Utilization Review Nurse Jobs

RN Utilization Review Full-time
Johns Hopkins Medicine

Utilization Review Nurse - Managed Care

Johns Hopkins Medicine Hanover, MD
Excel. Empower. Advance. Shine. Belong. Explore. Flourish. Champion. Make It Happen At Hopkins! Johns Hopkins Health Plans (JHHP) is the managed care and health services business of Johns Hopkins Medicine, one of the premier health delivery, academic, and research institutions in the United States. JHHP is a $2.5B business serving over 400,000 lives with lines of business in Medicaid, Medicare, commercial, military health, health solutions, and venture investments. JHHP has become a leader in provider-sponsored health plans and is poised for future growth. About this position: Work Monday - Friday, the core business hours are 8:00 AM - 5:00 PM As a Utilization Review Registered Nurse for Johns Hopkins Health Plans, you have the opportunity to use your clinical, managed care, utilization review, and verbal/written communication skills to make a difference in our members’ lives. Your in-depth knowledge of the appropriate levels of care makes you a valuable resource to our members when they are in need. What you’ll do: Monitor the appropriateness of care received by plan members in a variety of settings Evaluate member benefits and medical criteria to determine authorization of services Communicate authorization and/or denial of covered services with all parties involved Initiate discharge planning of members What awaits you: Work-life balance - This is a remote role! Candidates in the following approved states will be given priority: MD, DC, VA, PA, DE, FL Medical, Dental, and Vision Insurance. 403B Savings Plan w/employer contribution. Paid Time off & Paid holidays. Employee and Dependent Tuition assistance benefits. Health and wellness programs and MORE! What you’ll bring: Understanding of managed care delivery systems and utilization management Knowledge and expertise in utilizing various criteria sets (i.e. InterQual) Ability to negotiate and resolve conflicts with external customers. Unencumbered Registered Nurse (RN) license in Maryland (or Compact state) 3+ years’ experience as an acute care RN 1+ years’ experience in Managed Care/Utilization Review is required Many organizations talk about transforming the future of healthcare, at Johns Hopkins Health Plans, we are setting the pace for change within the healthcare industry. We develop innovative, analytics-driven health programs in collaboration with provider partners to drive improved quality and better health outcomes for our members and the communities we serve. If you are interested in improving how healthcare is delivered, and have a passion to be at the forefront of change, JHHP is the place to call home. Salary Range: Minimum 39.64/hour - Maximum 61.45/hour. Compensation will be commensurate with equity and experience for roles of similar scope and responsibility. In cases where the range is displayed as a $0 amount, salary discussions will occur during candidate screening calls, before any subsequent compensation discussion is held between the candidate and any hiring authority. The Hospital reserves the right to modify employee schedules as needed. We are committed to creating a welcoming and inclusive environment, where we embrace and celebrate our differences, where all employees feel valued, contribute to our mission of serving the community, and engage in equitable healthcare delivery and workforce practices. Johns Hopkins Health System and its affiliates are drug-free workplace employers.
LPN Utilization Review Full-time
Guthrie

LPN Utilization Management Reviewer - Case Management - Full Time

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

(RN) Quality Review Manager- Registered Nurse

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

Utilization/Clinical Review RN -PRN

Children's Healthcare of Atlanta Atlanta, GA
Note: If you are CURRENTLY employed at Children's and/or have an active badge or network access, STOP here. Submit your application via Workday using the Career App (Find Jobs). Work Shift Variable Work Day(s) Variable Shift Start Time 6:00 AM Shift End Time 5:00 PM Worker Sub-Type PRN Children’s is one of the nation’s leading children’s hospitals. No matter the role, every member of our team is an essential part of our mission to make kids better today and healthier tomorrow. We’re committed to putting you first, and that commitment is at the heart of our company culture: People first. Children always. Find your next career opportunity and make a difference doing what you love at Children’s. Job Description Participates as a member of a multidisciplinary team in completing pre-screening assessments of prospective patients. Ensures completion of appropriate clinical review of all applicable patients as stated in system utilization management plan. Oversees Clinical Review Specialist as indicated. Maintains necessary documentation and communication with internal and external customers. This role is PRN and requires (6) 8-hour days per month with 1 day being on the weekend. We'll be open to offering more if possible. Some Holidays are required as well. Training/Orientation will be 3 days/week (8-hour days) for 8-10 weeks. Onsite Orientation is needed 3-4 days for first week. This role will be remote BUT regular meetings/trainings require being onsite at the Support Center in Atlanta GA. Experience 3 years of experience in a healthcare setting; pediatrics preferred Preferred Qualifications Bachelor of Science in Nursing Previous experience with MCG and/or InterQual systems 2 years of experience in hospital or insurance related utilization review highly preferred Education Graduation from an accredited school of nursing Certification Summary Licensure as a Registered Nurse in the single State of Georgia or Multi-State through the Enhanced Nurse Licensure Compact Knowledge, Skills, and Abilities Working knowledge of financial aspects of third-party payors and reimbursement Effective decision-making/problem-solving skills Demonstration of creativity in problem-solving Must possess above-average computer skills Must be able to successfully pass the Basic Windows Skill Assessment at 80% or higher rating within 30 days of employment Job Responsibilities Provides clinical information to insurance companies as needed for completion of pre-certification process as noted in Children's Healthcare of Atlanta utilization management plan. Evaluates all patients, including critical care, for appropriateness of admission type and setting, utilizing a combination of clinical information, screening criteria, and third-party information within 24 hours or next business day. Initiates and facilitates physician communications relative to utilization review process when indicated without prompting and follows up to ensure completion, including peer-to-peer reviews, securing admission orders, and reporting quality issues. Reviews concurrently all inpatients, including critical care, every three days or sooner if payor requests, including information regarding patient's medical condition, intensity of services being utilized, treatment plan, and established review criteria. Ensures all pertinent information is documented into various systems for utilization review process. Gathers and reviews relevant medical information and documents utilization review process outcome based on system accepted utilization criteria on the accepted current review forms and in computer systems. Supports organizational efforts to ensure accurate capture of admission status and level of care using Epic and escalating cases for status change where necessary. Refers denied cases to appropriate personnel and provides assistance and/or clinical support to aid in appeal process. Serves as resource to Case Management for facilitation of patients moving to appropriate level of care and notifying when patients no longer meet medical necessity to aid in discharge planning. Meets productivity (10-12 reviews/day) and quality assurance (95%) standards and demonstrates utilization review proficiency with the successful completion and passing of McKesson Interrater Reliability testing. Attends all required onsite, telephonic, and mandatory department meetings. Participates in department activities to help promote utilization review process, aids in denial prevention, and serves as resource to peers and team members. Children’s Healthcare of Atlanta is an equal opportunity employer committed to providing equal employment opportunities to all qualified applicants and employees without regard to race, color, sex, religion, national origin, citizenship, age, veteran status, disability or any other characteristic covered by applicable law. Primary Location Address 1575 Northeast Expy NE Job Family Nursing-Non Bedside
RN Utilization Review Part-time
Silver Cross Hospital

