Utilization Review Nurse Jobs

RN Utilization Review Full-time
Texoma Medical Center

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

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

Utilization Management Coordinator Non RN

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

RN, Utilization Management

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

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

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

Registered Nurse Utilization Management Specialist

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

Claims Medical Review Nursing Consultant

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

Utilization Management RN

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

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

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

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

Atlantic Health System Morristown, NJ
$40 - $70.40 / hour
Job Description Utilization Reviewer (RN) – Emergency Department Atlantic Health System – Overlook Medical Center Full-Time | Days | Monday-Friday | 8:00 AM – 4:00 PM Atlantic Health System is seeking a Full-Time Utilization Reviewer RN to support Emergency Department operations at Overlook Medical Center. The Utilization Reviewer is responsible for conducting real-time medical necessity reviews and level-of-care determinations for patients presenting to the Emergency Department. This role serves as a key liaison between clinical teams and utilization management to ensure appropriate patient status assignment, regulatory compliance, and optimal patient throughput. Responsibilities Perform concurrent medical necessity reviews for Emergency Department patients utilizing MCG and/or InterQual criteria. Evaluate admission, observation, and level-of-care determinations in accordance with CMS, payer, and organizational guidelines. Collaborate with Emergency Department physicians, hospitalists, physician advisors, and care management teams to support timely patient placement decisions. Provide education and guidance regarding CMS Observation Rules, Two-Midnight Rule, and documentation requirements. Identify potential denial risks and compliance concerns and escalate as appropriate. Communicate patient status determinations and pertinent clinical information to inpatient Utilization Review staff for continuity of care. Participate in departmental quality initiatives, data collection, reporting, and performance improvement activities related to utilization management and patient throughput. Maintain current knowledge of regulatory and payer requirements impacting utilization review practices. Required QUALIFICATIONS Graduate of an accredited School of Nursing. Current New Jersey Registered Nurse (RN) License in good standing. Strong clinical assessment and critical thinking skills. Excellent communication and interdisciplinary collaboration abilities. Preferred Bachelor of Science in Nursing (BSN). Previous Case Management, Utilization Review, or Care Coordination experience. Experience utilizing MCG and/or InterQual criteria. Knowledge of CMS regulations, Observation Status requirements, and Utilization Management principles. Prior Emergency Department, Acute Care, Case Management, or Clinical Documentation experience. About Us At Atlantic Health, our promise to our communities is; Anyone who enters one of our facilities will receive the highest quality care delivered at the right time, at the right place, and at the right cost. This commitment is also echoed in the respect, development and opportunities we give to our more than 22,000 team members. Headquarters in Morristown, New Jersey, we are one of the leading non-profit health care systems in the nation. Our facilities and sites of care include: Atlantic Health Morristown Medical Center, Morristown, NJ Atlantic Health Overlook Medical Center, Summit, NJ Atlantic Health Newton Medical Center, Newton, NJ Atlantic Health Chilton Medical Center, Pompton Plains, NJ Atlantic Health Hackettstown Medical Center, Hackettstown, NJ Atlantic Health Goryeb Children's Hospital, Morristown, NJ Atlantic Health CentraState Healthcare System, Freehold, NJ Atlantic Medical Group Atlantic Visiting Nurse Atlantic Mobile Health Atlantic Rehabilitation We have more than 900 community-based healthcare providers affiliated through Atlantic Medical Group. We Have Received Awards And Recognition For The Services We Have Provided To Our Patients, Team Members And Communities. Below Are Just a Few Of Our Accolades Chosen for 17 years by Fortune as one of the magazine’s “100 Best Companies to Work For." Atlantic Health Morristown and Atlantic Health Overlook Named by Newsweek as two of the “World’s Best Hospitals” in 2026. Atlantic Health Morristown and Atlantic Health Overlook ranked within the top three hospitals in New Jersey by U.S. News & World Report’s 2025-2026 Best Hospital rankings. Atlantic Health scored four “A” grades by The Leapfrog Group in its Fall 2025 Hospital Safety Grades, performance measures reflecting errors, accidents, injuries and injections, as well as systems hospitals have in place to prevent harm. Atlantic Health Morristown and Atlantic Health Overlook are New Jersey's only hospitals to be named among America's 50 Best hospitals by Healthgrades in 2026. Named by Becker's Healthcare as one of the "165 Top Places to Work in Healthcare – 2026. Atlantic Health Morristown, Atlantic Health Overlook, Atlantic Health Chilton and Atlantic Health Newton all Forbes Top Hospitals for 2026. Named by Newsweek as one of America’s Greatest Workplaces for Inclusion & Diversity 2025. Atlantic Health rated LEVEL 9 - 2025 CHIME Digital Health Most Wired. Summary Atlantic Health offers a competitive and comprehensive Total Rewards package that supports the health, financial security, and well-being of all team members. Offerings vary based on role level (Team Member, Director, Executive). Below is a general summary, with role-specific enhancements highlighted: Team Member Benefits Medical, Dental, Vision, Prescription Coverage (22.5 hours per week or above for full-time and part-time team members) Life & AD&D Insurance. Short-Term and Long-Term Disability (with options to supplement) 403(b) Retirement Plan: Employer match, additional non-elective contribution PTO & Paid Sick Leave Tuition Assistance, Advancement & Academic Advising Parental, Adoption, Surrogacy Leave Backup and On-Site Childcare Well-Being Rewards Employee Assistance Program (EAP) Fertility Benefits, Healthy Pregnancy Program Flexible Spending & Commuter Accounts Pet, Home & Auto, Identity Theft and Legal Insurance ____________________________________________ Note: In Compliance with the NJ Pay Transparency Act (effective Sunday, June 1, 2025), all job postings will include the hourly wage or salary (or a range), as well as this summary of benefits. Final compensation and benefit eligibility may vary by role and employment status and will be confirmed at the time of offer. EEO STATEMENT Atlantic Health, Inc. is an equal employment opportunity employer and federal contractor or subcontractor and therefore abides by applicable laws to protect applicants and employees from discrimination in hiring, promotion, discharge, pay, fringe benefits, job training, classification, referral, and other aspects of employment, on the basis of race, color, religion, sex (including pregnancy, gender identity and sexual orientation), national origin, citizenship status, disability, age, genetics, or veteran
RN Utilization Review Full-time
Atlantic Health System

