstrated by compliance with all applicable regulations, policies and timelines. Adheres to CMS guidelines for utilization reviews as evidenced by utilization of the relevant guidelines and appropriate referrals to the physician advisor and the UR Committee. Identifies, develops and implements strategies to reduce length of stay and resource consumption. . Confers proactively with admitting physician to provide coaching on accurate level of care determinations at point of hospital entry. Keeps current on all regulatory changes that affect delivery or reimbursement of acute care services. Uses knowledge of national and local coverage determinations to appropriately advise physicians. Understands and applies federal law regarding the use of Hospital Initiated Notice of Non-Coverage (HINN) and Lifetime Reserve Days letters. Identifies and records consistently any information on any progression of care or patient flow barriers using the Avoidable Days tool in the Utilization software program. Consults with medical staff, care team and case managers as necessary to resolve immediate progression of care barriers through appropriate administrative and medical channels. Engages care team colleagues in collaborative problem solving regarding appropriate utilization of resources. Recognizes and responds appropriately to patient safety and risk factors. Represents Utilization Management at various committees, professional organizations an physician groups as needed. Promotes the use of evidence based protocols and or order sets to influence high quality and cost effective care. Identifies, develops and implements strategies to reduce lengths of stay and resource consumption in the patient population. Participates in performance improvement activities. Promotes medical documentation that accurately reflects findings and interventions, presence of complication or comorbidities, and patient's need for continued stay. Identifies and records episodes of preventable delays or avoidable days due to failure of progression of care processes. Maintains appropriate documentation in the Utilization software system on each patient to include specific information of all resource utilization activities. Participates actively in daily huddles, patient care conferences, and hospitalist or nurse handoff reports to maintain knowledge about intensity of services and the progression of care. Identifies potentially wasteful or misused resources and recommends alternatives if appropriate by analyzing clinical protocols. Maintains related continuing education credits = 15 per calendar year. MINIMUM REQUIREMENTS Education: Minimum of Associate's degree in Nursing. Graduate of an accredited school of nursing. CPHQ, CCM or CPUR preferred. Experience: Three years of clinical nursing or two years quality management, utilization review or discharge planning experience. Other Credentials: Registered Nurse - NJ Knowledge and Skills: Three years of clinical nursing or two years quality management, utilization review or discharge planning experience. CPHQ, CCM or CPUR preferred. Special Training: Basic computer skills including the working knowledge of Microsoft Office, UR software and EMR. Possesses familiarity with MCG guidelines. Mental, Behavioral and Emotional Abilities: Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form. Usual Work Day: 8 Hours PHYSICAL DEMANDS AND WORK ENVIRONMENT Frequent physical demands include: Sitting , Standing , Walking Occasional physical demands include: Climbing (e.g., stairs or ladders) , Carry objects , Push/Pull , Twisting , Bending , Reaching forward , Reaching overhead , Keyboard use/repetitive motion , Talk or Hear Continuous physical demands include: Lifting Floor to Waist 10 lbs. Lifting Waist Level and Above 5 lbs. Sensory Requirements include: Accurate Near Vision, Accurate Far Vision, Accurate Color Discrimination, Accurate Depth Perception, Accurate Hearing Anticipated Occupational Exposure Risks Include the following: N/A This position is eligible for the following benefits: Medical Plan Prescription drug coverage & In-House Employee Pharmacy Dental Plan Vision Plan Flexible Spending Account (FSA) - Healthcare FSA - Dependent Care FSA Retirement Savings and Investment Plan Basic Group Term Life and Accidental Death & Dismemberment (AD&D) Insurance Supplemental Group Term Life & Accidental Death & Dismemberment Insurance Disability Benefits – Long Term Disability (LTD) Disability Benefits – Short Term Disability (STD) Employee Assistance Program Commuter Transit Commuter Parking Supplemental Life Insurance - Voluntary Life Spouse - Voluntary Life Employee - Voluntary Life Child Voluntary Legal Services Voluntary Accident, Critical Illness and Hospital Indemnity Insurance Voluntary Identity Theft Insurance Voluntary Pet Insurance Paid Time-Off Program The pay range listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future. When determining base salary and/or rate, several factors may be considered including, but not limited to location, years of relevant experience, education, credentials, negotiated contracts, budget, market data, and internal equity. Bonus and/or incentive eligibility are determined by role and level. The salary applies specifically to the position being advertised and does not include potential bonuses, incentive compensation, differential pay or other forms of compensation, compensation allowance, or benefits health or welfare. Actual total compensation may vary based on factors such as experience, skills, qualifications, and other relevant criteria.
RN Utilization Review Full-time
Emanate Health

