Utilization Review Nurse Jobs

RN Utilization Review Full-time
SUNY Downstate Health Sciences University

Utilization Review Nurse

SUNY Downstate Health Sciences University New York, NY
Are you looking to take your career to new heights with a leader in healthcare? SUNY Downstate Health Sciences University is one of the nation's leading metropolitan medical centers. As the only academic medical center in Brooklyn, we serve a large population that is among the most diverse in the world. We are also highly-ranked by Castle Connolly Medical, a healthcare rating company for consumers, among the top 5 leading U.S. medical schools for training doctors. Bargaining Unit UUP Job Summary The Department of Case Management at SUNY Downstate Health Sciences University is seeking a full-time TH Utilization Review & Quality Assurance Senior Coordinator / Utilization Review Nurse. The successful candidate will: Report directly to the RN Case Management Manager. Review patient records for chief complaints, signs and symptoms of disease to justify medical necessity for admission to acute inpatient rehabilitation facility (IRF) per Milliman Care Guidelines (MCGs). Provide critical feedback per established MCGs. Collaborate with social workers, referring case managers, and physicians for alternative care sites when appropriate. Validate admission and continuing stay criteria with third party payers as well as primary care and attending physicians. Complete clinical reviews and forward to MCOs. Use clinical knowledge and knowledge of anticipated response to treatment to assess patient progression toward anticipated outcomes. Assess patients and care support for continuing care needs to develop, implement and evaluate an effective discharge plan in collaboration with the multidisciplinary team. Use knowledge of usual length of stay to initiate a plan for discharge. Determine medical necessity, appropriateness of admission, continuing stay and level of care using a combination of clinical information, clinical criteria, and third-party information. Intervene when determinations are not in alignment with clinical information, clinical criteria, IT systems or third-party information to resolve the situation. Communicate and coordinate with patients/care teams to intervene when progression is stalled or diverted. Collaborate and communicate with patients/care teams related to reimbursement issues and to create a discharge plan. Support the process of patient choice in establishing a discharge plan. Actively contribute to and participate in all IRF AM huddles, Rehab Unite team meetings, rehab unit related length of stay meetings, discharge planning rounds, unit daily reports, clinical practice team and department meetings. PRN participate in med-surg unit interdisciplinary team rounds. Complete IRF discharge calls, perform utilization reviews, and facilitate peer-to-peer reviews in care management module. Complete PRls and forward to SAR/SNF after patient/care team selection. Assist in Joint Reconstruction surgery QAPI and optimization. Work in dynamic work environment across multiple settings, while frequently communicating with team members as necessary and appropriate. Be a team player and a role model for other staff members and students. Model the organization's WE CARE values. Demonstrate flexibility and perform other job related duties as business need demands, as the position is not limited to the above description. Required Qualifications New York State Registered Nurse Licensure. Current Patient Review Instrument (PRI) Certification. 2+ years of recent acute care clinical nursing experience (Critical Care preferred). Working knowledge of Utilization Review processes. Use of CareGuidelines (MCG/Interqual). Computer proficiency in Microsoft Word, Excel, PowerPoint. Strong interpersonal, communication, administrative, and organizational skills. Or, a satisfactory equivalent combination of experience, education and training to the above. Preferred Qualifications Bachelor of Science Degree preferred. Competency/experience with Careport, Allscripts EHR. Work Schedule Monday to Friday; 9:00am to 5:00pm (Full-Time) Salary Grade/Rank SL-4 Salary Range Commensurate with experience and qualifications Executive Order Pursuant to Executive Order 161, no State entity, as defined by the Executive Order, is permitted to ask, or mandate, in any form, that an applicant for employment provide his or her current compensation, or any prior compensation history, until such time as the applicant is extended a conditional offer of employment with compensation. If such information has been requested from you before such time, please contact the Governor’s Office of Employee Relations at (518) 474-6988 or via email at info@goer.ny.gov. Equal Employment Opportunity Statement SUNY Downstate Health Sciences University is an affirmative action, equal opportunity employer and does not discriminate on the basis of race, color, national origin, religion, creed, age, disability, sex, gender identity or expression, sexual orientation, familial status, pregnancy, predisposing genetic characteristics, military status, domestic violence victim status, criminal conviction, and all other protected classes under federal or state laws. Women, minorities, veterans, individuals with disabilities and members of underrepresented groups are encouraged to apply. If you are an individual with a disability and need a reasonable accommodation for any part of the application process, or in order to perform the essential functions of a position, please contact Human Resources at ada@downstate.edu
RN Utilization Review Full-time
CVS Health

Utilization Management Nurse Consultant

CVS Health
$32.01 - $68.55 / hour
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary Supports comprehensive coordination of medical services through composition and auditing of approval, extensions, and denial letters. Promotes and supports quality effectiveness of the healthcare services. Maintains accurate and complete documentation to meet risk management, regulatory, and accreditation requirements. Promotes communication, both internally and externally to enhance effectiveness of medical management services. Training Schedule-9am-6pm Monday-Friday Perm Schedule-9am-8pm Thursday - Sunday Required Qualifications - Must have active, current, and unrestricted RN license in the state of residence -1+ years of clinical experience - Must be willing and able to work occasional holiday and weekends depending on business needs Preferred Qualifications 1+ years as a RN - Utilization management experience - Managed care experience - Must be a team player - Good communication skills - Good grammar and syntax - Ability to multi-task - Schedule flexibility Education Associates degree required BSN preferred Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $32.01 - $68.55 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan . No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 03/25/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
RN Utilization Review Full-time
CVS Health

Utilization Management Nurse Consultant

CVS Health
$26.01 - $56.14 / hour
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours. • Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. • Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care • Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs • Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization • Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function. • Typical office working environment with productivity and quality expectations. • Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor. • Sedentary work involving periods of sitting, talking, listening. • Work requires sitting for extended periods, talking on the telephone and typing on the computer. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment. • Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding. • Effective communication skills, both verbal and written Required Qualifications - 2+ years of experience as a Registered Nurse in adult acute care/critical care setting - Must have active current and unrestricted RN licensure in state of residence - Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours Preferred Qualifications - 2+ years of clinical experience required in med surg or specialty area - Managed Care experience preferred, especially Utilization Management - Preference for those residing in CST zones Education Associates Degree required BSN preferred Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $26.01 - $56.14 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan . No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 03/31/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
RN Utilization Review Full-time
UHS