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

Atlantic Health System Morristown, NJ
$40 - $70.40 / hour
Job Description Utilization Reviewer (RN) – Emergency Department Atlantic Health System – Newton, Hackettstown & Chilton Medical Center Full-Time | Days | Monday-Friday | 8:00 AM – 4:00 PM Atlantic Health System is seeking a Full-Time Utilization Reviewer RN to support Emergency Department operations at Overlook Medical Center. The Utilization Reviewer is responsible for conducting real-time medical necessity reviews and level-of-care determinations for patients presenting to the Emergency Department. This role serves as a key liaison between clinical teams and utilization management to ensure appropriate patient status assignment, regulatory compliance, and optimal patient throughput. Responsibilities Perform concurrent medical necessity reviews for Emergency Department patients utilizing MCG and/or InterQual criteria. Evaluate admission, observation, and level-of-care determinations in accordance with CMS, payer, and organizational guidelines. Collaborate with Emergency Department physicians, hospitalists, physician advisors, and care management teams to support timely patient placement decisions. Provide education and guidance regarding CMS Observation Rules, Two-Midnight Rule, and documentation requirements. Identify potential denial risks and compliance concerns and escalate as appropriate. Communicate patient status determinations and pertinent clinical information to inpatient Utilization Review staff for continuity of care. Participate in departmental quality initiatives, data collection, reporting, and performance improvement activities related to utilization management and patient throughput. Maintain current knowledge of regulatory and payer requirements impacting utilization review practices. Required QUALIFICATIONS Graduate of an accredited School of Nursing. Current New Jersey Registered Nurse (RN) License in good standing. Strong clinical assessment and critical thinking skills. Excellent communication and interdisciplinary collaboration abilities. Preferred Bachelor of Science in Nursing (BSN). Previous Case Management, Utilization Review, or Care Coordination experience. Experience utilizing MCG and/or InterQual criteria. Knowledge of CMS regulations, Observation Status requirements, and Utilization Management principles. Prior Emergency Department, Acute Care, Case Management, or Clinical Documentation experience. About Us At Atlantic Health, our promise to our communities is; Anyone who enters one of our facilities will receive the highest quality care delivered at the right time, at the right place, and at the right cost. This commitment is also echoed in the respect, development and opportunities we give to our more than 22,000 team members. Headquarters in Morristown, New Jersey, we are one of the leading non-profit health care systems in the nation. Our facilities and sites of care include: Atlantic Health Morristown Medical Center, Morristown, NJ Atlantic Health Overlook Medical Center, Summit, NJ Atlantic Health Newton Medical Center, Newton, NJ Atlantic Health Chilton Medical Center, Pompton Plains, NJ Atlantic Health Hackettstown Medical Center, Hackettstown, NJ Atlantic Health Goryeb Children's Hospital, Morristown, NJ Atlantic Health CentraState Healthcare System, Freehold, NJ Atlantic Medical Group Atlantic Visiting Nurse Atlantic Mobile Health Atlantic Rehabilitation We have more than 900 community-based healthcare providers affiliated through Atlantic Medical Group. We Have Received Awards And Recognition For The Services We Have Provided To Our Patients, Team Members And Communities. Below Are Just a Few Of Our Accolades Chosen for 17 years by Fortune as one of the magazine’s “100 Best Companies to Work For." Atlantic Health Morristown and Atlantic Health Overlook Named by Newsweek as two of the “World’s Best Hospitals” in 2026. Atlantic Health Morristown and Atlantic Health Overlook ranked within the top three hospitals in New Jersey by U.S. News & World Report’s 2025-2026 Best Hospital rankings. Atlantic Health scored four “A” grades by The Leapfrog Group in its Fall 2025 Hospital Safety Grades, performance measures reflecting errors, accidents, injuries and injections, as well as systems hospitals have in place to prevent harm. Atlantic Health Morristown and Atlantic Health Overlook are New Jersey's only hospitals to be named among America's 50 Best hospitals by Healthgrades in 2026. Named by Becker's Healthcare as one of the "165 Top Places to Work in Healthcare – 2026. Atlantic Health Morristown, Atlantic Health Overlook, Atlantic Health Chilton and Atlantic Health Newton all Forbes Top Hospitals for 2026. Named by Newsweek as one of America’s Greatest Workplaces for Inclusion & Diversity 2025. Atlantic Health rated LEVEL 9 - 2025 CHIME Digital Health Most Wired. Summary Atlantic Health offers a competitive and comprehensive Total Rewards package that supports the health, financial security, and well-being of all team members. Offerings vary based on role level (Team Member, Director, Executive). Below is a general summary, with role-specific enhancements highlighted: Team Member Benefits Medical, Dental, Vision, Prescription Coverage (22.5 hours per week or above for full-time and part-time team members) Life & AD&D Insurance. Short-Term and Long-Term Disability (with options to supplement) 403(b) Retirement Plan: Employer match, additional non-elective contribution PTO & Paid Sick Leave Tuition Assistance, Advancement & Academic Advising Parental, Adoption, Surrogacy Leave Backup and On-Site Childcare Well-Being Rewards Employee Assistance Program (EAP) Fertility Benefits, Healthy Pregnancy Program Flexible Spending & Commuter Accounts Pet, Home & Auto, Identity Theft and Legal Insurance ____________________________________________ Note: In Compliance with the NJ Pay Transparency Act (effective Sunday, June 1, 2025), all job postings will include the hourly wage or salary (or a range), as well as this summary of benefits. Final compensation and benefit eligibility may vary by role and employment status and will be confirmed at the time of offer. EEO STATEMENT Atlantic Health, Inc. is an equal employment opportunity employer and federal contractor or subcontractor and therefore abides by applicable laws to protect applicants and employees from discrimination in hiring, promotion, discharge, pay, fringe benefits, job training, classification, referral, and other aspects of employment, on the basis of race, color, religion, sex (including pregnancy, gender identity and sexual orientation), national origin, citizenship status, disability, age, genetics, or veteran
RN Manager/Supervisor Utilization Review Telehealth Full-time
Centene