Quality Review Nurse - DOU & NSU - Full Time - Days - 10hr QVH

Emanate Health Walnut Valley, CA
$54.63 - $84.67 / hour
Current Emanate Health Employees - Please log into your Workday account to apply Everyone at Emanate Health plays a vital role in the care we deliver. No matter what department you belong to, the work you do at Emanate Health affects lives. When you join Emanate Health, you become part of a team that works together to strengthen our communities and grow as individuals. On Glassdoor's list of "Best Places to Work" in 2021, Emanate Health was named the #1 ranked health care system in the United States, and the #19 ranked company in the country. J ob S u mma r y Provides expertise to the organization in the form of quality management review and performance improvement knowledge. Supports the hospital units and staff in preparation for surveys, clinical documentation review, regulatory needs and rounding on patients with discharge calls. Assists in the review process and peer education/correction. J ob Re q u i reme nts M ini m um E du ca ti o n Re qui reme nt : BSN preferred. M i n i m um E x p er i e n c e Re qui reme nt : Minimum of three years of acute care experience. Excellent customer service skills required. Experience in Telemetry, DOU, or Neuroscience preferred M ini m um Li ce n s e Re qui reme nt : California RN license and BLS required. ACLS required within 90 days of hire or transfer. NIHSS Stroke Certification required within 90 days of hire or transfer. Delivering world-class health care one patient at a time. Pay Range: $54.63 - $84.67
RN Utilization Review Full-time
University of Rochester Medical Center

RN, Utilization Management

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

Supervisor, Clinical Review Nurse

TurningPoint Healthcare Solutions Lake Mary, FL
Position: Supervisor, Clinical Review Nurse Location: Any Job Id: 694-TBD # of Openings: 1 Job Description TurningPoint is an innovative healthcare services and technology organization that is committed to working with Health Plans and Providers to develop advanced technical and clinical solutions that improve the quality and affordability of surgical care patients receive. We are seeking a highly motivated and results orientated Nurse Supervisor to join our fast-paced and rapidly growing company. Primary Responsibilities This position is responsible for Utilization Management (UM) activities, including but not limited to the supervision of UM and Prior Authorization clinical team processes. This individual develops, implements, supports and promotes managed care strategies, policies and programs that drive the delivery of quality healthcare. Providing leadership and demonstrating responsibility and accountability for the delivery of quality services to a team of clinical staff Reviewing pre-authorization requests for appropriateness of care within established evidence-based criteria sets Interacting with other TurningPoint personnel to assure quality customer service is provided. Acting as an internal resource by answering questions requiring clinical interpretation Identifying high cost utilization and making appropriate referral Assisting the Director of Utilization Management in developing guidelines and procedures for the department Skills, Education & Experience Requirements An active and unrestricted Registered Nurse (RN) Associate’s Degree is required. Bachelor of Science in Nursing (BSN) Degree is preferred Five (5) years of clinical experience; or any combination of education and experience, which would provide an equivalent background Experience in surgical utilization review, pain management, case management, or health insurance pre-authorization and/or utilization management Minimum of 3 years experience Supervising and Managing a team of clinical and non-clinical staff members Ability to function effectively in an interdisciplinary team that includes physicians, nurses, other healthcare personnel and administrative staff Ability to work independently with minimal supervision Ability to organize, prioritize and complete work in a timely manner despite many deadlines and competing priorities Benefits TurningPoint offers a number of benefits to full-time employees including, but not limited to: medical, dental, vision, disability, life, PTO. All employees, age 21 and over, are eligible to participate in the 401(k)-retirement savings plan. Job Type: Full-time Apply for this Position
RN Utilization Review Full-time
University of Miami Health System

Utilization Case Manager RN (H)