Utilization Review/Management Coordinator

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

Utilization Management Nurse Consultant

CVS Health
$32.01 - $68.55 / hour
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary Supports comprehensive coordination of medical services through composition and auditing of approval, extensions, and denial letters. Promotes and supports quality effectiveness of the healthcare services. Maintains accurate and complete documentation to meet risk management, regulatory, and accreditation requirements. Promotes communication, both internally and externally to enhance effectiveness of medical management services. Required Qualifications - Must have active, current, and unrestricted RN license in the state of residence -1+ years of clinical experience - Must be willing and able to work Monday through Friday, 11:00am to 7:00pm EST - Must be willing and able to work occasional holiday and weekends depending on business needs Preferred Qualifications - Utilization management experience - Managed care experience - Must be a team player - Good communication skills - Good grammar and syntax - Ability to multi-task - Schedule flexibility Education Associates degree required BSN preferred Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $32.01 - $68.55 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan . No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 03/25/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
NP Director of Nursing Utilization Review Full-time
L.A. Care Health Plan

Medical Director, Utilization Management

L.A. Care Health Plan Los Angeles, CA
$206,311 - $350,729 / year
Salary Range: $206,311.00 (Min.) - $278,520.00 (Mid.) - $350,729.00 (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 Medical Director, Utilization Management provides clinical oversight of authorization decision making and processing, pre and post payment claims review activities, payment integrity clinical validation and program integrity functions. This position requires evaluation and insight for both medical and behavioral health cases. In this position, the Medical Director supports the development of and ensures the application of clinical policies are consistent with evidence-based medicine and regulatory requirements. The Medical Director collaborates with internal teams to support timely consistent and defensible clinical decisions and promotion of appropriate high-value care. In support of payment and program integrity initiatives, the Medical Director reviews clinical documentation to validate coding accuracy and appropriateness and completion of billed services. This position plays a critical role in the mitigation of Fraud, Waste and Abuse (FWA) and requires proactive analysis of service level utilization data to identify trends, outliers and emerging risk areas and recommend corrective action to minimize utilization variation, prevent improper payments and ensure financial stewardship. Works collaboratively with Health Services departments and key organizational stakeholders, to ensure alignment of utilization management, claims review, and regulatory compliance activities. Partners with executive leadership, clinical teams, and external stakeholders to improve outcomes, support regulatory compliance, and advance organizational goals. Duties Provides physician leadership within the Health Services division, with primary responsibility for overseeing Utilization Management (UM) reviews, conducting medical claims review under Payment Integrity and supporting Behavioral Health (BH). Applies clinical expertise and evidence-based criteria to behavioral health and medical/surgical services, conducting claims reviews in compliance with regulatory timeframe requirements. Leads efforts to strengthen Payment Integrity by overseeing clinical validation of requested services, ensuring alignment between documentation and medical necessity. Analyzes utilization and claims data to identify trends, outliers, cost drivers, and opportunities to reduce unnecessary services and prevent improper payments. Identifies and mitigates Fraud, Waste, and Abuse (FWA) risks by detecting patterns, and partners with internal teams as appropriate. Develops, approves, and updates medical policies, procedures, and standards of care based on current, evidence-based practices. Oversees and reviews the delivery of patient care to ensure it meets quality standards and regulatory guidelines. Guides quality assurance and performance improvement (QAPI) programs and participates in quality review committees. Maintains and enforces compliance with all federal and state laws, accreditation standards (such as NCQA), and other regulatory requirements. Assists in the preparation and monitoring of departmental budgets, including managing costs and resource utilization. Performs other duties as assigned. Duties Continued Education Required Doctor of Medicine (M.D.) Education Preferred Experience Required: At least 8 years of experience in medical management, managed care and quality management. Experience in Payment Integrity. Experience in maintaining liaison with Federal, State, and local bodies and medical organizations. Experience in performance management and possession of strong analytic ability. Extensive post-medical degree experience in clinical practice. Significant experience in a clinical development, medical affairs, or management role within the biotech, pharmaceutical, or healthcare industry. Proven experience in a physician leadership role, including managing teams. Preferred: Experience with Medicaid managed care and/or governmental programs for underserved, safety net populations including women, children, person with disabilities, seniors, and those of varied ethnic and cultural backgrounds. Skills Required: Ability to provide leadership to physicians, nurses, and other health care professionals, and an interest and involvement in the affairs of the health care community. Excellent written and verbal communication skills with the ability to effectively collaborate with multidisciplinary teams and senior leadership. Strong leadership, consensus-building, and stakeholder engagement skills, as well as a commitment to evidence-based practice, continuous quality improvement, regulatory compliance, and health equity. Demonstrated ability for teamwork and collaborative problem-solving. Commitment to patient-centered, value-based care. Strong leadership presence with the ability to lead, mentor, and motivate a team. Exceptional presentation skills to effectively convey complex medical concepts to diverse audiences. Ability to think strategically and take a broad, business-oriented perspective. Strong analytical and problem-solving skills, with a data-driven approach to evaluating programs. Ability to work in a fast-paced, dynamic, and often ambiguous environment. Licenses/Certifications Required Board Certified, preferably in Internal Medicine, Family Medicine, Emergency Medicine or Psychiatry. Clinical License to practice or an Administrative License to review Utilization Management cases. - Active, current and unrestricted California License Licenses/Certifications Preferred Certification as a Certified Medical Director (CMD) 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
CVS Health

Utilization Management Nurse Consultant

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

Utilization Management Nurse Consultant

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

RN DRG Downgrades Appeals Review Specialist

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

Nurse Case Manager - Inpatient

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

RN- Utilization Review- Part-time Weekends (Temple Hospital)

Temple Health Philadelphia, PA
Utilizing InterQual and other appropriate criteria, responsible for reviewing all admissions and continued stay of patients in conformance with the established criteria set forth in the hospital's utilization management and quality assurance plan. Will determine the medical necessity for admission and continued stays for patients within department's scope of service and to meet the hospital's objectives for assuring a high quality of patient care as well as assuring the effective and efficient utilization of available health services. Identifies appropriate level of care for inpatients and outpatients requiring overnight care. Education Other Graduate Of An Accredited School Of Nursing Required Bachelor's Degree BSN Required Experience 1 year experience of recent Utilization Review in acute care or in insurance company setting. Required 1 Year Experience In Medical-surgical Setting. Required 1 year experience in working with competency utilizing InterQual criteria. Required General Experience In Working With Utilization Review Standards Required Licenses PA Registered Nurse License Required Certified Case Manager Preferred Multi State Compact RN License Required Or
RN Utilization Review Per Diem
UHS