Supervisor, Utilization Management (RN)

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

Registered Nurse – Outpatient – Urology – Ambulatory Referral Review

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

Registered Nurse 3 - Utilization

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

Nurse Utilization RN

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

Utilization Management Claims Review Nurse RN II

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

(RN) Quality Review Manager- Registered Nurse

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

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

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

Utilization Management Clinical Quality Nurse Reviewer RN II

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

CDI Quality Review RN

UT Southwestern Medical Center Dallas, TX
WHY UT SOUTHWESTERN? With over 75 years of excellence in Dallas-Fort Worth, Texas, UT Southwestern is committed to excellence, innovation, teamwork, and compassion. As a world-renowned medical and research center, we strive to provide the best possible care, resources, and benefits for our valued employees. Ranked as the number 1 hospital in Dallas-Fort Worth according to U.S. News & World Report, we invest in you with opportunities for career growth and development to align with your future goals. Our highly competitive benefits package offers healthcare, PTO and paid holidays, on-site childcare, wage, merit increases and so much more. We invite you to be a part of the UT Southwestern team where you'll discover a culture of teamwork, professionalism, and a rewarding career! Job Summary The CDI Quality Review Nurse (QRN) will work under the direction of the Clinical Documentation Integrity ("CDI") Manager and conduct second-level reviews of targeted cases to identify and capture opportunities to improve the integrity of the medical record. The focus of the Quality Review Nurse will be on identifying and capturing methodology-specific risk variables (Vizient, HCC's, Elixhauser) on a post-discharge, pre-coding/billing basis, as well as identifying potential process improvements to capture the opportunities concurrently. The Quality Review Nurse will also validate that the record reflects the most appropriate principal diagnosis and diagnosis related group (DRG). The Quality Review Nurse will support the objective for accurate reflection of patient acuity, severity of illness, risk of mortality, and DRG assignment in compliance with industry rules and regulations. Benefits UT Southwestern is proud to offer a competitive and comprehensive benefits package to eligible employees. Our benefits are designed to support your overall wellbeing, and include: PPO medical plan, available day one at no cost for full-time employee-only coverage 100% coverage for preventive healthcare-no copay Paid Time Off, available day one Retirement Programs through the Teacher Retirement System of Texas (TRS) Paid Parental Leave Benefit Wellness programs Tuition Reimbursement Public Service Loan Forgiveness (PSLF) Qualified Employer Learn more about these and other UTSW employee benefits! Experience And Education Required Education Bachelor's Degree in Nursing Experience 5 years patient care nursing experience in an acute care setting and 3 years Clinical Document Integrity experience Licenses and Certifications (RN) REGISTERED NURSE Upon Hire and (CCDS) Cert Clinical Documentation Upon Hire or (CDIP) CERT DOCUMNTATN IMPROVMNT PRAC Upon Hire Preferred Education Master's Degree in Nursing Experience 7 years patient care nursing experience in an acute care setting 5 years Clinical Document Integrity experience Experience working in a remote environment Job Duties Conduct post-discharge, pre-coding/billing reviews on targeted records identified for second-level review for opportunity to accurately capture methodology-specific risk variables (Vizient, HCC‿s, Elixhauser); present on admission (POA) status, patient admission source, avoidable patient safety indicators (PSI‿s), and DRG assignment in compliance with industry rules and regulations If a documentation opportunity is identified, place physician query and follow up for response If coding opportunity is identified, coordinate with Coding Team to review and address opportunity, as applicable Utilize methodology-specific risk calculators and guidance documents to understand if additional diagnoses and/or risk variables will impact the reported quality impact of a specific patient encounter Maintain a summary of opportunities identified through second-level review for feedback and education with the CDS Team, Providers, and Coding Team Identify and communicate any process improvement opportunities for front-end correction and education Periodically review the criteria established for cases triggering a second-level review and recommend updates or modifications to the criteria to maximize impact on quality scores Maintains an expert level of knowledge of CDI and Coding related guidelines and practices Other duties as assigned SECURITY AND EEO STATEMENT Security This position is security-sensitive and subject to Texas Education Code 51.215, which authorizes UT Southwestern to obtain criminal history record information. EEO UT Southwestern Medical Center is committed to an educational and working environment that provides equal opportunity to all members of the University community. As an equal opportunity employer, UT Southwestern prohibits unlawful discrimination, including discrimination on the basis of race, color, religion, national origin, sex, sexual orientation, gender identity, gender expression, age, disability, genetic information, citizenship status, or veteran status. Primary Location Texas-Dallas-5323 Harry Hines Blvd Work Locations 5323 Harry Hines Blvd Organization 844004 - Clin Documentation Integrity Schedule Full-time Shift Day Job Employee Status Regular Job Type Standard Job Posting Jun 4, 2026, 8:44:48 PM
RN Utilization Review Full-time
South Texas Health System McAllen