Utilization Review Nurse

Silver Cross Hospital New Lenox, IL
$34.73 - $45.15 / hour
Silver Cross Hospital is an extraordinary place to work. We’re known for our culture of excellence and delivery of unrivaled experiences for our patients, their families, the communities we serve…and for each other. Come join us! It’s the way you want to be treated. Position Summary: Performs medical record review for severity of illness and intensity of service; liaison function with external review agencies to ensure compliance with regulations affecting financial reimbursement; identifies variance from established pathways Essential Duties and Responsibilities: Collects information from clinical medical record for severity of illness and intensity of service and documents such in clinical database Monitors all levels of care for appropriateness and communicates variance; evaluates plan of care to ensure it is based on accepted standards Provides information to external review organizations, documents pertinent communications Refers to designated physician advisor those patients not meeting criteria as well as quality of care concerns Maintains knowledge and incorporates current standards into practice Required Qualifications : Knowledge of clinical norms; excellent communication skills; critical thinking skills; organized and efficient time management skills Education and Training : Nurse, Registered (RN) licensure BSN preferred. 2-5 years previous Utilization Review experience preferred. Current CPR Relevant hospital nursing; hospital case management; insurance case management or utilization management experience preferred Work Shift Details: Various, Day; weekend rotation; holiday rotation; occasional on site requirement for meetings and mandatory training Department: CONTINUUM OF CARE Benefits for You At Silver Cross Hospital, we care about your health and well-being and that is why we work hard to provide quality and affordable benefit options for you and your eligible family members. Silver Cross Hospital and Silver Cross Medical Groups offer a comprehensive benefit package available for Full-time and Part-time employees which includes: · Medical, Dental and Vision plans · Life Insurance · Flexible Spending Account · Other voluntary benefit plans · PTO and Sick time · 401(k) plan with a match · Wellness program · Tuition Reimbursement Registry employees who meet eligibility may participate in our 401(k) Savings plan with a potential match. However, registry employees are ineligible for Health and Welfare benefits. The final pay rate offered may be more than the posted range based on several factors including but not limited to: licensure, certifications, work experience, education, knowledge, demonstrated abilities, internal equity, market data, and more. The expected pay for this position is listed below: $34.73 - $45.15
RN Utilization Review Full-time
Parkland Health (TX)

Registered Nurse - Care Coordinator - Utilization Review

Parkland Health (TX) Dallas, TX
Location: Main Hospital Bldg - 1st Flr Shift- Days (10hrs) 7:30am-6pm Work Hours: Monday- Friday with rotating weekends **This position will hybrid- must be okay with coming onsite** Employment Type: Full Time Primary Purpose Establishes and maintains an efficient, cost effective care management process by determining patient financial and medical eligibility, medical necessity, and by developing, implementing and monitoring individual patient plans of care and communicating these plans to patients, families, and Parkland staff to ensure quality patient care throughout the healthcare continuum and compliance with program/Parkland policies and procedures. Responsible for the maintaining the knowledge and skill set related to utilization review, care coordination, performance improvement and professional licensure and certification. Minimum Specifications Education Must be a graduate of an accredited school of Nursing. Experience Must have two (2) years of hospital or community based patient care nursing, preferably in assigned clinical area. Equivalent Education and/or Experience Certification/Registration/Licensure Must have current, valid RN license or temporary RN license from the Texas Board of Nursing; or, valid Compact RN license. Must have current healthcare provider BLS for Healthcare Providers certification from one of the following: American Heart Association American Red Cross Military Training Network Required Tests for Placement Skills or Special Abilities Provides care to assigned patient population in accordance with the current State of Texas Nursing Practice Act, established protocols, multidisciplinary plan of care, and clinical area specific standards. Must be able to communicate and collaborate effectively with a diverse group of patients, families and healthcare staff. Must be able to demonstrate a working knowledge of specific patient populations, and be able to demonstrate knowledge of disease processes affecting this group. Must be able to demonstrate a working knowledge of PC operations and the ability to use word processing software in a Windows environment. Must be able to demonstrate a working knowledge of the laws and regulations governing Medicare, Medicaid and community-based funding sources. Must be self-directed and capable of priority setting and problem solving. Must be able to demonstrate patient centered/patient valued behaviors. Responsibilities Conducts assessment of patients on assigned Care Coordination team to develop a case management plan of care. Gathers information from patient, physicians, other pertinent members of the healthcare team. Determines funding sources for patients and potential eligibility if appropriate. Plans and develops specific objectives, goals and actions designed to meet the patient's needs as identified through the assessment process. Utilizes hospital approved review criteria to ensure appropriate bed status. Identifies at-risk populations using approved screening tool and follows established reporting procedures. Ensures appropriate admission status is documented. Collaborates with all members of the multidisciplinary team and the patient to implement the plan of care. Monitors the patient's progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective. Communicates all financial counseling as appropriate. Addresses and resolves system barriers impeding diagnostic or treatment progress. Proactively identifies and resolves delays and obstacles to discharge. Ensures/maintains plan consensus from patient/family, physician, and payer. Serves as patient advocate to secure coverage for needed community services. Mobilizes resources and coordinates the effort to the health care team to achieve a positive patient transition to appropriate next level of care. Communicates plan of care to patient and their family providing updates and reassesses the plan of care to determine effectiveness. Completes appropriate coordinator management documentation. Evaluates the plan of care at appropriate intervals to determine effectiveness in meeting outcomes and goals. Works with nursing and other disciplines to ensure that discharge needs, including teaching, are met. Collaborates with the healthcare team to identify 'best' practices for achieving patient outcomes. Develops reporting mechanisms to communicate outcomes to physicians and other members of the health care team. Responsible for Utilization Management activities for assigned patients. Applies approved utilization criteria to monitor appropriateness of admissions and continued stays, and documents findings based on department standards. Monitors length of stay (LOS) and ancillary resource use on an ongoing basis and takes action to achieve continuous improvement in both areas. Monitors and addresses outcome variances. Identifies causes of outcome variances and implements actions to improve the variances. Seeks the most efficient, cost effective ways to provide appropriate care. Supports cost containment efforts through the recommendation of performance improvement opportunities by the health care team. Communicates with Care Management team to facilitate covered-day reimbursement certification and/or authorization for assigned patients. Discusses payer criteria and issues on a case-by-case basis with clinical staff and follows up to resolve problems with payers as needed. Transitions patients through the health care system based upon individual and patient population needs. Directs liaison activities to appropriately integrate the patient into the health care continuum including procuring of services, health promotion and counseling, disease prevention, health education and screening, and community resource linkage. Engages in special projects and serves on committees, as assigned. Requisition ID: 988689
RN Utilization Review Full-time
Renown Health