UTILIZATION MANAGMENT (UM) COORDINATOR - PRN

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

UM/ECM - RN Reviewer HP

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

Utilization Review Manager

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

RN Utilization Manager - Medicine, Oncology, Cardiac, & Psychiatry Services

UNC Health Chapel Hill, NC
$35.87 - $51.57 / hour
Description Areas of focus include Medicine, Oncology, Cardiac, and Psychiatry Services Preferences given to candidates with Medical Surgical and/or Psychiatry bedside experience. The Team: Completes clinical reviews for all areas: Inpatient, Observation, Extended Recovery Ensures compliance in accordance to government's federal rules and regulations related to patient care and reimbursement Interacts with the Interdisciplinary Team for patient care progression Protects hospital revenue by working with payors for insurance authorizations, denials, and appeals Delivers mandated federal notices to patients/ patient representatives related to their payer source 40 hrs/week (Monday-Friday) Weekend rotation Holiday rotation No Nights No on-call Become part of an inclusive organization with over 40,000 teammates, whose mission is to improve the health and well-being of the unique communities we serve. Summary: Works in collaboration with the patient/family, and interdisciplinary team (including physicians, other care providers, and payors), and assesses the patient care progression from acute care episode through post discharge for quality, efficiency, and effectiveness. The Utilization Manager works collaboratively with other Clinical Care Management staff to ensure patient needs are met and care delivery is coordinated across the continuum. The Utilization Manager completes admission, continued stay, and discharge reviews in accordance with federal regulations & the Hospitals? Utilization Management Plan. In addition, the Utilization Manager is responsible for revenue protection by reconciling physician orders, bed billing type, and medical necessity. This may include delivering notifications to patients directly. Interface is completed verbally, via email, data base tasks, or other electronic communication and via telephone. Responsibilities: 1. Clinical Review Process - Uses approved criteria and conducts admission review/status change review within 24 hours of patient admission to the hospital to ensure appropriateness of the setting and timely implementation of the plan of care. Identifies and obtains observation status as appropriate. Partners with physicians, nursing, and other care providers to help ensure timely and accurate documentation of patient data and treatments. Communicates daily with the Case Manager to manage level of care transitions & appropriate utilization of services. Coordinates with the support center to assure third party payor pre-certification and/or re-certifications when required. Utilizes high risk screening criteria to make appropriate referrals to Manager. 2. Discharge Facilitation - Identifies patient/families with the complex psychosocial, on-going medical discharge planning issues, continuing care needs by initiating appropriate case management referrals. Initiates appropriate social work referrals. 3. Utilization Management Process - Performs utilization management assessments and interventions, using collaboration with interdisciplinary team approach, on assigned patients as appropriate to ensure optimal patient outcomes. Using approved criteria, conducts continued stay and quality reviews to monitor the patient's progress along the continuum of care and intervenes as necessary to ensure appropriateness of setting and that the services provided are quality-driven, efficient, and effective. Enters all pertinent review data into the correct computer system in a timely manner. Consults with Physician Advisor as necessary to resolve barriers through appropriate administrative and medical channels. 4. Utilization Outcomes Management - Monitors and guides to trend interdisciplinary documentation and guides medical staff in documentation that will assist in coding accuracy, enhance quality of care, reflect accurate severity of illness and appropriate reimbursement. Facilitates patient movement to appropriate (acuity) level of care including observation status issues through collaboration with patient/family, multidisciplinary team, third party payors and resource center. Provides information regarding denials and approvals to designated entities. Assists in coordination of practice parameter development with the assigned departments/sections/specialties of Medical Staff. Oversees collection and analysis of patient care and financial data relevant to the target case types. Directs delivery of notifications to patients (includes traveling to hospital(s) to deliver notifications. Other Information Other information: Education Requirements: ● Graduation from a state-accredited school of professional nursing ● If hired after October 1, 2015, must be enrolled in an accredited program within four years of employment, and obtain a Bachelor's degree with a major in Nursing or a Master's degree with a major in Nursing within seven years of employment date. Licensure/Certification Requirements: ● Licensed to practice as a Registered Nurse in the state of North Carolina. Professional Experience Requirements: ● Two (2) years of clinical experience in a medical facility and/or comparable Utilization Management experience. Knowledge/Skills/and Abilities Requirements: Job Details Legal Employer: STATE Entity: UNC Medical Center Organization Unit: UNCH Care Mgmt-Medical Center Work Type: Full Time Standard Hours Per Week: 40.00 Salary Range: $35.87 - $51.57 per hour (Hiring Range) Pay offers are determined by experience and internal equity Work Assignment Type: Onsite Work Schedule: Day Job Location of Job: US:NC:Chapel Hill Exempt From Overtime: Exempt: Yes This is a State position employed by UNC Health Care System with UNC Health benefits. If, however, you are presently an employee of another North Carolina agency and currently participate in TSERS or the ORP, you will be eligible to continue participating in those plans at UNC Health. Qualified applicants will be considered without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, status as a protected veteran or political affiliation. UNC Health makes reasonable accommodations for applicants' and employees' religious practices and beliefs, as well as applicants and employees with disabilities. All interested applicants are invited to apply for career opportunities. Please email applicant.accommodations@unchealth.unc.edu if you need a reasonable accommodation to search and/or to apply for a career opportunity.
RN Pediatric Utilization Review Full-time
Rady Children's Hospital-San Diego