University of Miami Health System Miami, FL
Current Employees: If you are a current Staff, Faculty or Temporary employee at the University of Miami, please click here to log in to Workday to use the internal application process. To learn how to apply for a faculty or staff position, please review this tip sheet . CORE JOB SUMMARY The purpose of the Utilization Case Manager RN is to conduct initial chart reviews for medical necessity and identify the need for authorization. The Utilization Case Manager RN coordinates with the healthcare team for optimal and efficient patient outcomes, while avoiding potential treatment delays and authorization denials. They are accountable for a designated patient caseload and provide intervention and coordination to decrease avoidable delays. At all times they provide communication of progress and or determination to the clinical team and or the patient as it pertains to treatment or treatment barriers. Finally, the nurse serves as the subject matter expert to her team, providing support and education. CORE JOB FUNCTIONS 1. Adhere and perform timely prospective reviews for services requiring prior authorization 2. Follows the authorization process using established criteria as set forth by the payer or clinical guidelines 3. Accurate review of coverage benefits and payer policy limitations to determine appropriateness of requested services 4. Refers to the treatment plan for clinical reviews in accordance with established criteria in recommended compendia and or guidelines 5. Serves as a resource to provide education regarding payer policies and facilitates coordination of alternative treatment options 6. Ensures and maintains effective communication regarding prior authorization status and determination to the clinical team and on occasion the patient. 7. Facilitates interdepartmental communication regarding authorization status in advance of the patient’s appointment 8. Identifies potential delays in treatment by reviewing the treatment plan and proactively communicates with the healthcare team and or patient regarding the potential treatment barrier 9. Maintains knowledge regarding payer reimbursement policies and clinical guidelines. 10. Adheres to University and department level policies and procedures and safeguards University assets. This list of duties and responsibilities is not intended to be all-inclusive and may be expanded to include other duties or responsibilities as necessary. CORE QUALIFICATIONS Education: Bachelor’s degree in Nursing Certification and Licensing: Registered Nurse License; Basic Life Support Certification (BLS). Core_Utilization Case Manager RN Experience: Minimum 2 years of relevant experience Knowledge, Skills and Attitudes: • Ability to exercise sound judgment in making critical decisions. • Skill in completing assignments accurately and with attention to detail. • Ability to analyze, organize and prioritize work under pressure while meeting deadlines. • Ability to work independently and/or in a collaborative environment. • Ability to communicate effectively in both oral and written form. The University of Miami offers competitive salaries and a comprehensive benefits package including medical, dental, tuition remission and more. UHealth-University of Miami Health System, South Florida's only university-based health system, provides leading-edge patient care powered by the ground breaking research and medical education at the Miller School of Medicine. As an academic medical center, we are proud to serve South Florida, Latin America and the Caribbean. Our physicians represent more than 100 specialties and sub-specialties, and have more than one million patient encounters each year. Our tradition of excellence has earned worldwide recognition for outstanding teaching, research and patient care. We're the challenge you've been looking for. The University of Miami is an Equal Opportunity Employer. Applicants and employees are protected from discrimination based on certain categories protected by Federal law. Job Status: Full time Employee Type: Staff
RN Utilization Review Psych Per Diem
Telecare Corporation

On Call Acute RN Utilization Review - Mental Health 194

Telecare Corporation Santa Cruz, CA
$70 - $86.49 / hour
“They made it easier for me to live, breathe, eat, and stay clean. Without them, I’d be waiting somewhere, waiting for someone to give me a chance to live...” - Client from Telecare What You Will Do to Change Lives The Utilization Review (UR) Nurse works collaboratively with the county or customer utilization and the treatment team to ensure that the care provided is appropriate and medically necessary. The UR Nurse also ensures that medical record documentation explains the care provided as well as the members served response to treatment. The UR Nurse will support programs as assigned and attend treatment team meetings. Shifts Available: On-Call Looking for people who can pick up shifts : Monday – Friday 7:00 AM - 3:30 PM Expected starting wage range is $70.00 - $86.49. Telecare applies geographic differentials to its pay ranges. The pay range assigned to this role will be based on the geographic location from which the role is performed. Starting pay is commensurate with relevant experience above the minimum requirements. What You Bring to the Table (Must Have) Graduation from an accredited Registered Nursing Program (RN). Two (2) years of inpatient psychiatric nursing experience. Current RN State license. Current BLS certification. Must be at least 18 years of age Must be CPR, First Aid, and CPI certified (hands-on course) on date of employment or prior to providing direct client care and maintain current certification throughout employment All opportunities at Telecare are contingent upon successful completion and receipt of acceptable results of the applicable post-offer physical examination, 2-step PPD test for tuberculosis, acceptable criminal background clearances, excluded party sanctions, and degree or license verification. If the position requires driving, valid driver’s license, a motor vehicle clearance and proof of auto insurance is required at time of employment and must be maintained throughout employment. Additional regulatory, contractual or local requirements may apply What’s In It For You* Paid Time Off: Eligible employees (20+ hours/week) earn PTO each pay period for vacation and personal needs, with pro-rated accrual for part-time schedules and annual carryover up to set caps. Nine Paid Holidays & Shift differentials for hourly staff (6% for PM Shift, 10% for Overnight Shift). Weekend Shift differentials for hourly staff (5% for Weekend AM Shift, 11% for Weekend PM Shift, 15% for Weekend Overnight Shift) Free CEUs, free Supervision for BBS Associate License, coaching, and mentorship Online University Tuition Discount and Company Scholarships Medical, Vision, Dental Insurance, 401K, Employee Stock Ownership Plan For more information visit: https://www.telecarecorp.com/benefits Join Our Compassionate Team Telecare's mission is to deliver excellent and effective behavioral health services that engage individuals in recovering their health, hopes, and dreams. Telecare continues to advance cultural diversity, humility, equity, and inclusion at all levels of our organization by hiring mental health peers, BIPOC, LGBTQIA+, veterans, and all belief systems. The Santa Cruz County Psychiatric Health Facility (PHF) is a 16-bed locked acute psychiatric inpatient program for adults aged 18+, diagnosed with serious mental illness (SMI), experiencing a mental health emergency and require intensive treatment and support. EOE AA M/F/V/Disability *May vary by location and position type Full Job Description will be provided if selected for an interview. If job posting references any sign-on bonus internal applicants and applicants employed with Telecare in the previous 12 months would not be eligible.
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.
LVN Utilization Review Psych Contract
Telecare Corporation