Case Manager RN Utilization Review FT McAllen

South Texas Health System McAllen McAllen, TX
Responsibilities POSITION SUMMARY: RN Case Manager responsible to manage resource utilization and clinical outcomes for patients as well discharge needs of the patients. RN will also be responsible to help with the denial management process. There may be occasions when it will be necessary to work weekends, holidays, evenings, nights, and/or on-call/call-back status. Demonstrates Service Excellence standards at all times. Qualifications QUALIFICATIONS: 1. 1 years previous acute care RN experience required. (Previous defined as: ‘within the last three years’) 2. Bilingual preferred (Spanish). 3. Experience in Health Care Coordination preferred. 4. Must demonstrate commitment and adherence to STHS’s Compliance Program and Code of Conduct through compliance with all policies and procedures, the Code of Conduct, attendance at required training and immediately reporting suspected compliance issue(s) to the Compliance Officer. EDUCATION / LICENSURE: 1. Licensed in the State of Texas 2. Registered Nurse currently licensed in the State of Texas, or part of a compact state license, or has a valid temporary RN license for the State of Texas while waiting to receive the permanent license. BSN preferred. 3. Effective January 6, 2016, must possess an Associate Degree, Baccalaureate Degree or Diploma from a School of Nursing or University. EEO Statement All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws. We believe that diversity and inclusion among our teammates is critical to our success. Notice At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skillset and experience with the best possible career path at UHS and our subsidiaries. We take pride in creating a highly efficient and best in class candidate experience. During the recruitment process, no recruiter or employee will request financial or personal information (Social Security Number, credit card or bank information, etc.) from you via email. The recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc. If you are suspicious of a job posting or job-related email mentioning UHS or its subsidiaries, let us know by contacting us at: https://uhs.alertline.com or 1-800-852-3449. Authorized by Corporate Human Resources
RN Utilization Review Full-time
Wooster Community Hospital Health System