Utilization Management RN-Acute

Renown Health Reno, NV
Position Purpose Under the supervision Hospital Care Management, incumbent promotes appropriate utilization, high quality care and cost effective outcomes. Incumbent is also responsible for utilization review, coordination of acute inpatient denials, performs admission and concurrent reviews and communication with physicians and payers regarding the medical necessity for services. Nature and Scope Conduct medical certification review for medical necessity for acute care facility and services. Use nationally recognized, evidence-based guidelines approved by medical staff to recommend level of care to the physician and serve as a resource to the medical staff on issues related to admission qualifications, resource utilization, national and local coverage determinations, and documentation improvement opportunities. This position also provides information (certified LOS and reimbursement issues) to the care team (RN, physicians, and case manager) as needed to ensure the appropriate and timely disposition of the client. The Utilization Management RN, documents all chart and phone reviews, identifies and communicates potentially avoidable/non-reimbursed days, quality indicators (such as readmissions). Delivers non-covered letters as set forth by payer and/or regulatory compliance. This position will be required to work a flexible schedule that may include evenings and weekends to provide coverage for the department as needed. This position participates in Quality Improvement initiatives. Knowledge, Skills & Abilities Strong interpersonal communication skills both verbal and written. Knowledge of applicable regulatory requirements and community resources Knowledge of continuous quality improvement process. Philosophy consistent with the strategic plan of Renown Health The ability to understand and resolve complex problems in a timely and effective manner using critical thinking skills. The ability to keep current with new developments and acquire the needed knowledge for the position in order to keep skill sets up to date. The ability to work under stress and to meet deadlines. This position does not provide patient care. Disclaimer The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job. Minimum Qualifications Requirements - Required and/or Preferred Name Description Education: Must have working-level knowledge of the English language, including reading, writing and speaking English. English. Appropriate education to obtain and maintain Registered Nursing licensure in the State of Nevada. Experience Applicants with 1 year previous managed care and/or case management experience including acute hospital case management is preferred. Minimum of one-year in hospital setting required. License(s) Ability to obtain and maintain State of Nevada Registered Nurse license. Certification(s) Utilization or Case Management Certification preferred. Certification in Case Management (CCM), Certified Managed Care Nurse (CMCN), or ABQAURP HCQM is preferred. Computer / Typing Must possess, or be able to obtain within 90 days, the computers skills necessary to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.
RN Utilization Review Full-time
IU Health

Registered Nurse-Utilization Management (Acute Rehab Unit)

IU Health Muncie, IN
Overview Registered Nurse – Utilization Management (Acute Rehab Unit) Ball Memorial Hospital | Muncie, Indiana Full-Time | Day Shift Monday-Friday | 8:00 AM - 4:30 PM No Call • No Weekends • No Holidays Join Our Team Ball Memorial Hospital is seeking a dedicated Registered Nurse - Utilization Management to support our Acute Rehabilitation Unit . This role offers an excellent opportunity for an experienced RN who enjoys combining clinical expertise with care coordination, utilization review, and patient advocacy to ensure patients receive the right care at the right time throughout their healthcare journey. In this position, you will serve as a critical liaison between patients, providers, payers, and the interdisciplinary care team to promote quality outcomes, appropriate resource utilization, and seamless transitions of care. What You'll Do Conduct utilization review activities for inpatient admissions, outpatient procedures, and ancillary services. Perform pre-certification, concurrent, and retrospective reviews to ensure medical necessity and appropriate levels of care. Apply established clinical review criteria, regulatory requirements, and payer guidelines to assess appropriateness of services. Collaborate with physicians, rehabilitation specialists, case managers, and interdisciplinary care teams to optimize patient outcomes. Coordinate and support discharge planning efforts to facilitate safe and timely transitions across the continuum of care. Advocate for patients by expediting access to medically necessary services and removing barriers to care. Monitor compliance with documentation, quality standards, and utilization management policies. Promote efficient, cost-effective healthcare delivery while maintaining a strong focus on quality and patient-centered care. Serve as a clinical resource related to utilization management, reimbursement, and care coordination processes. Why You'll Love This Opportunity Day shift schedule with excellent work-life balance No call requirements No weekends No holidays Opportunity to leverage your clinical expertise in a collaborative, multidisciplinary environment Make a meaningful impact on patient outcomes and care transitions Professional growth within a highly respected healthcare organization Qualifications Requires an Associates of Nursing (ASN). Bachelors of Nursing (BSN) preferred. Requires an active Registered Nurse (RN) license in the state of Indiana or an active Nurse Licensure Compact (NLC) RN license. Requires that the RN has graduated from a nationally accredited nursing program. Requires 3-5 years of relevant experience. Inpatient nursing experience preferred. Basic Life Support certification through the AHA or other advanced life support certifications may be required per unit/department specialty according to patient care policies. Requires proficiency in Microsoft Office and applications. Requires understanding of medical record requirements, regulations and policies.
RN Utilization Review Telehealth Full-time
Molina Healthcare

RN- Care Review Clinician- UM/Discharge Planning (Remote- CA License Req)

Molina Healthcare Long Beach, CA
$30.37 - $59.21 / hour
JOB DESCRIPTION Job Summary Provides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines. • Analyzes clinical service requests from members or providers against evidence based clinical guidelines. • Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. • Conducts reviews to determine prior authorization/financial responsibility for Molina and its members. • Processes requests within required timelines. • Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner. • Requests additional information from members or providers as needed. • Makes appropriate referrals to other clinical programs. • Collaborates with multidisciplinary teams to promote the Molina care model. • Adheres to utilization management (UM) policies and procedures. Required Qualifications • At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience. • Registered Nurse (RN). License must be active and unrestricted in state of practice. • Ability to prioritize and manage multiple deadlines. • Excellent organizational, problem-solving and critical-thinking skills. • Strong written and verbal communication skills. • Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications Certified Professional in Healthcare Management (CPHM). Utilization review, prior authorization, inpatient review desirable. MCG experience, strongly preferred. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $30.37 - $59.21 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
RN Utilization Review Full-time
Palmetto General Hospital

Utilization Review RN, Case Management/UR, Full Time, Day Shift, Job ID # 1815702

Palmetto General Hospital Miami Lakes, FL
Position Summary: Performs Case Management activities to assure medical necessity of admissions and appropriateness of continued stay utilizing the Interqual Criteria guidelines. Monitors the utilization of resources of all patients reviewed. Working with clients, family and friend support networks and health care professionals to put care plans in place. Evaluating clients' progress daily and making adjustments as needed to improve outcomes. Maintains confidential communication with physicians and multi-disciplinary personnel to meet individual needs or the patients served. Functions as an independent contributor as well as a team member. Position Qualification: Communication is an essential skill requiring the ability to see, hear, and speak. Fluent in written and spoken English. Must be able to fulfill the essential functions of the position. Possess three or more years of acute care hospital experience preferred. Familiar with the operations of the healthcare industry and healthcare delivery systems. Able to use the medical record in order to obtain clinical information to perform Interqual reviews. Utilize Outlook, and the computer based systems to perform reviews/CM assessments/CM tasks. Work experience in Medical-Surgical, Telemetry, Critical Care, and/or Pediatrics, NICU preferred. Required Licenses/Certifications: Current Florida RN Licensure BLS Certification. Must possess a solid clinical background to accomplish extensive Medical Record review. Computer skills Communication Skills: Ability to effectively communicate in writing and orally with all levels of the organization
RN Utilization Review Outpatient Full-time
Adventist Health