UM/QI/Capitation Nurse (RN) - Utilization Management

Rady Children's Hospital-San Diego San Diego, CA
$45.75 - $62.90 / hour
This is a fulltime authorization nurse, experience with health plan authorization process is strongly preferred. May be considered a hybrid position JOB SUMMARY: Under the supervision of the Supervisor, UM Clinical, the Utilization/Case Manager Nurse coordinates the delivery of care through assessment, planning, facilitation, & patient advocacy to ensure cost-effective, quality outcomes of care. The Utilization/Case Manager Nurse works with all members of the health care team to ensure optimal outcomes are reached while appropriate utilization occurs MINIMUM QUALIFICATIONS: Associate’s Degree 3 years of experience California RN License Knowledge of common medical insurance operations Managed Care experience (will consider Hospital Case Management Experience) Strong mathematical and reasoning skills PREFERRED QUALIFICATIONS: Bachelor’s Degree Pediatric Nursing Experience The current salary range for this position is $45.75 to $62.90 Rady Children’s Hospital is committed to compensation that is externally competitive and internally equitable. We demonstrate this commitment by conducting regular market reviews to remain competitive with organizations of similar size in the nonprofit, healthcare sector. The range listed above does not represent the full salary range for the position but is the expected hiring range for qualified candidates. Compensation decisions consider a variety of factors including experience, education, licensure, unique skillsets, organizational need, and internal equity. This posting will remain open from the “date posted” until the hiring manager has determined there is a sufficient applicant pool or until the position is filled.
RN Utilization Review Full-time
Lexington Medical Center

Utilization Review Specialist RN - Onsite

Lexington Medical Center West Columbia, SC
Utilization Management Dept. Full Time Day Shift 8-4:30 Lexington Health is a comprehensive network of care that includes six community medical and urgent care centers, nearly 80 physician practices, more than 9,000 health care professionals and Lexington Medical Center, a 607-bed teaching hospital in West Columbia, South Carolina. It was selected by Modern Healthcare as one of the Best Places to Work in Healthcare and was first in the state to achieve Magnet with Distinction status for excellence in nursing care. Consistently ranked as best in the Columbia Metro area by U.S. News & World Report, Lexington Health delivers more than 4,000 babies each year, performs more than 34,000 surgeries annually and is the region's third largest employer. Lexington Health also includes an accredited Cancer Center of Excellence, the state’s first HeartCARE Center, the largest skilled nursing facility in the Carolinas, and an Alzheimer’s care center. Its postgraduate medical education programs include family medicine and transitional year residencies, as well as an informatics fellowship. Job Summary Performs admission and concurrent stay medical record review to determine appropriateness of admission, continued stay, and setting. Follows patient throughout hospitalization collaborating with attending physician and other health care providers. Communicates with third party payors to obtain authorization. Contributes to appropriate throughput and length of stay. Assists with denial management. Reviews physician medical record documentation and consults with physicians regarding completeness. Minimum Qualifications Minimum Education: ADN, Diploma Nursing Degree, or Bachelor of Science in Nursing Minimum Years of Experience: 3 Years of experience in an acute care hospital setting Substitutable Education & Experience: None. Required Certifications/Licensure: Registered Nurse currently licensed in the State of South Carolina Required Training: None. Essential Functions Works in a cooperative manner, which fosters favorable relations between employees and patients, patients' families, visitors, fellow employees, and the medical staff. Accepts chain of command, supervision, and constructive criticism. Exhibits commitment and pride through personal example by positively speaking about LMC, the department, employees and guests. Contributes to teamwork and creates harmonious, effective and positive working relationships with others. Respects, understands, and responds with sensitivity to employees and guests by treating others as one would wish to be treated. Resolves conflicts and problems-solves by remaining calm when confronted, attempting to identify solutions or referring person to appropriate authority and attempting to deliver more than is expected. Exhibits telephone courtesy by: Answering promptly with name and department. Speaking with pleasant tone while focusing on caller. Transferring calls correctly and promptly. Attending to calls on hold in a timely manner. Maintains confidentiality by: Discouraging gossip. Using discretion when discussing patient, work, or LMC-related information with others. Utilizes the service recovery process to resolve complaints (GIFT). Demonstrates competence in providing duties within role. Demonstrates competence to provide developmentally appropriate planning/review for patients of all age groups. Identifies need for professional growth and seeks appropriate professional development opportunities attaining a minimum of 15 hours of continuing education in topics related to the role annually. Serves as role model for other members of the health care team. Demonstrates receptiveness to change and flexibility in meeting department needs. Assists in orientation and training of staff. Performs admission and continued stay medical record review to gather information to support medical necessity of the admission and communicate with third party payors. Performs timely review of admissions utilizing InterQual criteria to assess for appropriate level of care assignment. Reviews both inpatient admissions and patients placed in Observation. Incorporates applicable governmental regulatory guidelines in effect for Medicare and/or Medicaid admissions. Submits clinical data to third party payors and documents authorization in electronic medical record system. Performs continued stay reviews based on intensity of service, clinical response to care, expected length of stay and readiness for discharge, or at intervals which correspond to authorized days. Refers Observation or Inpatient admissions that lack documented medical necessity for the stay to the Physician Advisor and completes any needed follow through to ensure correct level of care and billing based on the Physician Advisor’s determination. Documents pertinent clinical data on worksheets. Ensures regulatory compliance and revenue integrity utilizing appropriate billing policies. Certifies Medicare admission utilizing established admission screening criteria. Duties & Responsibilities Applies appropriate condition codes and modifiers in electronic medical record system to communicate accurate claims information for billing. Documents denial information in electronic medical record system including attempts at resolution/overturning of the denial. Provides all payor communication to be scanned into the system for use in appeals. Maintains good working relationships with other departments within the revenue cycle. Conveys and receives information efficiently to and from third party payors, physicians, patients/families, physician practices, other members of the health care team, and other external agencies. Respects patient confidentiality and uses discretion in all interactions regarding patient protected health information. Consults with attending physician when documentation in the medical record does not support admission or continued stay and seeks to ensure completeness of all clinical documentation. Functions as liaison between the Physician Advisor and the attending physician. Serves as a resource to physicians, patients, physician practices, and other members of the health care team regarding issues related to patient classification and reimbursement. Issues letters of non-coverage in cases where the admission or continued stay is not certified, as necessary. Ensures patient/family notification of Observation status and documents in electronic medical record. Communicates insurance authorization information to physician's office as requested. Communicates with case management triad regarding reimbursement issues. Uses appropriate channels for reporting progress or concerns. Participates in making appropriate and efficient discharge plans for patients on assigned areas. Consults with members of the health care team effectively and efficiently regarding patient discharge plans. Manages inpatient Medicare discharge expedited appeals process through the QIO. Notifies attending physician and other members of the health care team of inappropriate admissions, denials, end of authorized days, or other factors that have a reimbursement impact. Consults Physician Advisor in cases where patient demonstrates readiness for discharge, but there is no documented intent to discharge. Identifies and documents potentially avoidable days in electronic medical record system. Assist Social Work staff to coordinate/obtain authorization for post acute services as needed. Identifies opportunities for improvement and coordinates/participates in the development and implementation of action plans to make improvements. Participates in unit discharge planning activities and in interdisciplinary patient care conferences. Indentifies abnormal patterns of utilization and refers to Manager/Director. Recommends changes to system/processes to eliminate identified problems. Represents department on various committees/taskforces. Adapts to change in timely and positive manner. Strives to meet department and hospital goals. Performs all other duties as assigned by authorized personnel or as required in an emergency (e.g., fire or disaster). We are committed to offering quality, cost-effective benefits choices for our employees and their families: Day ONE medical, dental and life insurance benefits Health care and dependent care flexible spending accounts (FSAs) Employees are eligible for enrollment into the 403(b) match plan day one. LHI matches dollar for dollar up to 6%. Employer paid life insurance – equal to 1x salary Employee may elect supplemental life insurance with low cost premiums up to 3x salary Adoption assistance LHI provides its full-time employees employer paid short-term disability and long-term disability coverage after 90 days of eligible employment Tuition reimbursement Student loan forgiveness Equal Opportunity Employer It is the policy of Lexington Health to provide equal opportunity of employment for all individuals, and to remain compliant with applicable state and federal laws and regulations. Lexington Health strives to provide a discrimination-free environment, and to recruit, select, on-board, and employ all employees without regard to race, color, religion, sex, age, disability, national origin, veteran status, or pregnancy, childbirth, or related medical conditions, including but not limited to, lactation. Lexington Health endeavors to upgrade and promote employees from within the hospital where possible and consistent with the employee’s desires and abilities and the hospital’s needs.
RN Utilization Review Full-time
L.A. Care Health Plan