2217 Utilization Review Nurse PT

Wooster Community Hospital Health System Wooster, OH
2217 Utilization Review Nurse PT MAIN FUNCTION: The Utilization Management Nurse Reviewer (RN) serves as the Subject Matter Expert for the organization for patient admission status (inpatient and observation) and works with Providers, Case Management, and the Revenue Cycle team in a consultative manner to ensure appropriate admission status. The UM RN protects the financial interests of the organization by ensuring that the UM review cycle is successfully completed from the point of admission through and including appeal of any denials received. The UM RN is an integral part of the Revenue Cycle team by tracking and trending payer issues and reporting the same to team leaders in order to address identified concerns with payer representatives. REPORTS TO: Manager of Utilization and Denials and System Director of Revenue Cycle MUST HAVE REQUIREMENTS: LPN or RN possessing an active Ohio license 3-5 years clinical nursing experience in varied settings 1-3 year UM experience in an acute care setting Experience using InterQual and/or Milliman criteria. Solid working knowledge of reimbursement methodology. Strong organization, prioritizing and delegation skills. Demonstrated emotional intelligence – self-control, self-awareness, social awareness and relationship management. Excellent oral and written communication Ability to work independently in a fast-paced environment, meeting all deadlines. Ability to problem solve complex, multifaceted situations. Ability to use computers and analytical software. PREFERRED ATTRIBUTES: Bachelor’s degree. UM certification. Strong background in Medicare/Medicaid regulations related to UM and billing compliance. Experience using MCG Indicia tools. POSITION EXPECTATIONS: All expectations detailed below are considered Americans with Disabilities Act (ADA) essential. Follows Appropriate Service Standards Clinical review of 100% of acute bedded patients admitted to inpatient or observation against medical necessity criteria (InterQual or MCG) utilizing provided tools (Meditech, MCG Indicia, payer portals) and prescribed process for appropriateness of status. Clinical review includes the life cycle of the admission, starting with initial case review (ICR) through and including resolution of any claims denied for status or medical necessity. Ensures continued stay reviews are submitted timely per the payer’s requirements, and that responses from the payer include coverage for all days of the stay. Monitors submitted cases for a response from the payer in a timely manner to respond appropriately to any threatened or actual denials immediately to avoid the appeal process whenever possible. Submits reconsiderations immediately (when available) according to the prescribed process. Confers with the Physician Risk Advisor (PRA) on any concerns with current patient status, then communicates needed changes to the attending provider via provided communication tools. Fully documents all case reviews in MCG Indicia/Meditech, including all pertinent information, such as method and proof of submission of all case reviews, results of case reviews and any denials received, communication with PRA and attending providers. Facilitates Peer-to-peer opportunities between the attending provider and the payer. Attends the daily huddle with Case Management and PRA to keep apprised of any changes, and to contribute to the huddle as the Subject Matter Expert on status. Strong collaboration with Case Management, serving as the SME for utilization and status. Ensures that denials are identified in the prescribed manner and ensures all appeals are submitted timely to the payer. Adheres to department productivity standards (35-40 reviews per shift) Assigns submitted appeals to the UM Clerical support team member for follow-up on appeal response. Collaborates with the UM Lead Nurse Reviewer to identify opportunities for improvement through daily work processes and communicates to leadership. Collaborates with the PRA, Director and UM Lead Nurse Reviewer for issues/concerns to submit to the quarterly UM Committee. Performs other duties as assigned, including but not limited to: Demonstrates professional responsibility required of a Utilization Review Nurse. Complies with all department and organization policies at all times. Maintains compliance with all state/federal guidelines and standards, as well as CMS Conditions of Participation. Demonstrates a positive attitude, openness to change and responsiveness to constructive feedback.
RN Utilization Review Full-time
Southeast Health