RN, Care Manager, Utilization Management

Adventist Health Roseville, CA
Job Description Located in the metropolitan area of Sacramento, the Adventist Health corporate headquarters have been based in Roseville, California, for more than 40 years. In 2019, we unveiled our WELL-certified campus - a rejuvenating place for associates systemwide to collaborate, innovate and connect. Whether virtual or on campus, Adventist Health Roseville and shared service teams have access to enjoy a welcoming space designed to promote well-being and inspire your best work. Job Summary Plays a critical role in ensuring that patients receive high-quality care while efficiently utilizing medical resources. Reviews patient medical records, assessing the appropriateness and necessity of proposed treatments, and collaborating with healthcare providers and insurance companies to ensure a seamless care experience and the practicing of financial stewardship and denial prevention. Focuses on maximizing patient outcomes and optimizing resource allocation. Utilizes exceptional clinical knowledge, excellent communication skills, and the ability to thrive in a fast-paced and ever-changing healthcare environment. Job Requirements Education and Work Experience: Associate’s Degree in nursing or equivalent combination of education/related experience: Required Bachelor's Degree in Nursing (BSN): Preferred Five years' acute hospital experience required with preferred experience in critical care areas: Required Two years' utilization review experience using the Optum/Inter Qual product within the last 12 months: Required Licenses/Certifications Registered Nurse (RN) licensure in the state of practice: Required Essential Functions Completes clinical reviews of acute medical patients using the Optum/Inter Qual tool to determine if the patient is in the right acute setting, receiving the right acute services, during the appropriate length of stay. Participates in annual Optum/Inter Qual training required. Takes the required annual Optum/Inter Qual Interrater Reliability (IRR) test with a minimum passing score as defined in the yearly departmental goals. Meets weekly productivity metrics within 90 days of completing orientation and maintains on a weekly basis as defined in the yearly departmental goals. Meets quality audit metrics within 90 days of completing orientation and maintained on the audit cadence set within the department as defined in the yearly departmental goals. Completes all required departmental education assigned with timeliness and accuracy. Follows all departmental workflows in communication variances to the on-site care management teams when appropriate. Reviews and analyzes medical records to assess the necessity and appropriateness of treatments and interventions. Collaborates with healthcare professionals to develop and implement comprehensive patient care plans. Facilitates communication between the patient, healthcare team, insurance providers, and other stakeholders to ensure a coordinated and efficient care process. Stays up to date with the latest healthcare regulations, insurance guidelines, and evidence-based practices to ensure the delivery of optimal healthcare services. Performs other job-related duties as assigned. Organizational Requirements Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations as a condition of employment and annually thereafter, where applicable. Medical and religious exemptions may apply. Adventist Health participates in E-Verify. Visit https://adventisthealth.org/careers/everify/ for more information about E-Verify. By choosing to apply, you acknowledge that you have accessed and read the E-Verify Participation and Right to Work notices and understand the contents therein. About Us Adventist Health is a faith-based, nonprofit, integrated health system serving more than 100 communities on the West Coast and Hawaii with over 440 sites of care, including 27 acute care facilities. Founded on Adventist heritage and values, Adventist Health provides care in hospitals, clinics, home care, and hospice agencies in both rural and urban communities. Our compassionate and talented team of more than 38,000 includes employees, physicians, Medical Staff, and volunteers driven in pursuit of one mission: living God's love by inspiring health, wholeness and hope.
RN Utilization Review Full-time
Atlanticare

Registered Nurse - Utilization Management - Full Time

Atlanticare Egg Harbor Township, NJ
JOB DESCRIPTION " POSITION SUMMARY The RN Utilization Management is responsible for the overall Utilization Management process for assigned patient population. This includes reviewing clinical information to determine the appropriate level of care assignment, along with the completion and submission of reviews to insurance payers with appropriate follow-up. The RN u tilizes Evidenced Based ""MCG"" criteria/guidelines and other approved Atlanticare applications to assess and document the medical necessity and appropriate patient status/level of care determination. This position a nalyzes clinical information received to facilitate authorization from insurance providers, maximize reimbursement by preventing denials, and ensures clinical data is sufficient to obtain an authorization. The RN works closely with Physician Advisors (PAs) to confirm that status and level-of-care mismatches, along with provider documentation concerns, are thoroughly reviewed and addressed, including follow-up on final decisions and peer-to-peer discussion outcomes as required. This position ensures that the obligation for clinical review is met according to the payer contracts and validates the accuracy of insurance information in the system. The RN is knowledgeable of the payer contracting arrangements, admission notification and clinical review requirements, as well as the regulatory and compliance requirements for government payers regarding clinical reviews and medical necessity. This role ensures that appropriate and accurate information is placed into the patient accounting system to result in clean, compliant, and timely claim processing. This role also provides notification of denial issues and potential avoidance of a denial, along with changes in insurance information to all appropriate areas (e.g. clinical team, Patient Accounting). The RN supports system-wide improvement initiatives within the hospitals and the medical staff structure to ensure effective and timely performance improvement. This role Participates in UR Committee work as requested. Q UALIFICATIONS EDUCATION: Graduate of an accredited school of nursing required. Bachelor's in nursing Required. Utilization/Coding certification preferred or in process. LICENSE/CERTIFICATION: Current licensure as a Registered Nurse in the State of New Jersey or current multi state license required. Effective Jan 2026: Current MCG (Milliman Clinical Guideline) certification required within 2 years of hire or transfer. Current incumbents must obtain MCG by 1/1/2027. American Heart Association BLS certification required within 6 months of hire or transfer. Current incumbents must obtain BLS by 6/30/2026. EXPERIENCE: Prior Utilization/insurance case management experience Preferred. Experience on MCG/InterQual, HEDIS, CDI or Quality review preferred. Recent acute care Medical-Surgical nursing experience preferred. Proficient in using common computer software applications preferred (Word, Excel formatting). Proficiency in Clinical Applications preferred at time of hire; incumbents within position will be trained appropriately and then skill will be required for this position within 30-60 days from date of hire. PERFORMANCE EXPECTATIONS Demonstrates the technical competencies as established on the Assessment and Evaluation Tool. WORK ENVIRONMENT This position requires desk/computer work a majority of the time. There is some standing, walking and occasional lifting up to 20 pounds. The essential functions for this position are listed on the Assessment and Evaluation Tool. REPORTING RELATIONSHIP This position reports to department leadership. The above statement reflect the general details considered necessary to describe the principle functions of the job as identified and shall not be considered as a detailed description of all work requirements that may be inherent in the position. Total Rewards at AtlantiCare At AtlantiCare, We Believe In Supporting The Whole Person. Our Market-competitive Total Rewards Package Is Designed To Promote The Physical, Emotional, Social, And Financial Well-being Of Our Team Members. We Offer a Comprehensive Suite Of Benefits And Resources, Including: Generous Paid Time Off (PTO) Medical, Prescription Drug, Dental & Vision Insurance Retirement Plans with employer contributions Short-Term & Long-Term Disability Coverage Life & Accidental Death & Dismemberment Insurance Tuition Reimbursement to support your educational goals Flexible Spending Accounts (FSAs) for healthcare and dependent care Wellness Programs to help you thrive Voluntary Benefits , including Pet Insurance and more Benefits offerings may vary based on position and are subject to eligibility requirements. Join a team that values your well-being and invests in your future. " ABOUT US Total Rewards at AtlantiCare At AtlantiCare, We Believe In Supporting The Whole Person. Our Market-competitive Total Rewards Package Is Designed To Promote The Physical, Emotional, Social, And Financial Well-being Of Our Team Members. We Offer a Comprehensive Suite Of Benefits And Resources, Including: Generous Paid Time Off (PTO) Medical, Prescription Drug, Dental & Vision Insurance Retirement Plans with employer contributions Short-Term & Long-Term Disability Coverage Life & Accidental Death & Dismemberment Insurance Tuition Reimbursement to support your educational goals Flexible Spending Accounts (FSAs) for healthcare and dependent care Wellness Programs to help you thrive Voluntary Benefits , including Pet Insurance and more Benefits offerings may vary based on position and are subject to eligibility requirements. Join a team that values your well-being and invests in your future. Pay Transparency In order to support the Fair Compensation Strategy by the US Govt., HR Dept., clients are required to adhere to "Pay Transparency Law" in impacted states, which mandate employers to list salary ranges in job advertisements and promotions. AtlantiCare is an Equal Opportunity Employer
RN Utilization Review Full-time
Atlanticare