Utilization Management Admissions Liaison RN II

L.A. Care Health Plan Los Angeles, CA
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) Admissions Liaison RN II is primarily responsible for receiving/reviewing admission requests and higher level of care (HLOC) transfer requests from inpatient facilities within regular timelines. Reviews clinical data in real-time and post admission to issue a determination based on clinical criteria for medical necessity. Assures timely, accurate determination and notification of admission and inter-facility transfer requests. Generates approval, modification, and denial communications for inpatient admission requests. Actively monitors for appropriate level of care (inpatient vs. observation) admission in the acute setting. Works with UM leadership, including the Utilization Management Medical Director, on requests where determination requires extended review. Collaborates with the inpatient care team for facilitation/coordination of patient transfers between acute care facilities. Acts as a department resource for medical service requests/referral management and processes. Actively participates in the discharge planning process, including providing clinical review and authorization for alternate levels of care, home health, durable medical equipment, and other discharge needs. Provides support to the inpatient review team as necessary to ensure timely processing of concurrent reviews. Duties Provides the primary clinical point of contact for inpatient acute care hospitals requesting Inpatient care/post-stabilization admission requests, Higher level of care transfers and other emergent transfers or needs. Ensures appropriate determination for admission requests/HLOC transfers based on clinical data presented and established criteria/guidelines, escalating to the medical director if needed. Triages and assesses members for admission needs, including, but not limited to, bed and accepting physician availability. (40%) Establishes and maintains ongoing communication with internal stakeholders and external customers while securing the L.A. Care member's admission or inter-facility transfer. Interfaces with physicians, house supervisors, and other hospital delegates to ensure that telephone triage results in appropriate patient placement. (10%) Applies clinical expertise and the nursing process to triage and prioritize admission acuity, servicing as an expert clinical resource for patient placement while utilizing medical knowledge and experience to facilitate consensus-building and development of satisfactory outcomes (10%) Continually seeks new ways to improve processes and increase efficiencies. Takes the initiative to communicate recommendations to UM Leadership. (5%) Completes all inpatient and discharge planning requests appropriately and timely including, but not limited to: Skilled nursing facility, outpatient needs (home health, physical therapy, infusion), and case management referrals (5%) Performs prospective, concurrent, post-service, and retrospective claim medical review processes. Utilizes clinical judgement, independent analysis, critical-thinking skills, detailed knowledge of medical policies, clinical guidelines and benefit plans to complete reviews and determinations within required turnaround times specific to the case type. Identifies requests needing medical director review or input and presents for second level review (20%) Performs other duties as assigned. (10%) Duties Continued Education Required Associate's Degree in Nursing Education Preferred Bachelor's Degree in Nursing Experience Required: Minimum of 7 years of clinical experience in an acute hospital setting. Previous experience to have a strong understanding of Utilization Management/Case Management practices including, but not limited to, placement (with level of care) criteria (MCG, InterQual), concurrent review, and discharge planning. Preferred: Consistent Critical Care experience (Emergency Department, Intensive Care, Labor & Delivery) background highly desirable. Experience in bed placement decision-making highly desirable. Skills Required: Must be computer literate, with expertise in Outlook, Word, Excel, PowerPoint. Provision of excellent customer service required due to frequent communication with providers and other members of the interdisciplinary team Knowledge of personal computer, keyboarding, and appropriate software to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment. Prepare clear, comprehensive written and oral reports and materials. Excellent time management and priority-setting skills. Maintains strict member confidentiality and complies with all HIPAA requirements. Strong verbal and written communication skills. Preferred: Knowledge of National Committee for Quality Assurance (NCQA) requirements for Utilization Management or CM. Knowledge of Department of Health Care Services (DHCS) or Centers for Medicare and Medicaid Services(CMS) requirements for health plan compliance with UM or CM. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California License Licenses/Certifications Preferred Certified Case Manager (CCM) American Case Management Association (ACM) Required Training Physical Requirements Light Additional Information Required: Attend mandatory department trainings as scheduled Financial Impact: Management of all medical services has a tremendous potential impact on the cost of health care and budget. This position manages determinations to ensure services requested are medically appropriate and provided in the most cost effective manner without compromising quality healthcare delivery. Types of Shift: Day (7:00am - 3:30pm), Evening (3:00pm -11:30 pm), Night (11:00pm -7:30am). Float (Varies)* *All possible shifts. 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)
LPN Utilization Review Full-time
TriStar Health