Utilization Review Nurse

Southeast Health Dothan, AL
Southeast. Always the right career direction. Job Description Summary The Utilization Review Nurse screens medical records in accordance with contractual agreement and regulatory requirements for medical necessity on admission and continued stay in the acute care setting. The Utilization Review case manager collaborates with all components of the healthcare system, managing appropriate use of acute care to aid in the achievement of quality outcomes, fiscal responsibility, and patient satisfaction. Job Description Essential Functions Performs admissions and continued stay reviews of all inpatients and outpatient/observation patients in a bed; at times, this may be retrospective. Performs precertification on procedures ordered while patients are hospitalized. Issues required Medicare/Medicaid notifications of medical necessity changes to patients while hospitalized. Issues notifications of non-coverage letters to patients if received during hospital stay. Documents clear billing notes into the Electronic Medical Record (EMR) payer communications navigator to avoid billing denials. Performs medical necessity denial appeals. Maintains a close, collaborative relationship with the medical staff to promote continuity of care and avoid delays in service. Performs other duties as requested by primary manager that do not compromise moral code of conduct or protocols set in place for patient or employee safety Supervised Positions None Qualifications Minimum Education Required Associates degree in Nursing Current Registered Nurse license in the State of Alabama Minimum Education Preferred Bachelor’s degree or higher in Nursing Minimum Experience Required Two (2) years acute care experience Must pass Blue Cross Blue Shield Iterator Reliability Test with 90% within six (6) months of hire Minimum Experience Preferred Three (3) years acute care experience One (1) year utilization review experience Required Knowledge/ Skills/ Abilities Maintain current licensure in the State of Alabama Demonstrates appropriate utilization of the skills of the Registered Nurse as approved by the Alabama Board of Nursing Ability to quickly adapt to changing circumstances in fast-paced environment Actively accepts, understands, and practices appropriate standards of nursing practice. Must demonstrate basic knowledge of discharge planning needs Demonstrates advanced computer skills (ability to generate reports, graph trends). Clinical knowledge and experience in the care of patients with multiple and complex diagnoses, disease process, and care needs. Ability to prioritize work and meet deadlines. Ability to problem solve in a proactive, creative manner, using sound judgment based on factual information and clinical knowledge. Ability to develop leadership skills and to serve as a role model for clinical staff. Ability to lead and actively participate in multidisciplinary teams. Ability to work independently within a team structure. Demonstrates responsibility for educational requirements as evidenced by reading all assigned related references, and attending all required educational meetings, or webinars, and completing annual Symplr requirements. Demonstrates commitment to organizations five (5) priorities and Six Ground Rules Person in this position is required to understand, agree upon and follow our Six Ground Rules: No excuses. We are a team. Bring up your ideas. Poor performance will be addressed. ‘That’s not my job’ is not acceptable Manage Up. Shift Day Shift Details 8:00 am - 4:30 pm FTE 1 Type Regular Join one of Forbes 500 best mid-sized employers in America. Equal Employment Employer Southeast Health is committed to provide equal employment opportunity (EEO) to all persons regardless of age, color, national origin, citizenship status, physical or mental disability, race, religion, creed, gender, sex, sexual orientation, gender identity and/or expression, genetic information, marital status, status with regard to public assistance, veteran status, or any other characteristic protected by federal, state or local law. In addition, Southeast Health will provide reasonable accommodations for qualified individuals with disabilities.
RN Utilization Review Full-time
UF Health

RN, Utilization Management | Utilization Management

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

Utilization Review Nurse: Emergency Dept

Albany Medical Center Albany, NY
$84,783 - $131,414 / year