On Call Acute LVN Utilization Review Nurse - Mental Health 194

Telecare Corporation Santa Cruz, CA
$43.04 - $53.15 / hour
“They made it easier for me to live, breathe, eat, and stay clean. Without them, I’d be waiting somewhere, waiting for someone to give me a chance to live...” - Client from Telecare What You Will Do to Change Lives The Utilization Review (UR) Nurse works collaboratively with the treatment team to ensure that the care provided is appropriate and medically necessary. The UR Nurse also ensures that medical record documentation explains the care provided as well as the members served responses to treatment. Shifts Available: On-Call: Shifts: 7:00 AM - 3:30 PM | Days: Monday – Friday Expected starting wage range is $43.04 - $53.15. Telecare applies geographic differentials to its pay ranges. The pay range assigned to this role will be based on the geographic location from which the role is performed. Starting pay is commensurate with relevant experience above the minimum requirements. What You Bring to the Table (Must Have) Graduation from accredited LVN program. Two (2) years of acute inpatient psychiatric nursing experience. Current LVN State license. Current BLS certification Must be at least 18 years of age Must be CPR, Crisis Prevention Institute (CPI), and First Aid certified on date of employment or within 60 days of employment and maintain current certification throughout employment All opportunities at Telecare are contingent upon successful completion and receipt of acceptable results of the applicable post-offer physical examination, 2-step PPD test for tuberculosis, acceptable criminal background clearances, excluded party sanctions, and degree or license verification. If the position requires driving, valid driver’s license, a motor vehicle clearance and proof of auto insurance is required at time of employment and must be maintained throughout employment. Additional regulatory, contractual or local requirements may apply What’s In It For You* Paid Time Off: Eligible employees (20+ hours/week) earn PTO each pay period for vacation and personal needs, with pro-rated accrual for part-time schedules and annual carryover up to set caps. Nine Paid Holidays & Shift differentials for hourly staff (6% for PM Shift, 10% for Overnight Shift). Weekend Shift differentials for hourly staff (5% for Weekend AM Shift, 11% for Weekend PM Shift, 15% for Weekend Overnight Shift) Free CEUs, free Supervision for BBS Associate License, coaching, and mentorship Online University Tuition Discount and Company Scholarships Medical, Vision, Dental Insurance, 401K, Employee Stock Ownership Plan For more information visit: https://www.telecarecorp.com/benefits Join Our Compassionate Team Telecare's mission is to deliver excellent and effective behavioral health services that engage individuals in recovering their health, hopes, and dreams. Telecare continues to advance cultural diversity, humility, equity, and inclusion at all levels of our organization by hiring mental health peers, BIPOC, LGBTQIA+, veterans, and all belief systems. The Santa Cruz County Psychiatric Health Facility (PHF) is a 16-bed locked acute psychiatric inpatient program for adults aged 18+, diagnosed with serious mental illness (SMI), experiencing a mental health emergency and require intensive treatment and support. EOE AA M/F/V/Disability *May vary by location and position type Full Job Description will be provided if selected for an interview. If job posting references any sign-on bonus internal applicants and applicants employed with Telecare in the previous 12 months would not be eligible.
RN Utilization Review Per Diem
UNC Health