Clinical LVN - LPN Nurse Reviewer

TriStar Health Nashville, TN
Introduction Do you want to join an organization that invests in you as a(an) Clinical Nurse Reviewer? At Methodist Hospital, you come first. HCA Healthcare has committed up to 300 million in programs to support our incredible team members over the course of three years. Benefits Methodist Hospital offers a total rewards package that supports the health, life, career and retirement of our colleagues. The available plans and programs include: Comprehensive medical coverage that covers many common services at no cost or for a low copay. Plans include prescription drug and behavioral health coverage as well as free telemedicine services and free AirMed medical transportation. Additional options for dental and vision benefits, life and disability coverage, flexible spending accounts, supplemental health protection plans (accident, critical illness, hospital indemnity), auto and home insurance, identity theft protection, legal counseling, long-term care coverage, moving assistance, pet insurance and more. Free counseling services and resources for emotional, physical and financial wellbeing 401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service) Employee Stock Purchase Plan with 10% off HCA Healthcare stock Family support through fertility and family building benefits with Progyny and adoption assistance. Referral services for child, elder and pet care, home and auto repair, event planning and more Consumer discounts through Abenity and Consumer Discounts Retirement readiness, rollover assistance services and preferred banking partnerships Education assistance (tuition, student loan, certification support, dependent scholarships) Colleague recognition program Time Away From Work Program (paid time off, paid family leave, long- and short-term disability coverage and leaves of absence) Employee Health Assistance Fund that offers free employee-only coverage to full-time and part-time colleagues based on income. Learn more about Employee Benefits Note: Eligibility for benefits may vary by location. You contribute to our success. Every role has an impact on our patients’ lives and you have the opportunity to make a difference. We are looking for a dedicated Clinical Nurse Reviewer like you to be a part of our team. Job Summary and Qualifications Recruiter to insert Job Summary and requirements here Recruiter to check inserted requirements to ensure it included all credentials below. Then they should delete the credentials What qualifications you will need: (LPN/LVN) Licensed Practical or Vocational Nurse, or (RN) Registered Nurse " Parallon provides full-service revenue cycle management, or total patient account resolution, for HCA Healthcare. Our services include scheduling, registration, insurance verification, hospital billing, revenue integrity, collections, payment compliance, credentialing, health information management, customer service, payroll and physician billing. We also provide full-service revenue cycle management as well as targeted solutions, such as Medicaid Eligibility, for external clients across the country. Parallon has over 17,000 colleagues, and serves close to 1,000 hospitals and 3,000 physician practices, all making an impact on patients, providers and their communities. HCA Healthcare has been recognized as one of the World’s Most Ethical Companies® by the Ethisphere Institute more than ten times. In recent years, HCA Healthcare spent an estimated 3.7 billion in cost for the delivery of charitable care, uninsured discounts, and other uncompensated expenses. " "Good people beget good people." - Dr. Thomas Frist, Sr. HCA Healthcare Co-Founder We are a family 270,000 dedicated professionals! Our Talent Acquisition team is reviewing applications for our Clinical Nurse Reviewer opening. Qualified candidates will be contacted for interviews. Submit your resume today to join our community of caring! We are an equal opportunity employer. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.
RN Utilization Review Full-time
UNC Health

Utilization Manager (RN)

UNC Health Hendersonville, NC
Description Become part of an inclusive organization with over 40,000 teammates, whose mission is to improve the health and well-being of the unique communities we serve. Summary: The Utilization Manager (UM) assesses new admissions, continued stay and discharge review cases for medical necessity, appropriate class and level of care (LOC). This position works collaboratively with an interdisciplinary team (including physicians, other care providers, payers, etc.) to ensure the patient’s needs are met and care delivery is coordinated. The UM completes utilization reviews in accordance with federal regulations and the health system’s Utilization Review Plan. Responsibilities: Uses approved criteria and conducts admission review/class change review as trigger by patient admission to the hospital to ensure appropriateness of the setting and timely implementation of the plan of care. Identifies and obtains observation services as appropriate . Partners with physicians, nursing, and other care providers to help ensure timely and accurate documentation of patient data and treatments. Communicates daily with the Care Manager to manage level of care transitions & appropriate utilization of services. Coordinates with the appropriate staff/payers to assure third party payer pre-certification and/or re-certifications when required . Discharge Facilitation: Utilizes high risk screening criteria to make appropriate referrals . Identifies patient/families with the complex psychosocial, on-going medical transition planning issues , continuing care needs by initiating appropriate care management referrals. Initiates appropriate social work referrals. Performs utilization management assessments and interventions, using collaboration with interdisciplinary team approach, on assigned patients as appropriate to ensure optimal patient outcomes. Using approved criteria, conducts initial and continued stay reviews to monitor the patient's progress along the continuum of care and intervenes as necessary to ensure appropriateness of setting and that the services provided are quality-driven, efficient, and effective. Enters all pertinent review data into the correct computer system in a timely manner . Consults with Physician Advisor as necessary to resolve barriers through appropriate administrative and medical channels. Monitors and guides to trend interdisciplinary documentation and guides medical staff in documentation that will assist in coding accuracy, enhance quality of care, reflect accurate severity of illness and appropriate reimbursement . Facilitates patient movement to appropriate (acuity) level of care including observation services issues through collaboration with patient/patient representative, multidisciplinary team, third party payers and care managers/social workers. Provides information regarding denials and approvals to appropriate staff and/or designated entities. Documents and delivers notifications to patients, patient representative and/or appropriate staff . Reviews Pre-Scheduled surgery admissions for proper status order for inpatient-only procedures. Collaborates to problem-solve issues with complex patients and identify trends. Formulates potential solutions with Care Manager and Social Worker and continuously monitors cases/follows up on all action items. Proactively identify high risk cases that need to be escalated to the list that are not scheduled for discussion that week. PARDEE Other information: Required Must be licensed to practice as a Registered Nurse in the state of North Carolina or one of compact states. Two (2) years of experience working as a Registered Nurse. Strong verbal and written communication. Basic Life Support (BLS) certification. Preferred Bachelor's of Science in Nursing (BSN) Certification in Case Management 01.6015.1542 Job Details Legal Employer: Pardee - HCHC Entity: Pardee UNC Health Care Organization Unit: Acute Care Case Management Work Type: Full Time Standard Hours Per Week: 40.00 Work Assignment Type: Onsite Work Schedule: Day Job Location of Job: PARDEEHOSP Exempt From Overtime: Exempt: No Qualified applicants will be considered without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, status as a protected veteran or political affiliation.
RN Utilization Review Full-time
JPS Health Network