Department/Unit: Care Management/Social Work Work Shift: Day (United States of America) Salary Range: $84,783.00 - $131,414.00 Responsible for Utilization Management, Quality Screening and Delay Management for assigned patients. Most qualified candidates will have experience in Emergency/Trauma Care and/or previous Utilization Review roles. Qualifications and Ideal Characteristics Registered nurse with a New York State current license. Bachelor's degree required. Masters degree preferred. Minimum of three years clinical experience in an assigned service. Recent experience in case management, utilization management and/or discharge planning/home care in a high volume, acute care hospital preferred. PRI and Case Management certification preferred. Assertive and creative in problem solving, critical thinking skills, systems planning and patient care management. Self-directed with the ability to adapt in a changing environment. Basic knowledge of computer systems with skills applicable to utilization review process. Excellent written and verbal communication skills. Working knowledge of MCG criteria and ability to implement and utilize. Understanding of Inpatient versus Outpatient surgery and ICD10-Coding (preferred) and Observation status qualifications. Ability to work independently and demonstrate organizational and time management skills. Strong analytic, data management and PC skills. Working knowledge of Medicare regulatory requirements, Managed Care Plans A. Mission, Core Values and Service Excellence Contributes to the creation of a compassionate and caring environment for patients, families, and colleagues through displays of kindness and active listening. Recognizes and appreciates that each employee’s work is valuable and contributes to the success of the Mission. Demonstrates excellence in daily work. Willing to actively participate in performance and quality improvement activities and to work towards enhancing customer/patient satisfaction. Exhibits positive service excellence skills to patients, visitors, and coworkers by greeting others in a friendly manner, keeping customers/patients/colleagues informed about progress, delays, and changes. Demonstrates effective teamwork by interacting in a positive manner with colleagues and creating a collaborative work environment. Initiates open communication, conveys positive intent, offers assistance. Contributes to a safe and secure environment for patients, visitors, colleagues by following established procedures and protocols. Demonstrates stewardship by thoughtful and responsible use of resources including maintaining a clean and hospitable environment, starting work on time, displaying a consciousness regarding costs, supplies and department finances. Demonstrates respect for individual differences of each person by acknowledging the essence of each person, appreciating, and responding to unique, spiritual, personal, and cultural backgrounds of patients, families, and colleagues. B. Utilization Management Completes Utilization Management and Quality Screening for assigned patients. Applies MCG criteria to monitor appropriateness of admissions and continued stays, and documents findings based on Departmental standards. While performing utilization review identifies areas for clinical documentation improvement and contacts appropriate department. Identifies at-risk populations using approved screening tool and follows established reporting procedures. Monitors LOS and ancillary resource use on an ongoing basis. Takes actions to achieve continuous improvement in both areas. Refers cases and issues to Medical Director and Triad Team in compliance with Department procedures and follows up as indicated. Communicates covered day reimbursement certification for assigned patients. Discusses payor criteria and issues and a case-by-case basis with clinical staff and follows up to resolve problems with payors as needed. Uses quality screens to identify potential issues and forwards information to the Quality Department. Demonstrates proper use of MCG and documentation requirements through case review and inter-rater reliability studies. Delay Management Facilitates removal of delays and documents delays when they exist. Reports internal and external delays to the Triad Team. Collaborates with the health care team and appropriate department in the management of care across the continuum of care by assuring communication with Triad Team and health care team. Maintains complete confidentiality of patient information, in addition to hospital and individual physician practice pattern data. Provides information and inservices as necessary to physicians and ancillary staff. Thank you for your interest in Albany Med Health System!​ Albany Med Health System is an equal opportunity employer. This role may require access to information considered sensitive to Albany Med Health System, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that: Access to information is based on a “need to know” and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Med Health System policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification.
RN Utilization Review Full-time
Sarasota Memorial