RN Utilization Manager - (Per Diem) Care Management

UNC Health Smithfield, NC
$35.87 - $51.57 / hour
Description Become part of an inclusive organization with over 40,000 teammates, whose mission is to improve the health and well-being of the unique communities we serve. Summary: Works in collaboration with the patient/family, and interdisciplinary team (including physicians, other care providers, and payors), and assesses the patient care progression from acute care episode through post discharge for quality, efficiency, and effectiveness. The Utilization Manager works collaboratively with other Clinical Care Management staff to ensure patient needs are met and care delivery is coordinated across the continuum. The Utilization Manager completes admission, continued stay, and discharge reviews in accordance with federal regulations & the Hospitals? Utilization Management Plan. In addition, the Utilization Manager is responsible for revenue protection by reconciling physician orders, bed billing type, and medical necessity. This may include delivering notifications to patients directly. Interface is completed verbally, via email, data base tasks, or other electronic communication and via telephone. Responsibilities: 1. Clinical Review Process - Uses approved criteria and conducts admission review/status change review within 24 hours of patient admission to the hospital to ensure appropriateness of the setting and timely implementation of the plan of care. Identifies and obtains observation status as appropriate. Partners with physicians, nursing, and other care providers to help ensure timely and accurate documentation of patient data and treatments. Communicates daily with the Case Manager to manage level of care transitions & appropriate utilization of services. Coordinates with the support center to assure third party payor pre-certification and/or re-certifications when required. Utilizes high risk screening criteria to make appropriate referrals to Manager. 2. Discharge Facilitation - Identifies patient/families with the complex psychosocial, on-going medical discharge planning issues, continuing care needs by initiating appropriate case management referrals. Initiates appropriate social work referrals. 3. Utilization Management Process - Performs utilization management assessments and interventions, using collaboration with interdisciplinary team approach, on assigned patients as appropriate to ensure optimal patient outcomes. Using approved criteria, conducts continued stay and quality reviews to monitor the patient's progress along the continuum of care and intervenes as necessary to ensure appropriateness of setting and that the services provided are quality-driven, efficient, and effective. Enters all pertinent review data into the correct computer system in a timely manner. Consults with Physician Advisor as necessary to resolve barriers through appropriate administrative and medical channels. 4. Utilization Outcomes Management - Monitors and guides to trend interdisciplinary documentation and guides medical staff in documentation that will assist in coding accuracy, enhance quality of care, reflect accurate severity of illness and appropriate reimbursement. Facilitates patient movement to appropriate (acuity) level of care including observation status issues through collaboration with patient/family, multidisciplinary team, third party payors and resource center. Provides information regarding denials and approvals to designated entities. Assists in coordination of practice parameter development with the assigned departments/sections/specialties of Medical Staff. Oversees collection and analysis of patient care and financial data relevant to the target case types. Directs delivery of notifications to patients (includes traveling to hospital(s) to deliver notifications. Other Information Other information: Education Requirements: ● Graduation from a state-accredited school of professional nursing ● If hired after October 1, 2015, must be enrolled in an accredited program within four years of employment, and obtain a Bachelor's degree with a major in Nursing or a Master's degree with a major in Nursing within seven years of employment date. Licensure/Certification Requirements: ● Licensed to practice as a Registered Nurse in the state of North Carolina. Professional Experience Requirements: ● Two (2) years of clinical experience in a medical facility and/or comparable Utilization Management experience. Knowledge/Skills/and Abilities Requirements: Job Details Legal Employer: NCHEALTH Entity: Johnston Health Organization Unit: Care Management - Work Type: Per Diem Standard Hours Per Week: 4.00 Salary Range: $35.87 - $51.57 per hour (Hiring Range) Pay offers are determined by experience and internal equity Work Assignment Type: Onsite Work Schedule: Weekend Location of Job: US:NC:Smithfield Exempt From Overtime: Exempt: Yes This position is employed by NC Health (Rex Healthcare, Inc., d/b/a NC Health), a private, fully-owned subsidiary of UNC Heath Care System. This is not a State employed position. Qualified applicants will be considered without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, status as a protected veteran or political affiliation. UNC Health makes reasonable accommodations for applicants' and employees' religious practices and beliefs, as well as applicants and employees with disabilities. All interested applicants are invited to apply for career opportunities. Please email applicant.accommodations@unchealth.unc.edu if you need a reasonable accommodation to search and/or to apply for a career opportunity.
RN Utilization Review Full-time
The MetroHealth System