Registered Nurse - Utilization Management - Full Time

Atlanticare Egg Harbor Township, NJ
JOB DESCRIPTION " POSITION SUMMARY The RN Utilization Management is responsible for the overall Utilization Management process for assigned patient population. This includes reviewing clinical information to determine the appropriate level of care assignment, along with the completion and submission of reviews to insurance payers with appropriate follow-up. The RN u tilizes Evidenced Based ""MCG"" criteria/guidelines and other approved Atlanticare applications to assess and document the medical necessity and appropriate patient status/level of care determination. This position a nalyzes clinical information received to facilitate authorization from insurance providers, maximize reimbursement by preventing denials, and ensures clinical data is sufficient to obtain an authorization. The RN works closely with Physician Advisors (PAs) to confirm that status and level-of-care mismatches, along with provider documentation concerns, are thoroughly reviewed and addressed, including follow-up on final decisions and peer-to-peer discussion outcomes as required. This position ensures that the obligation for clinical review is met according to the payer contracts and validates the accuracy of insurance information in the system. The RN is knowledgeable of the payer contracting arrangements, admission notification and clinical review requirements, as well as the regulatory and compliance requirements for government payers regarding clinical reviews and medical necessity. This role ensures that appropriate and accurate information is placed into the patient accounting system to result in clean, compliant, and timely claim processing. This role also provides notification of denial issues and potential avoidance of a denial, along with changes in insurance information to all appropriate areas (e.g. clinical team, Patient Accounting). The RN supports system-wide improvement initiatives within the hospitals and the medical staff structure to ensure effective and timely performance improvement. This role Participates in UR Committee work as requested. Q UALIFICATIONS EDUCATION: Graduate of an accredited school of nursing required. Bachelor's in nursing Required. Utilization/Coding certification preferred or in process. LICENSE/CERTIFICATION: Current licensure as a Registered Nurse in the State of New Jersey or current multi state license required. Effective Jan 2026: Current MCG (Milliman Clinical Guideline) certification required within 2 years of hire or transfer. Current incumbents must obtain MCG by 1/1/2027. American Heart Association BLS certification required within 6 months of hire or transfer. Current incumbents must obtain BLS by 6/30/2026. EXPERIENCE: Prior Utilization/insurance case management experience Preferred. Experience on MCG/InterQual, HEDIS, CDI or Quality review preferred. Recent acute care Medical-Surgical nursing experience preferred. Proficient in using common computer software applications preferred (Word, Excel formatting). Proficiency in Clinical Applications preferred at time of hire; incumbents within position will be trained appropriately and then skill will be required for this position within 30-60 days from date of hire. PERFORMANCE EXPECTATIONS Demonstrates the technical competencies as established on the Assessment and Evaluation Tool. WORK ENVIRONMENT This position requires desk/computer work a majority of the time. There is some standing, walking and occasional lifting up to 20 pounds. The essential functions for this position are listed on the Assessment and Evaluation Tool. REPORTING RELATIONSHIP This position reports to department leadership. The above statement reflect the general details considered necessary to describe the principle functions of the job as identified and shall not be considered as a detailed description of all work requirements that may be inherent in the position. Total Rewards at AtlantiCare At AtlantiCare, We Believe In Supporting The Whole Person. Our Market-competitive Total Rewards Package Is Designed To Promote The Physical, Emotional, Social, And Financial Well-being Of Our Team Members. We Offer a Comprehensive Suite Of Benefits And Resources, Including: Generous Paid Time Off (PTO) Medical, Prescription Drug, Dental & Vision Insurance Retirement Plans with employer contributions Short-Term & Long-Term Disability Coverage Life & Accidental Death & Dismemberment Insurance Tuition Reimbursement to support your educational goals Flexible Spending Accounts (FSAs) for healthcare and dependent care Wellness Programs to help you thrive Voluntary Benefits , including Pet Insurance and more Benefits offerings may vary based on position and are subject to eligibility requirements. Join a team that values your well-being and invests in your future. " ABOUT US Total Rewards at AtlantiCare At AtlantiCare, We Believe In Supporting The Whole Person. Our Market-competitive Total Rewards Package Is Designed To Promote The Physical, Emotional, Social, And Financial Well-being Of Our Team Members. We Offer a Comprehensive Suite Of Benefits And Resources, Including: Generous Paid Time Off (PTO) Medical, Prescription Drug, Dental & Vision Insurance Retirement Plans with employer contributions Short-Term & Long-Term Disability Coverage Life & Accidental Death & Dismemberment Insurance Tuition Reimbursement to support your educational goals Flexible Spending Accounts (FSAs) for healthcare and dependent care Wellness Programs to help you thrive Voluntary Benefits , including Pet Insurance and more Benefits offerings may vary based on position and are subject to eligibility requirements. Join a team that values your well-being and invests in your future. Pay Transparency In order to support the Fair Compensation Strategy by the US Govt., HR Dept., clients are required to adhere to "Pay Transparency Law" in impacted states, which mandate employers to list salary ranges in job advertisements and promotions. AtlantiCare is an Equal Opportunity Employer
RN Utilization Review Full-time
The Christ Hospital Health Network

