jobs matching Utilization Review

Utilization Review Nurse Jobs

Registered Nurse - CASE MANAGER - Utilization Management

RNDISCG-3130 JOB DUTIES Participation in coordination of care for patients that are admitted or in observation status at MMC. Provides leadership for other team members. This Clinical Liaison would be expected to meaningfully impact length of stay, quality of care, and discharge experience by working to develop a multi-disciplinary plan for successful transition to the next level of care and determining appropriate discharge disposition while also driving the elimination of barriers Round with hospitalists- Complete daily review of length of stay and discharge probability based on clinical presentation and post-acute care needs. Clinical liaison for discharge planning with direct communication and involvement with patients/families, providers, social service discharge planners, Utilization Management team, and clinical services This position involves strong clinical skills, communication, database analysis, trending and tracking performance measures, as well as independent pursuit, and performing high quality work on a deadline. This person must work collaboratively with physicians, nurses, agencies, administration, patients and families. Prioritizes caseload based on length of stay, acuity level, and identified patient needs. Evaluates and modifies plan of care based on patient responses and attainment of expected outcomes. Evaluates comprehension of clinical information presented in regards to discharge planning needs and provides additional education as needed. Ensures timely and accurate documentation and communication of the next steps in the continuum of care to the patient, family, and agencies involved in care. Provide privacy for interviews/consultations for patients/families whenever possible, and is sensitive to surroundings when identifying and discussing additional support needed to foster self-management of medical needs. Provides list of available agencies for referrals, as well as information on DNR and advanced directives when appropriate, and facilities discussion with patient/ family and community agency accepting referral as needed. Is aware of psychosocial status and cognitive abilities of patient, and facilitates follow up with family members or next of kin as needed for discharge planning. Uses appropriate communication skills for specific ages, education, and cognitive level and is aware of psychosocial status and cognitive abilities of patient when facilitating discussions regarding discharge-planning needs. Is aware of child and elderly abuse issues and domestic violence, and makes the appropriate referrals. Identifies potential safety hazards in the home environment and provides contact information for identified community resources in the discharge instructions that may assist in the elimination of such hazards. Promotes decreased lengths of observation stays or inpatient stays when appropriate. Identifies appropriate alternative resources and demonstrate creativity in managing each case to fully utilize all available resources. Performs other duties as assigned. SPECIFIC JOB DEMANDS Strength: Sedentary Work - Lifting, Carrying, Pushing, Pulling 10 Lbs. occasionally. Mostly sitting, may involve standing or walking for brief periods of time. Reaching: Occasionally - Extending hand(s) or arm(s) in any direction. Handling: Occasionally - Seizing, holding, grasping, turning, or otherwise working with hand or hands. Fingers are involved only to the extent that they are an extension of the hand. Fingering: Occasionally - Picking, pinching, typing or otherwise working primarily with fingers rather than with the whole hand or arm as in handling. Talking: Frequently - Expressing or exchanging ideas by means of the spoken word to impart oral information to clients or to the public and to convey detailed spoken instructions to other workers accurately, loudly, or quickly. Hearing: Frequently - Perceiving the nature of sounds by ear. Near Acuity: Frequently - Clarity of vision at 20 inches or less. Accommodation: Occasionally - Adjustment of lens of eye to bring an object into sharp focus. This factor is required when doing near point work at varying distances from the eye. Color Vision: Frequently - Ability to identify and distinguish colors. MINIMUM EDUCATION, KNOWLEDGE, SKILLS, AND ABILITIES REQUIRED Proof of successful completion of education requirements for registered nurse as defined by the state in which the employee is to practice as well as proof of such licensure in good standing. Preferred have at least 5 years’ experience as a Registered Nurse. Advanced clinical expertise and extensive knowledge of complex disease processes with a broad clinical experience in an inpatient setting required Ability to read analyze and interpret documents, reports, technical procedures, governmental regulations and correspondence BLS required. WORKING CONDITIONS Generally, works in a well-lit, clean, temperature regulated office environment. May be required to be in various hospital departments. DISCLOSURE MMC commits to review, under the intent of this standard, and in coordination with medical professional opinion’s and physical demands job analysis performed by certified professionals, an individual’s ability to be reasonably accommodated within the role they are responsible and qualified to perform. MMC is committed to complying with the Americans with Disabilities Act (“ADA”) and providing equal opportunity employment for qualified persons with disabilities. All employment practices and activities are conducted on a nondiscriminatory basis. Meadville Medical Center will follow any state or local law that provides individuals with disabilities greater protection that the ADA. Every effort has been made to make your job description as complete as possible. However, this in no way states or implies that these are the only duties you will be required to perform. The omission of specific tasks does not exclude them from the position if the task is similar, related, or is a logical assignment to the position, or is imperative for patient care and to meet emergency situations.