Utilization Review Nurse-Utilization Management

The MetroHealth System Cleveland, OH
Location: METROHEALTH MEDICAL CENTER Biweekly Hours: 80.00 Shift: Days; Rotating Weekends and Holidays The MetroHealth System is redefining health care by going beyond medical treatment to improve the foundations of community health and well-being: affordable housing, a cleaner environment, economic opportunity and access to fresh food, convenient transportation, legal help and other services. The system strives to become as good at preventing disease as it is at treating it. Founded in 1837, Cuyahoga County’s safety-net health system operates four hospitals, four emergency departments and more than 20 health centers. Summary Responsible for supporting the physician and interdisciplinary team in the provision of patient care by ensuring the appropriate level of care at the point of entry. The utilization review nurse will work on defined patient populations and is responsible for an initial clinical review at the point of patient entry to the inpatient care setting, this includes observation status. Will collaborate with other interdisciplinary team members to develop and participate in a systematic approach to denial management, and in so doing reduce organizational exposure to revenue loss. Actively participates in the denial management process; improve reimbursement by optimizing revenue recovery due to inappropriate level of care, failure to meet medical necessity, and/or severity of illness. Upholds the mission, vision, values, and customer service standards of The MetroHealth System. Qualifications Required: Bachelor’s degree in Nursing (applies to placements after 1/1/2017). Current Registered Nurse License State of Ohio. Minimum of five years clinical experience. Able to work independently and as a member of an interdisciplinary team. Knowledge and experience with medical necessity criteria for inpatient admission and observation placement. Knowledge and experience of denials based on the absence of documented medical necessity or failure to meet severity of illness and intensity of service criteria. Knowledge of internal criteria set and Milliman Health Management Guidelines. Excellent interpersonal communication and negotiation skills. Strong analytical, data management, and PC skills. Current working knowledge of, utilization management, case-management, performance improvement, and managed care reimbursement. Strong organizational and time management skills. Preferred: Two years of experience with case management, utilization review. Physical Demands: May need to move around intermittently during the day, including sitting, standing, stooping, bending, and ambulating. May need to remain still for extended periods, including sitting and standing. Ability to communicate in face-to-face, phone, email, and other communications. Ability to read job related documents. Ability to use computer.
RN Utilization Review Part-time
UF Health

RN, Utilization Management | Utilization Management

UF Health Gainesville, FL
Overview Join an onsite clinical team focused on ensuring the right care at the right time for every patient. 💻 Work Style: Onsite 📍 Location: Gainesville, FL 🕒 FTE: Part-Time (.6) 🗓️ Schedule: Weekend Only (12-hour shifts) Evaluates patient medical records to determine the medical necessity and appropriateness of healthcare services in alignment with utilization management guidelines. Collaborates with healthcare providers to support compliance, optimize treatment plans, and promote efficient resource utilization. Communicates authorization decisions clearly and monitors patient progress to support timely discharge planning. Analyzes utilization data to identify trends and opportunities for improvement. Partners with interdisciplinary teams to enhance care coordination, ensure accurate documentation, and maintain compliance with regulatory and organizational standards. Responsibilities Key Responsibilities Evaluates patient medical records to ensure the necessity and appropriateness of healthcare services. Coordinates with healthcare providers to ensure compliance with utilization management guidelines. Supports the optimization of treatment plans to promote effective patient care and appropriate resource utilization. Communicates authorization decisions clearly and supports timely discharge planning. Analyzes utilization data to identify trends and opportunities to improve care coordination. Collaborates with interdisciplinary teams to ensure accurate documentation and regulatory compliance. Qualifications Education & Experience: Registered Nurse (RN) with a current Florida license required. Three (3) years of critical care nursing experience, or Five (5) years of medical-surgical nursing experience, or Three (3) years of utilization review, case management, or third-party payer experience. Qualifications Active Registered Nurse (RN) license with 3+ years of experience in utilization review or case management. Strong knowledge of healthcare utilization management guidelines and regulatory compliance. Experience evaluating medical necessity and optimizing treatment plans. Excellent communication skills with the ability to clearly convey authorization decisions. Ability to analyze utilization data and support effective care coordination. Strong organizational skills with the ability to manage multiple priorities simultaneously. Ability to work independently and collaboratively with multidisciplinary teams. Strong attention to detail and innovative problem-solving skills. Flexibility to adjust work hours and days based on departmental needs. Motor Vehicle Operator Designation: Employees in this position will not operate vehicles for an assigned business purpose. Note: Please indicate the appropriate operator designation on the Request for Personnel (RFP) form at the time of submission. Licensure/Certification/Registration: Registered Nurse (RN) with a current Florida license required.
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
Lexington Medical Center