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

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

Registered Nurse - Utilization Management - Per Diem

Atlanticare Egg Harbor Township, NJ
JOB DESCRIPTION " POSITION SUMMARY The RN Utilization Management is responsible for the overall Utilization Management process for assigned patient population. This includes reviewing clinical information to determine the appropriate level of care assignment, along with the completion and submission of reviews to insurance payers with appropriate follow-up. The RN u tilizes Evidenced Based ""MCG"" criteria/guidelines and other approved Atlanticare applications to assess and document the medical necessity and appropriate patient status/level of care determination. This position a nalyzes clinical information received to facilitate authorization from insurance providers, maximize reimbursement by preventing denials, and ensures clinical data is sufficient to obtain an authorization. The RN works closely with Physician Advisors (PAs) to confirm that status and level-of-care mismatches, along with provider documentation concerns, are thoroughly reviewed and addressed, including follow-up on final decisions and peer-to-peer discussion outcomes as required. This position ensures that the obligation for clinical review is met according to the payer contracts and validates the accuracy of insurance information in the system. The RN is knowledgeable of the payer contracting arrangements, admission notification and clinical review requirements, as well as the regulatory and compliance requirements for government payers regarding clinical reviews and medical necessity. This role ensures that appropriate and accurate information is placed into the patient accounting system to result in clean, compliant, and timely claim processing. This role also provides notification of denial issues and potential avoidance of a denial, along with changes in insurance information to all appropriate areas (e.g. clinical team, Patient Accounting). The RN supports system-wide improvement initiatives within the hospitals and the medical staff structure to ensure effective and timely performance improvement. This role Participates in UR Committee work as requested. Q UALIFICATIONS EDUCATION: Graduate of an accredited school of nursing required. Bachelor's in nursing Required. Utilization/Coding certification preferred or in process. LICENSE/CERTIFICATION: Current licensure as a Registered Nurse in the State of New Jersey or current multi state license required. Effective Jan 2026: Current MCG (Milliman Clinical Guideline) certification required within 2 years of hire or transfer. Current incumbents must obtain MCG by 1/1/2027. American Heart Association BLS certification required within 6 months of hire or transfer. Current incumbents must obtain BLS by 6/30/2026. EXPERIENCE: Prior Utilization/insurance case management experience Preferred. Experience on MCG/InterQual, HEDIS, CDI or Quality review preferred. Recent acute care Medical-Surgical nursing experience preferred. Proficient in using common computer software applications preferred (Word, Excel formatting). Proficiency in Clinical Applications preferred at time of hire; incumbents within position will be trained appropriately and then skill will be required for this position within 30-60 days from date of hire. PERFORMANCE EXPECTATIONS Demonstrates the technical competencies as established on the Assessment and Evaluation Tool. WORK ENVIRONMENT This position requires desk/computer work a majority of the time. There is some standing, walking and occasional lifting up to 20 pounds. The essential functions for this position are listed on the Assessment and Evaluation Tool. REPORTING RELATIONSHIP This position reports to department leadership. The above statement reflect the general details considered necessary to describe the principle functions of the job as identified and shall not be considered as a detailed description of all work requirements that may be inherent in the position. Total Rewards at AtlantiCare At AtlantiCare, We Believe In Supporting The Whole Person. Our Market-competitive Total Rewards Package Is Designed To Promote The Physical, Emotional, Social, And Financial Well-being Of Our Team Members. We Offer a Comprehensive Suite Of Benefits And Resources, Including: Generous Paid Time Off (PTO) Medical, Prescription Drug, Dental & Vision Insurance Retirement Plans with employer contributions Short-Term & Long-Term Disability Coverage Life & Accidental Death & Dismemberment Insurance Tuition Reimbursement to support your educational goals Flexible Spending Accounts (FSAs) for healthcare and dependent care Wellness Programs to help you thrive Voluntary Benefits , including Pet Insurance and more Benefits offerings may vary based on position and are subject to eligibility requirements. Join a team that values your well-being and invests in your future. " ABOUT US Total Rewards at AtlantiCare At AtlantiCare, We Believe In Supporting The Whole Person. Our Market-competitive Total Rewards Package Is Designed To Promote The Physical, Emotional, Social, And Financial Well-being Of Our Team Members. We Offer a Comprehensive Suite Of Benefits And Resources, Including: Generous Paid Time Off (PTO) Medical, Prescription Drug, Dental & Vision Insurance Retirement Plans with employer contributions Short-Term & Long-Term Disability Coverage Life & Accidental Death & Dismemberment Insurance Tuition Reimbursement to support your educational goals Flexible Spending Accounts (FSAs) for healthcare and dependent care Wellness Programs to help you thrive Voluntary Benefits , including Pet Insurance and more Benefits offerings may vary based on position and are subject to eligibility requirements. Join a team that values your well-being and invests in your future. Pay Transparency In order to support the Fair Compensation Strategy by the US Govt., HR Dept., clients are required to adhere to "Pay Transparency Law" in impacted states, which mandate employers to list salary ranges in job advertisements and promotions. AtlantiCare is an Equal Opportunity Employer
RN School Utilization Review School Other
Stratford Public Schools

School Nurse for Summer Registration/Medical Records Review

Stratford Public Schools Stratford, CT
School Nurse for Summer Registration / Medical Records Review Nurse Duties: Nurse (RN or LPN) will review physicals and immunization records for newly registered students. If a student's medical records are out of state compliance the nurse will contact families and request updated documentation that is needed so students can start school on time. Note: one nurse per week will work, not to exceed 10 hours per week. Nurses will report to Supervisor of Nursing, Health and Wellness Rate of Pay - hourly based on union contract
RN Utilization Review Full-time
University of Miami Health System

Case Manager RN 3 (U)