Nurse Case Manager - Utilization Review

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

RN-Utilization Review

Baptist Memorial Health Care Memphis, TN
Overview Job Summary Manages the care for a specific population; facilitates the safe transition of patients throughout the continuum of care for appropriate utilization of resources, service delivery and compliance with federal and other payer requirements. Provides early assessment of transitional needs identified during their hospitalization, illness, and/or life situation. Performs other duties as assigned. Responsibilities Utilization Review Discharge planning Readmission Reduction Participation Payer Communication and denial reduction Completes assigned goals. Specifications Experience Minimum Required RN with at least one (1) year of clinical experience Preferred/Desired RN with 3 years of clinical experience with Case Management experience in a hospital or payer setting Education Minimum Required Diploma or Associate Degree in Nursing Preferred/Desired BSN or MSN Training Minimum Required Preferred/Desired Certified Case Manager Special Skills . Minimum Required Critical thinking skills, communication, organization, interpersonal and computer skills. Problem solving; and governmental regulations. Preferred/Desired Critical thinking skills, communication, organization, interpersonal and computer skills. Knowledge of payer requirements; problem solving; and governmental regulations. Licensure RN Minimum Required RN Preferred/Desired RN;CCM;ACM
RN Utilization Review Full-time
L.A. Care Health Plan

Utilization Management Nurse Specialist RN II

L.A. Care Health Plan Los Angeles, CA
Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job Summary The Utilization Management Nurse Specialist RN II facilitates, coordinates, and approves medically necessary referrals that meet established criteria. Assures timely and accurate determination and notification of referrals and reconsiderations based on the referral determination status. Generates approval, modification and denial communications, to include member and provider notification of referral determination. Actively monitors for admissions in any inpatient setting. Performs telephonic and/or onsite admission and concurrent review, and collaborates with onsite staff, physicians, providers, member/family interaction to develop and implement a successful discharge plan. Works with the UM Manager and Physician Advisor on case reviews for pre-service, concurrent, post-service and retrospective claims medical review. Monitors and oversees the collection and transfer of data (medical records) and referral requests by Providers. Acts as a department resource for medical service requests /referral management and processes. Receives incoming calls from providers, professionally handles complex calls, researches to identify timely and accurate resolution steps. Follows up with caller to provide response or resolution steps. Answers all inquiries in a professional and courteous manner. Duties Promote and support team engagements, programs and activities to create and ensure a positive and productive workplace environment. Perform telephonic and/or onsite admission and concurrent review, and collaborates with onsite staff, physicians, providers, the member and significant others to develop and implement a successful discharge plan. Process, finalize and facilitate inbound requests that are received from providers. Generate appropriate member and provider communication for all determinations within the required timelines as defined by the most current department policy. Facilitate/review requests for Higher level of care or skilled nursing/discharge planning needs. Research for appropriate facilities, specialty providers and ancillary providers to utilize for all lines of business. Identification of potential areas of improvement within the provider network. Identify and initiate referrals for appropriate members to the various L.A. Care programs/processes and external community based programs or Linked and Carve Out Services (e.g. DDS/CCS/MH). Potential quality of care/potential fraud issues are identified and documented per L.A. Care policy. High risk/high cost cases and reports are maintained and referred to the Physician Advisor/UM Director. Document in platform/system of record. Utilize designated software system to document reviews and/or notes. Receive incoming calls from providers, professionally handle complex calls, research to identify timely and accurate resolution steps. Follow up with caller to provide response or resolution steps. Answer all inquiries in a professional and courteous manner. Perform other duties as assigned. Duties Continued Education Required Associate's Degree in Nursing Education Preferred Bachelor's Degree in Nursing Experience Required: At least 5 years of varied RN clinical experience in an acute hospital setting. At least 2 years of Utilization Management/Case Management experience in a hospital or HMO setting . Preferred: Managed Care experience performing UM and CM at a medical group or management services organization. Experience with Managed Medi-Cal, Medicare, and commercial lines of business. Skills Required: Must be computer literate, with expertise in Outlook, Word, Excel, PowerPoint. Effectively utilizes computer and appropriate software and interacts as needed with L.A. Care Information System. Knowledge of personal computer, keyboarding, and appropriate software to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment. Prepare clear, comprehensive written and oral reports and materials. Provision of excellent customer service required due to frequent communication with providers and other members of the interdisciplinary team Excellent time management and priority-setting skills. Maintains strict member confidentiality and complies with all HIPAA requirements. Strong verbal and written communication skills. Preferred: Knowledge of National Committee for Quality Assurance (NCQA) requirements for Utilization Management or Care Management (CM). Knowledge of Department of Health Care Services (DHCS) or Centers for Medicare and Medicaid Services(CMS) requirements for health plan compliance with UM or CM. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California License Licenses/Certifications Preferred Certified Case Manager (CCM) Required Training Physical Requirements Light Additional Information May work on occasional weekends and some holidays depending on business needs. Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. L.A. Care offers a wide range of benefits including Paid Time Off (PTO) Tuition Reimbursement Retirement Plans Medical, Dental and Vision Wellness Program Volunteer Time Off (VTO)
RN Manager/Supervisor Utilization Review Full-time
MJHS