Quality Review Specialist-RN

Lexington Medical Center West Columbia, SC
Quality Management - Acute Full Time Day Shift 8am-430pm Lexington Health is a comprehensive network of care that includes six community medical and urgent care centers, nearly 80 physician practices, more than 9,000 health care professionals and Lexington Medical Center, a 607-bed teaching hospital in West Columbia, South Carolina. It was selected by Modern Healthcare as one of the Best Places to Work in Healthcare and was first in the state to achieve Magnet with Distinction status for excellence in nursing care. Consistently ranked as best in the Columbia Metro area by U.S. News & World Report, Lexington Health delivers more than 4,000 babies each year, performs more than 34,000 surgeries annually and is the region's third largest employer. Lexington Health also includes an accredited Cancer Center of Excellence, the state’s first HeartCARE Center, the largest skilled nursing facility in the Carolinas, and an Alzheimer’s care center. Its postgraduate medical education programs include family medicine and transitional year residencies, as well as an informatics fellowship. Job Summary The Quality Review Specialist-RN provides consultative services regarding quality assessment and trends to medical staff and to hospital ancillary department personnel. In this role, the employee will perform comprehensive retrospective reviews in a timely manner utilizing criteria developed and approved by the medical staff, hospital, and regulatory agents. Minimum Qualifications Minimum Education: High School Diploma or Equivalent Minimum Years of Experience: 4 Years of clinical or hospital experience; 2 Years of experience in quality or utilization review. Substitutable Education & Experience (Optional): None. Required Certifications/Licensure: Registered Nurse (RN) Required Training: None. Essential Functions Utilizes in-depth knowledge of clinical workflows, policies and procedures, patient care / clinical business processes, regulatory requirements, and best practices to: Risk Management- Perform daily review of new occurrence reports. Identify occurrences that require additional follow-up and reports these to the Director or designee in a timely manner. Ensure that occurrences are categorized correctly and all fields completed and correct. Verifies data accuracy with medical record if necessary. Ensure that occurrence reports are forwarded to all appropriate persons. Access other sources of data as needed for investigation and follow up. Serves as System Administrator for the occurrence reporting system. Primary liaison between Risk Management, Information Services, and system users. Manages access to the occurrence reporting system. Adds new locations and new users and provides new-user training. Assigns passwords. Removes users as needed. Provides new user training and ongoing user support, paying keen attention to user needs and opportunities to offer solutions and modify processes to improve efficiencies. Coordinates with vendor and Information Services to troubleshoot system as needed. Center for Best Practice & PN Quality- Assists with development, implementation, and evaluation of the hospital’s overall quality improvement program. Assist with coordination, preparation, and maintenance of performance improvement assessment and improvement activities. Responsible for data integrity and follows well defined processes for maintaining data integrity as well as manage assigned database. Assists in evaluation, analysis, maintenance and development of system functionality of the EHR to meet clinical objectives including participating in project plan development/tracking and workflow analysis. Duties & Responsibilities Provides accurate and timely routine statistical analyses and reports to designated parties. Identifies need for new reports and develops and creates reports. Generates user-friendly reports from other databases. Evaluates and analyzes data for trends, identifies areas of concern, and uses data display techniques to provide reports for various meetings and hospital committees. Prepares materials for meetings and assists with maintenance of performance improvement project records. Represents department on committees / teams as assigned. Participates and supports department goals, objectives and timelines, working with a sense of urgency and accuracy to ensure effective implementation. Successfully engages in multiple initiatives simultaneously and demonstrates flexibility in role and a willingness to help others. Attains an annual minimum of 12 hours of continuing education in topics related to role. May prepare materials for meetings and assists with maintenance of performance improvement project records. May represent department on committees / teams as assigned. Risk Management: Resolves problems and recommends solutions through research, inquiry, and data analysis, maintaining support call logs and tracking of issues. Compiles and maintains accurate statistics pertaining to occurrence data. Participates in and contributes to patient safety / risk reduction activities, including: Participates in and contributes to investigations of serious unanticipated events and "close-calls". Participates in and contributes to development, implementation and evaluation of corrective action plans. Supports a culture of safety by encouraging staff to speak up and report safety and quality issues. Center for Best Practice & PN Quality: Identifies opportunities for improvement and coordinates/participates in the development and implementation of action plans to make improvements- recommends changes to systems/processes that do not contribute to desired outcomes. Works collaboratively and communicates effectively with administration, IS, and clinical care teams through participation in the planning, development, and evaluation and maintenance of the Clinical Information system. Audits database contents for accuracy and validity. Acts as a resource person in quality assessment activities with hospital departments and committees. Works directly with hospital personnel to provide assistance and guidance in establishing criteria, reviewing medical records, etc. Requires efficient use of numerous software products (Word, Excel, PowerPoint, Outlook, etc.) Performs all other duties as assigned. We are committed to offering quality, cost-effective benefits choices for our employees and their families: Day ONE medical, dental and life insurance benefits Health care and dependent care flexible spending accounts (FSAs) Employees are eligible for enrollment into the 403(b) match plan day one. LHI matches dollar for dollar up to 6%. Employer paid life insurance – equal to 1x salary Employee may elect supplemental life insurance with low cost premiums up to 3x salary Adoption assistance LHI provides its full-time employees employer paid short-term disability and long-term disability coverage after 90 days of eligible employment Tuition reimbursement Student loan forgiveness Equal Opportunity Employer It is the policy of Lexington Health to provide equal opportunity of employment for all individuals, and to remain compliant with applicable state and federal laws and regulations. Lexington Health strives to provide a discrimination-free environment, and to recruit, select, on-board, and employ all employees without regard to race, color, religion, sex, age, disability, national origin, veteran status, or pregnancy, childbirth, or related medical conditions, including but not limited to, lactation. Lexington Health endeavors to upgrade and promote employees from within the hospital where possible and consistent with the employee’s desires and abilities and the hospital’s needs.
RN Utilization Review Full-time
Temple Health