University of Miami Health System Miami, FL
Current Employees: If you are a current Staff, Faculty or Temporary employee at the University of Miami, please click here to log in to Workday to use the internal application process. To learn how to apply for a faculty or staff position, please review this tip sheet . The Case Manager RN (U) coordinates the overall interdisciplinary plan of care for patients, from admission to discharge. Monitors care and acts as a liaison between patient/family, healthcare personnel, and insurers. Evaluates the needs of the patient, the resources available, and recommends and facilitates the plan for the best outcome. Develops a discharge plan that provides the best available resources to meet ongoing patient needs and that encourages compliance with medical advice. Identifies patient care issues and suggests revisions to or new clinical pathways to improve quality of care.Care facilitation for all assigned patients including extended recovery, outpatient observation and inpatient admissions to include care progression, timely consultations and testing facilitation , assure social service intervention and individual discharge planning that will include assuring that the transfer or discharge of a patient to another level of care, treatment, services or different setting is always based on the patient’s assessed needs, patient’s insurance coverage benefits and the organizations capabilities to meet these needs. Incorporate the fundamental principles of monitoring resource consumption and capture of avoidable days. Enter Ancillary notes utilizing the templates for care facilitation. Proactive in assuring the orders needed are obtained and facilitates delivery of clinical and community services to patients and families through effective utilization of available resources. Attend daily multidisciplinary huddles, meeting facilitation/address progression of care. Ensures the appropriateness and cost effectiveness of patient’s plan of care based on DRG. Proactively collaborate with physicians(s) to develop patient care plans and review medical needs for continued hospital services and resource consumption. Utilize Case Manager nurse driven protocols to facilitate care and request physician orders on items not part of CM nursing protocol. Provide all required Medicare documents to the patient and/or proxy when applicable inclusive of the discharge Important Message from Medicare, Code 44 patient notification required documents. Process QIO Medicare appeals. Acute Care transfers including Psychiatric transfers. Attend and facilitate the daily multi-disciplinary huddles. Attend and report on assigned LOS 10day outliers-Complex Case Review. Communicate to management daily on observation outliers related to care transition and discharge barriers. Identifies the patients’ risk factors or obstacles to care, and discharge and readmission risk. Evaluates the plan of care regularly by chart review and patient interviews, as well as collaborates with the medical team to facilitate the patients’ movement through the system. Educate patients and families on the progression of care. Serves as a liaison between patients, families, and healthcare personnel to ensure necessary care is provided promptly, effectively, and in a fiscally responsible manner. Promotes quality care to ensure patients receive medically appropriate services in appropriate status and stay standards. Facilitates regulatory notifications and patient signatures per policy. Maintains knowledge regarding insurance reimbursement policies. Relies on experience and judgement to plan and facilitate discharge and transition plans, and assures they meet the physical, social, and emotional needs of the patient. Adheres to University and unit-level policies and procedures and safeguards University assets. This list of duties and responsibilities is not intended to be all-inclusive and may be expanded to include other duties or responsibilities as necessary. CORE QUALIFICATIONS Education: Bachelor’s Degree in relevant field Certification and Licensing: Registered Nurse Licensing (RN) Experience: Minimum 7 years of relevant experience (5 years of case management/utilization review experience) Knowledge, Skills and Attitudes: · Ability to communicate effectively in both oral and written form. · Ability to recognize, analyze, and solve a variety of problems. · Ability to analyze, organize and prioritize work under pressure while meeting deadlines. · Ability to maintain effective interpersonal relationships. The University of Miami offers competitive salaries and a comprehensive benefits package including medical, dental, tuition remission and more. UHealth-University of Miami Health System, South Florida's only university-based health system, provides leading-edge patient care powered by the ground breaking research and medical education at the Miller School of Medicine. As an academic medical center, we are proud to serve South Florida, Latin America and the Caribbean. Our physicians represent more than 100 specialties and sub-specialties, and have more than one million patient encounters each year. Our tradition of excellence has earned worldwide recognition for outstanding teaching, research and patient care. We're the challenge you've been looking for. The University of Miami is an Equal Opportunity Employer. Applicants and employees are protected from discrimination based on certain categories protected by Federal law. Job Status: Full time Employee Type: Staff
RN Utilization Review Telehealth Full-time
Adventist Health

RN, Care Manager, Utilization Management (Part-time, Every weekend - Remote)

Adventist Health Roseville, CA
Job Description Located in the metropolitan area of Sacramento, the Adventist Health corporate headquarters have been based in Roseville, California, for more than 40 years. In 2019, we unveiled our WELL-certified campus - a rejuvenating place for associates systemwide to collaborate, innovate and connect. Whether virtual or on campus, Adventist Health Roseville and shared service teams have access to enjoy a welcoming space designed to promote well-being and inspire your best work. Job Summary This position is Part time, day shift, Every Weekends and rotating holidays. Must live near Roseville, Glendale, or Portland. Plays a critical role in ensuring that patients receive high-quality care while efficiently utilizing medical resources. Reviews patient medical records, assessing the appropriateness and necessity of proposed treatments, and collaborating with healthcare providers and insurance companies to ensure a seamless care experience and the practicing of financial stewardship and denial prevention. Focuses on maximizing patient outcomes and optimizing resource allocation. Utilizes exceptional clinical knowledge, excellent communication skills, and the ability to thrive in a fast-paced and ever-changing healthcare environment. Job Requirements Education and Work Experience: Associate’s Degree in nursing or equivalent combination of education/related experience: Required Bachelor's Degree in Nursing (BSN): Preferred Five years' acute hospital experience required with preferred experience in critical care areas: Required Two years' utilization review experience using the Optum/Inter Qual product within the last 12 months: Required Licenses/Certifications Registered Nurse (RN) licensure in the state of practice: Required Essential Functions Completes clinical reviews of acute medical patients using the Optum/Inter Qual tool to determine if the patient is in the right acute setting, receiving the right acute services, during the appropriate length of stay. Participates in annual Optum/Inter Qual training required. Takes the required annual Optum/Inter Qual Interrater Reliability (IRR) test with a minimum passing score as defined in the yearly departmental goals. Meets weekly productivity metrics within 90 days of completing orientation and maintains on a weekly basis as defined in the yearly departmental goals. Meets quality audit metrics within 90 days of completing orientation and maintained on the audit cadence set within the department as defined in the yearly departmental goals. Completes all required departmental education assigned with timeliness and accuracy. Follows all departmental workflows in communication variances to the on-site care management teams when appropriate. Reviews and analyzes medical records to assess the necessity and appropriateness of treatments and interventions. Collaborates with healthcare professionals to develop and implement comprehensive patient care plans. Facilitates communication between the patient, healthcare team, insurance providers, and other stakeholders to ensure a coordinated and efficient care process. Stays up to date with the latest healthcare regulations, insurance guidelines, and evidence-based practices to ensure the delivery of optimal healthcare services. Performs other job-related duties as assigned. Organizational Requirements Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations as a condition of employment and annually thereafter, where applicable. Medical and religious exemptions may apply. Adventist Health participates in E-Verify. Visit https://adventisthealth.org/careers/everify/ for more information about E-Verify. By choosing to apply, you acknowledge that you have accessed and read the E-Verify Participation and Right to Work notices and understand the contents therein. About Us Adventist Health is a faith-based, nonprofit, integrated health system serving more than 100 communities on the West Coast and Hawaii with over 440 sites of care, including 27 acute care facilities. Founded on Adventist heritage and values, Adventist Health provides care in hospitals, clinics, home care, and hospice agencies in both rural and urban communities. Our compassionate and talented team of more than 38,000 includes employees, physicians, Medical Staff, and volunteers driven in pursuit of one mission: living God's love by inspiring health, wholeness and hope.
RN Utilization Review Other
Community Medical Centers