Supervisor, Concurrent Review RN

MJHS New York, NY
$101,503.41 - $126,879.27 / year
Overview The challenges of affordable healthcare continue to create new opportunities. Elderplan and HomeFirst, our Medicare and Medicaid managed care health plans, are outstanding examples of how we are expanding services in response to our patients' and members' needs. These high-quality healthcare plans are designed to help keep people independent and living life on their own terms. The MJHS Difference At MJHS, we are more than a workplace; we are a supportive community committed to excellence, respect, and providing high-quality, personalized health care services. We foster collaboration, celebrate achievements, and promote fairness for all. Our contributions are recognized with comprehensive compensation and benefits, career development, and the opportunity for a healthy work-life balance, advancement within our organization and the fulfillment of having a lasting impact on the communities we serve. Benefits include: Sign-on Bonuses OR Student Loan Assistance for clinical staff FREE Online RN to BSN and MSN degree programs! Tuition Reimbursement for all full and part-time staff Dependent Tuition Reimbursement for clinical staff! Generous paid time off, including your birthday! Affordable and comprehensive medical, dental and vision coverage for employee and family members Two retirement plans ! 403(b) AND Employer Paid Pension Flexible spending And MORE! MJHS companies are qualified employers under the Federal Government’s Paid Student Loan Forgiveness Program (PSLF) Responsibilities Provides quality, cost-effective care to all members through the direct supervision of staff responsible for the management and coordination of the member's care through the incorporation of interdisciplinary strategies, medicare regulations, and medically accepted standards of care. Supervises the assessment of all acute and sub-acute inpatient care for appropriateness of setting and services, according to pre-established criteria and guidelines and ensure a 95% compliance or greater. Supervises the assessment and coordination of the members physical, psychosocial and discharge planning needs through communication with appropriate hospital staff including treating physician, PCP, utilization managers, social workers, discharge planners. Assures appropriate staffing to support departmental/agency services. Ensures all employees are oriented to their department/agency and job and provided with appropriate training, development and continuing education. Correctly interprets and applies all Human Resources policies and procedures relative to discipline, recruitment and selection, performance appraisals, salary reviews and staffing. Qualifications Bachelor's Degree in Nursing. Minimum one to three years previous management experience preferred. Previous managed care experience in the areas of utilization management and/or case management required. Working knowledge of Windows, Word, Excel. Knowledge of Federal and State regulations, managed care regulations and concepts, and CQI methodologies. Min USD $101,503.41/Yr. Max USD $126,879.27/Yr.
NP Director of Nursing Utilization Review Full-time
Astrana Health

Medical Director - Utilization Management

Astrana Health Monterey Park, CA
$275,000 - $325,000 / year
Medical Director - Utilization Management Department: HS - UM Employment Type: Full Time Location: 1600 Corporate Center Dr., Monterey Park, CA 91754 Reporting To: Dr. Dinesh Kumar Compensation: $275,000 - $325,000 / year Description As Medical Director - Utilization (UM) at Astrana Health, you will provide clinical oversight and strategic leadership through our utilization review operations to ensure members receive high-quality, medically appropriate, and cost-effective care. This is a critical, cross-functional role that bridges clinical expertise with operational execution across value-based care, capitated models, and delegated risk structures. You’ll work closely with teams in Care Management, Quality Improvement, Pharmacy, Behavioral Health, and Compliance to drive aligned decision-making that supports both optimal patient outcomes and efficient healthcare resource use. In this role, you’ll apply evidence-based criteria to utilization decisions, mentor clinical review teams, and support compliance with all applicable regulatory and contractual obligations. This position is ideal for a clinically grounded physician who thrives in a data-informed, team-based environment and is passionate about transforming how care is delivered in a risk-bearing, population health-focused ecosystem. Our Values: Put Patients First Empower Entrepreneurial Provider and Care Teams Operate with Integrity & Excellence Be Innovative Work As One Team What You'll Do Prior Authorization Management Review and issue timely determinations for prior authorization requests, ensuring medical necessity, regulatory compliance, and alignment with evidence-based clinical guidelines. Collaborate with care management and operational teams to streamline and enhance prior authorization workflows for efficiency and provider satisfaction. Provide clinical leadership in the development, implementation, and regular updating of authorization criteria and policies based on the latest medical standards. Promote transparency by clearly documenting and communicating authorization decisions to providers and members, including rationale and guidance for alternative treatment options when applicable. Utilization Management Provide oversight for the daily activities of the UM program, ensuring services are delivered appropriately and in accordance with clinical best practices. Analyze utilization data to identify trends, high-cost drivers, and opportunities for care optimization and cost containment. Participate in the clinical review of complex or high-cost cases, offering recommendations rooted in medical necessity and member-centered care. Collaborate with interdisciplinary clinical teams to ensure the appropriate use of healthcare resources without compromising quality. Quality Assurance and Improvement Ensure all UM activities meet applicable federal, state, and accreditation standards (e.g., CMS, NCQA). Lead and contribute to quality improvement initiatives focused on enhancing the effectiveness, accuracy, and consistency of the prior authorization and UM processes. Conduct audits and peer reviews to validate adherence to guidelines and evaluate the quality of medical decision-making. Provider and Member Communication Serve as the primary clinical contact for complex medical necessity determinations and escalated provider appeals. Build strong working relationships with providers by offering education and clarity around the prior authorization process and criteria. Support member care continuity by suggesting medically appropriate alternatives when requested services are denied. Regulatory Compliance and Accreditation Ensure full compliance with all applicable UM regulatory and accreditation standards, including NCQA and CMS requirements. Maintain up-to-date knowledge of evolving healthcare laws, policies, and industry standards affecting prior authorization and UM processes. Lead internal efforts to prepare for and maintain UM-related accreditation, including audits, documentation, and process improvement. Data Analysis and Reporting Monitor and analyze prior authorization and UM metrics (e.g., denial rates, turnaround times, appeal volumes) to identify performance gaps and track progress. Use data-driven insights to inform strategic decisions, improve process efficiency, and support cost management goals. Provide regular updates and reporting to senior leadership on program performance, cost impact, compliance status, and quality indicators. Qualifications Medical Degree (MD or DO) from an accredited institution; active and unrestricted medical license in CA. Board certification (preferred) in a relevant specialty (e.g., Internal Medicine, Family Medicine, or equivalent). Minimum 5+ years of clinical practice experience. At least 3 years of experience in utilization management or medical management within a health plan, IPA/MSO, or risk-bearing organization. Deep knowledge of managed care, value-based care, capitation, and CMS/Medi-Cal guidelines. Proficient in applying MCG, InterQual, or equivalent criteria. Strong understanding of state and federal regulations (e.g., CMS, DMHC, NCQA). Excellent communication skills, including the ability to engage providers in meaningful, respectful clinical dialogue. Highly collaborative mindset with a commitment to improving healthcare equity, quality, and cost-effectiveness. Environmental Job Requirements and Working Conditions This position operates on a hybrid schedule out of our Monterey Park office, located at 1600 Corporate Center Drive. We are seeking candidate who reside in Southern California who are able to go in-office for orientation, meetings, etc. The national target base salary range for this role is: $275,000 - $325,000. Actual compensation will be determined based on geographic location (current or future), experience, or other job-related factors. Astrana Health is proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based on race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. All employment is decided based on qualifications, merit, and business need. If you require assistance in applying for open positions due to a disability, please email us at humanresourcesdept@astranahealth.com to request an accommodation. Additional Information: The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.