Utilization Management Case Manager II - Sarasota

Sarasota Memorial Sarasota, FL
Department Integrated Case Management Job Summary The Utilization Management Case Manager (UMCM) utilizes professional nursing and critical thinking skills to assess patients for a clinically appropriate level of care. The UMCM maintains a strong knowledge base of evidence-based clinical criteria, federal and state UR requirements, and adeptly identifies pertinent clinical information that will support admission and continued stay hospitalization. When potential denials for payment or level of care arise, the UMCM collaborates with the floor ICM staff, Revenue Cycle, involved physicians and/or the Physician Advisors (PA) as needed to attain second level review/approval to effectively overturn the denial or help determine appropriate transition for the patient. UMCM interact extensively with clinical staff throughout the hospital, other ICM staff, physicians, payers, and hospital financial staff in order to achieve appropriate level of care or placement authorizations, and to avoid denials. The UMCM collaborates with other ICM staff to evaluate opportunities to optimize utilization and secure payer approvals across populations of patients to meet organizational strategic objectives. The UMCM acts as a mentor/preceptor for new staff. Required Qualifications - Require a Bachelor of Science in Nursing (BSN) from an accredited school of nursing. - Require three (3) years of utilization review experience. - Require a minimum of three (3) years in an acute care setting. - Require previous experience with hospital information systems (order entry, results reporting, case management). - Require basic experience using PC/computer (word processing minimum). Preferred Qualifications - Prefer active Case Management Certification (CCM or ACM) or within one (1) year of hire and membership in relevant CM/UM organization. - Prefer demonstrated ability to manage multiple tasks and adjust priorities according to patient and department/hospital needs. - Prefer solid clinical assessment, critical thinking, decision making and organizational skills. - Prefer strong ability to communicate effectively both verbally and in written work. - Prefer strong interpersonal skills and ability to work collaboratively with leaders, staff, patients, families, healthcare team, payers and external agencies. - Prefer knowledge of relevant federal and state utilization review and appeal requirements. Mandatory Education Preferred Education Required License and Certs FL RN: FL Registered Nurse License Preferred License and Certs Employment Screening Requirements As part of Sarasota Memorial Health Care System’s commitment to keeping people safe, all individuals providing care to vulnerable populations are required to undergo background screening through The Florida Care Provider Background Screening Clearinghouse. https://info.flclearinghouse.com/