Utilization Management Nurse Consultant - Medical Review (Remote)

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 Information Schedule: Monday–Friday 8:00am-5:00pm EST Location: 100% Remote (U.S. only) 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 a team that’s making a difference in the lives of patients facing complex medical journeys. As a Utilization Management (UM) Nurse Consultant specializing in Medical Review, you’ll play a vital role in ensuring members receive timely, medically necessary care through thoughtful clinical review and collaboration with providers. This fully remote position offers the opportunity to apply your clinical expertise in a fast-paced, desk-based environment where precision, communication, and compassion intersect. Key Responsibilities Utilizes clinical experience and skills in a collaborative process to implement, coordinate, monitor and evaluate medical review cases. Applies the appropriate clinical criteria/guideline and plan language or policy specifics to render a medical determination to the client. Applies critical thinking, evidenced based clinical criteria and clinical practice guidelines. Med Review nurses use specific criteria to authorize procedures/services or initiate a Medical Director referral as needed. Assists management with training new nurse reviewers/business partners or vendors to include initial and ongoing mentoring and feedback. Actively cross-trains to perform reviews of multiple case types to provide a flexible workforce to meet client needs. Recommends, tests, and implements process improvements, new audit concepts, technology improvements, etc. that enhance production, quality, and client satisfaction. Must be able to work independently without personal distractions to meet quality and metric expectations. 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 RN license in your state of residence with multistate/compact licensure privileges. Ability to obtain licensure in non-compact states as needed. Minimum 3 years of clinical experience. 5 years demonstrated to make thorough independent decisions using clinical judgement. 5 Years proficient use of equipment experience including phone, computer, etc. and clinical documentation systems. 1+ Year of Utilization Review Management and/or Medical Management experience. Commitment to attend a mandatory 3-week training (Monday–Friday, 8:30am–5:00pm EST) with 100% participation. Preferred Qualifications Experience with interpreting Plan Language, Policies, and Benefits to determine medical necessity. MCG Milliman, CPB or other criteria guideline application experience is preferred. 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: $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: 03/28/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

Clinical Claims Review Nurse

CVS Health

$26.01 - $68.55 / hour

Utilization Management Nurse Consultant

CVS Health

$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. Schedule: This is an Alternative Work Schedule weekend position. The role requires coverage of both Saturday and Sunday each week. Scheduling options may include four 10-hour shifts, five 8-hour shifts, three 12-hour shifts, or other approved configurations that meet operational needs. Specific schedules will be determined in collaboration with management to ensure adequate weekend coverage. Position Summary: Utilize your clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor, and evaluate options to facilitate appropriate healthcare services and benefits for members. Key Responsibilities: * Gather clinical information and apply the appropriate clinical criteria, guidelines, policies, procedures, and clinical judgment to render coverage determinations and recommendations along the continuum of care. * Communicate with providers and other parties to facilitate care and treatment. Identify members for referral opportunities to integrate with other products, services, or benefit programs. * Identify opportunities to promote quality and effectiveness of healthcare services and benefit utilization. * Consult and lend expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function. * Meet set productivity and quality expectations as established by UMNC. Required Skills and Abilities: * Effective verbal and written communication skills. * Proficiency with computer skills, including navigating multiple systems and keyboarding. * Ability to multitask, prioritize, and adapt effectively to a fast-paced, changing environment. * Capacity to sit for extended periods, talk on the telephone, and type on the computer. Work Location: This is a work-from-home position. During work hours, colleagues must be available by phone, videoconference, and email as required by their leader. Occasional on-site attendance at the office or client location may be required for meetings, training sessions, or other events as directed. `Required Qualifications Registered Nurse Education: Diploma RN acceptable; Associate degree/BSN preferred, 3+ years of experience as a Registered Nurse, 1+ years of clinical experience in acute or post-acute setting, and 1+ years of Utilization Management / Care Management Experience Must have active current and unrestricted RN licensure in state of residence. May be required to obtain additional Nursing Licenses as business needs require. * Preferred Qualifications - Utilization Management experience preferred Education Associates Degree 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. 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.

Clinical Claims Review Nurse

CVS Health Nashik, MH

$29.10 - $62.32 / hour

Utilization Management Nurse Consultant

CVS Health Harrisburg, PA

$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. 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 ET 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: $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. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan . No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 04/05/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

Utilization Management Nurse Consultant - San Antonio, TX Preferred

CVS Health San Antonio, TX

$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. As a Utilization Management Nurse Consultant, you will utilize clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. You would be responsible for ensuring the member is receiving the appropriate care at the appropriate time and at the appropriate location, while adhering to federal and state regulated turn-around times. This includes reviewing written clinical records. The UM Nurse Consultant job duties include (not all encompassing): -Reviews services to assure medical necessity, applies clinical expertise to assure appropriate benefit utilization, facilitates safe and efficient discharge planning and works closely with facilities and providers to meet the complex needs of the member. -Facilitate the delivery of appropriate benefits and/or healthcare information which determines eligibility for benefits while promoting wellness activities. -Develops, implements and supports Health Strategies, tactics, policies and programs that ensure the delivery of benefits and to establish overall member wellness and successful and timely return to work. -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 -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. Required Qualifications: -Must have current unrestricted RN licensure in their state of residence -2+ years clinical practice experience as an RN required -1+ year(s) experience utilizing multiple computer systems and applications including Microsoft Word, Excel, Outlook, and web-based applications -Must be willing to travel to the local office as needed. Preferred Qualifications: - It is preferred that the candidate live within driving distance of San Antonio, TX -Bilingual in Spanish and English -Strong computer skills Education: -Associates Degree in Nursing is minimum 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. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan . No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 04/04/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

Utilization Review

Full-time

3 months ago

Utilization Review/Management Coordinator

UHS Grand Rapids, MI

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

Utilization Review

Per Diem

4 months ago

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.