RN Case Manager - Utilization Review (Temple Hospital Jeanes Campus)

Temple Health Philadelphia, PA
Utilizing InterQual and other appropriate criteria, responsible for reviewing all admissions and continued stay of patients in conformance with the established criteria set forth in the hospital's utilization management and quality assurance plan. Will determine the medical necessity for admission and continued stays for patients within department's scope of service and to meet the hospital's objectives for assuring a high quality of patient care as well as assuring the effective and efficient utilization of available health services. Identifies appropriate level of care for inpatients and outpatients requiring overnight care. Education Other Graduate Of An Accredited School Of Nursing Required Bachelor's Degree BSN Required Experience 2 years experience in clinical nursing preferably in acute care Preferred General Experience in utilization review, case management, PreCertification, or discharge planning Preferred General Experience and knowledge of Medicare, Medicaid, and commercial insurance guidelines Preferred General Experience and knowledge of MCG and InterQual criteria tools Preferred Licenses PA Registered Nurse License Required or Multi State Compact RN License Required Schedule: M-F 8:00am-4:30pm with every third weekend requirement
RN Utilization Review Part-time
Grand Lake Health System

Utilization Review Nurse/Case Management

Grand Lake Health System Saint Marys, OH
Hours of Job Part Time - 40 hours/5 days per pay period 7:30 AM-4:00 PM Every third weekend rotation off-site; less than 3 hours per scheduled weekend Duties and Key Responsibilities The Utilization Review Coordinator reviews and clarifies patient status, applies initial and continued stay criteria to determine medical necessity, prepares clinical reviews to support payer authorization of hospital stays, and follows inpatient and observation cases through resolution with clear, trackable documentation in WellSky CarePort. Follows secondary review process as necessary. Provides continued stay reviews for behavioral health and attends the twice weekly team meetings. Identifies and documents avoidable variances and denial activity. Arranges P2P appeals. Audits and maintains compliance for IMM and MOON delivery. Cross trains to other positions in Case Management for coverage needs Must be receptive to changes as the position demands Practices the Caring Model. Requirements Clinical/Psychosocial skills in acute care setting. Strong team player with internal and external customers. Must be adept and organized and work effectively and efficiently with staff and physicians Patient advocacy, compliance, and confidentiality are a must. Education/Certifications Bachelor’s Degree from an accredited school is required. Current Ohio Licensed Nurse. Experience Background in Nursing required with 5 years or more of recent acute care clinical experience. Grand Lake Health System provides equal employment opportunities to all employees and applicants for employment without regard to race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, disability, genetic information, marital status, amnesty, or status as a covered veteran in accordance with applicable federal, state and local laws. GLHS complies with applicable state and local laws governing nondiscrimination in employment in all of our locations. In addition, Grand Lake Health System is an At-Will Employment employer.
RN Utilization Review Full-time
CVS Health

Utilization Management Nurse Consultant

CVS Health IL
$32.01 - $68.55 / hour
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours. Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function. Typical office working environment with productivity and quality expectations. Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor. Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment. Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding. Effective communication skills, both verbal and written Required Qualifications - 2+ years of experience as a Registered Nurse in adult acute care/critical care setting - Must have active current and unrestricted RN licensure in state of residence - Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours Preferred Qualifications - 2+ years of clinical experience required in med surg or specialty area - Managed Care experience preferred, especially Utilization Management - Preference for those residing in CT zones Education Associates Degree required BSN preferred Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $32.01 - $68.55 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan . No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 04/30/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.