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.

Utilization Review

Full-time

5 months ago

Utilization Review Nurse- Remote

Gainwell Technologies LLC Arkansas City, AR

$65,000 - $78,000 / year

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

Utilization Review

Full-time

5 months ago

DRG Nurse Reviewer Appeals and Hearings- Remote

Gainwell Technologies LLC Tampa, FL

$90,000 - $99,000 / year

It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you’ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development. Summary We are seeking a talented individual for a DRG Nurse Reviewer Appeals and Hearings to coordinate and perform all appeal related duties including analyzing and responding appropriately to appeals from providers; reviewing documentation to ensure all aspects of the appeal have been addressed properly and accurately; prepare case files and case summaries for hearings; and participate in in virtual and on-site hearings. Your role in our mission Reviews provider appeals and redeterminations using approved clinical and coding guidelines and documents appeal determinations clearly and concisely. Analyzes and reviews appeal documentation to ensure all aspects of the appeal have been addressed properly and accurately while maintaining production goals and quality standards. Prepares case files and case summaries for hearings and actively participates in hearings in conjunction with the Medical Director. Assists management with training new reviewers to include daily monitoring, mentoring, feedback and education. Maintains current knowledge of clinical criteria guidelines and/or coding guidelines; successfully completes required CEUs to maintain RN license and/or coding certification. Responsible for attending training and scheduled meetings to enhance skills and working knowledge of clinical policies, procedures, rules, and regulations. Actively cross-trains to perform reviews of multiple claim types to provide a flexible workforce to meet client needs. What we're looking for Active, Unrestricted RN license from the United States and in the primary home residency, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), required Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or Certified Professional Medical Auditor (CPMA) required 5+ years clinical experience or 5+ years medical record coding experience preferred Working knowledge of the appeals and hearings process Excellent written communication skills including ability to write clear, concise, accurate, and fact-based rationales in support of appeal determinations. Excellent oral communication skills with particular emphasis on verbally presenting case summaries and decisions. Ability to multi-task in a fast-paced production environment. What you should expect in this role Remote (Work from Home) Up to 25% Travel for onsite hearing testimony This position is for pipeline purposes, and we welcome applications on an ongoing basis. The pay range for this position is $90,000.00 - $99,000.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits , and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities. We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings. Gainwell Technologies is an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics.

Utilization Review Nurse Jobs Overview

As a utilization review (UR) nurse, you help ensure that patients are receiving the appropriate level of care while being mindful of expenditures to your employer, whether you work for a hospital, managed care facility, or insurance company.

If you’re in search of utilization review nurse jobs or other non-bedside nurse jobs, you’ve come to the right place. Start looking for full-time, part-time, remote, contract, temporary, or per diem positions on Credenza today. Some of the more in-demand roles include:

Utilization Review Nurse Job Locations

Wondering where you might work in this role? The federal government requires that organizations participating in Medicare and Medicaid conduct utilization reviews. This means that you’ll find a variety of workplace options for UR nurse jobs.

Education and Certifications for Utilization Review Nursing Jobs

Before you can work in utilization review, you must complete a nursing program from an approved institution. Once you pass the NCLEX and receive your license, you’ll want to gain clinical experience in direct patient care. Registered nurses may also want to pursue experience as an RN case manager.

While likely not required for most jobs, specialty certification can increase both your knowledge and also your leverage when it comes time to look for a new utilization review nurse job. Certifications include:

Health Utilization Management Certification (HUMC)
Health Care Quality and Management (HCQM)
Certified Case Manager (CCM)
Accredited Case Manager (ACM)

Utilization Review Nurse Resume and Cover Letter

Put some effort into customizing your utilization review nurse resume to each job posting. For instance, if an employer is seeking a candidate “proficient in insurance prior authorizations and medical necessity criteria for different payers,” include that phrase in your resume. This helps demonstrate that your skills are a good fit for the job.

In your UR nurse cover letter, explain a bit about what drew you to this particular position. Remember, you don’t want just any old job — you want this job. To reinforce this sentiment as you apply to UR nurse jobs, search the employer’s website for their mission statement and see where your values overlap.

Interviewing for a Utilization Review Nurse Job

A job interview has the potential to determine whether or not you’ll get a job offer. Need some pointers? Review our nursing interview tips in advance to help you formulate smart answers to common questions and boost your confidence.

Utilization Review Nurse Salary

The average annual salary for a UR nurse is around $92,000 for a registered nurse. Your location, level of education and experience, and employer can impact this number. For a more accurate picture of utilization review nurse jobs’ salary estimates in your area, explore the current UR nursing jobs on Credenza.

Ready to Find Utilization Review Nurse Jobs?

Check out all the positions available right now. Want additional options? Credenza can match you with even more nursing jobs that interest you.