RN, Quality Management Coordinator, Peer Review

Community Medical Centers Fresno, CA
Overview * All positions are located in Fresno/Clovis CA * We are looking for an RN Quality Management Coordinator to join our growing team. In this fast-paced environment, you will have the opportunity to collaborate with a close-knit team, all while caring for a wide acuity of patients. As the management coordinator, you will provide in-depth clinical analysis on confidential patient safety, peer, quality and risk issues. From facilitating and coordinating performance improvement projects to data tracking from a facility-specific, you will be provided endless personal and professional growth opportunities at every corner. The Community Health System is a locally owned, not-for-profit, public-benefit organization based in Fresno, California. Community is the region's largest healthcare provider and private employer. We operate a physician residency program with one of the nation's top medical schools – the University of California, San Francisco. We are home to the only Level 1 Trauma Center and comprehensive burn center between Los Angeles and Sacramento and also serve as the area's "safety net provider." In fiscal year 2021, Community provided nearly $231 million in uncompensated services and programs. Because we know our ability to provide the highest level of care begins with our incredible staff, we provide excellent benefits. On top of competitive pay, hearty retirement plans, and other core benefits, we provide extras like free concierge services to run your errands while you work, on-demand well-being, a free employee gym with free personal training, and more. Your Career at Community | Opportunity. Challenge. Growth. Responsibilities In your role, you will: Perform in-depth clinical analysis for confidential staff and physician issues related to patient safety, peer and quality. Provide oversight to non-clinical Quality Management staff. Complete responsibilities in a busy, demanding environment with competing priorities. Coordinate, direct and ensure completeness of the FMEA (Failure Mode Effectiveness Analysis), Safe Start of Tracer processes for vulnerable, high-risk operational processes. These processes require a high degree of legal, ethical, financial, clinical and organizational knowledge. Work with employees and physicians to investigate confidential quality, behavioral and patient safety concerns. Understand and make appropriate referrals to Risk Management, Peer, Quality Management or clinical operations as needed. Coordinate and facilitate hospital, CSTCC or departmental involvement with quality measures (e.g. Core Measures, Patient Safety Indicators and other preventable events) including analysis, comparative data, trending and tracking. Demonstrate ability to develop data spreadsheets and provide the analysis and communication to interpret data into information in order to drive quality and change. Facilitate turning data into information for point of service staff and performance improvement. Develop and assist with implementation of action plans focusing on quality outcomes and performance improvement projects using physician and staff input. Qualifications Education• Bachelor's Degree in Nursing or related field required Experience• 5 years of experience in Quality Assurance, Case Management, Discharge Planning, Utilization Review, Infection Control or nursing project development/education required Licenses and Certifications• RN - Current State of California Registered Nurse license required• One of the following is preferredo CPHQ - Certified Professional Healthcare Qualityo CPHRM - Certified Healthcare Risk Managemento CJCP - Certified Joint Commission Professionalo Clinical certification in area specialty Click HERE to learn more about our awesome benefits offerings as well! Disclaimers • Pay ranges listed are an estimate and subject to change.• If any bonuses are noted, they are only applicable to external hires meeting criteria.
RN Utilization Review Full-time
Infirmary Health

Physician Peer Review RN Coordinator (not a remote position)

Infirmary Health Mobile, AL
Overview Responsibilities Coordinates, organizes, and facilitates Mobile Infirmary Medical Center (MIMC) physician peer review and professional practice evaluation processes. Ensures timely, objective, and confidential review of clinical events, supports medical staff leaders in evaluating practitioner performance, and maintains compliance with all Infirmary Health (IH), regulatory, and accreditation standards. Qualifications Minimum Qualifications: Bachelor of Science in Nursing (BSN) 3 of the most recent 5 years’ experience in acute care clinical setting Strong analytical and critical thinking skills Ability to perform with a high level of professionalism, discretion, and confidentiality Proficient computer skills in Microsoft Office and EHR systems (i.e. Epic) Licensure, Registration, Certification: One of the following: Current Alabama RN license Current Multi State RN License in accordance with Nurse Licensure Compact (NLC) for Alabama* *Infirmary Health abides by the NLC requirements and guidelines for the state of Alabama Desired Qualifications: Master of Science in Nursing (MSN) Working knowledge of quality, peer review, risk management, or medical staff services and processes Experience working or coordinating physician peer review in a hospital setting Working knowledge of clinical care standards and physician practice patterns Knowledge of FPPE/OPPE and Joint Commission standards Licensure, Registration, Certification: Certified Professional in Healthcare Quality (CPHQ) through the National Association for Healthcare Quality (NAHQ) Certified Professional in Patient Safety (CPPS) through the Certification Board for Professionals in Patient Safety (CBPPS)
RN Utilization Review Telehealth Full-time
Adventist Health

RN, Care Manager, Utilization Management (Part-time, Remote)

Adventist Health Roseville, CA
Job Description Located in the metropolitan area of Sacramento, the Adventist Health corporate headquarters have been based in Roseville, California, for more than 40 years. In 2019, we unveiled our WELL-certified campus - a rejuvenating place for associates systemwide to collaborate, innovate and connect. Whether virtual or on campus, Adventist Health Roseville and shared service teams have access to enjoy a welcoming space designed to promote well-being and inspire your best work. Job Summary Plays a critical role in ensuring that patients receive high-quality care while efficiently utilizing medical resources. Reviews patient medical records, assessing the appropriateness and necessity of proposed treatments, and collaborating with healthcare providers and insurance companies to ensure a seamless care experience and the practicing of financial stewardship and denial prevention. Focuses on maximizing patient outcomes and optimizing resource allocation. Utilizes exceptional clinical knowledge, excellent communication skills, and the ability to thrive in a fast-paced and ever-changing healthcare environment. Job Requirements Education and Work Experience: Associate’s Degree in nursing or equivalent combination of education/related experience: Required Bachelor's Degree in Nursing (BSN): Preferred Five years' acute hospital experience required with preferred experience in critical care areas: Required Two years' utilization review experience using the Optum/Inter Qual product within the last 12 months: Required Licenses/Certifications Registered Nurse (RN) licensure in the state of practice: Required Essential Functions Completes clinical reviews of acute medical patients using the Optum/Inter Qual tool to determine if the patient is in the right acute setting, receiving the right acute services, during the appropriate length of stay. Participates in annual Optum/Inter Qual training required. Takes the required annual Optum/Inter Qual Interrater Reliability (IRR) test with a minimum passing score as defined in the yearly departmental goals. Meets weekly productivity metrics within 90 days of completing orientation and maintains on a weekly basis as defined in the yearly departmental goals. Meets quality audit metrics within 90 days of completing orientation and maintained on the audit cadence set within the department as defined in the yearly departmental goals. Completes all required departmental education assigned with timeliness and accuracy. Follows all departmental workflows in communication variances to the on-site care management teams when appropriate. Reviews and analyzes medical records to assess the necessity and appropriateness of treatments and interventions. Collaborates with healthcare professionals to develop and implement comprehensive patient care plans. Facilitates communication between the patient, healthcare team, insurance providers, and other stakeholders to ensure a coordinated and efficient care process. Stays up to date with the latest healthcare regulations, insurance guidelines, and evidence-based practices to ensure the delivery of optimal healthcare services. Performs other job-related duties as assigned. Organizational Requirements Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations as a condition of employment and annually thereafter, where applicable. Medical and religious exemptions may apply. Adventist Health participates in E-Verify. Visit https://adventisthealth.org/careers/everify/ for more information about E-Verify. By choosing to apply, you acknowledge that you have accessed and read the E-Verify Participation and Right to Work notices and understand the contents therein. About Us Adventist Health is a faith-based, nonprofit, integrated health system serving more than 100 communities on the West Coast and Hawaii with over 440 sites of care, including 27 acute care facilities. Founded on Adventist heritage and values, Adventist Health provides care in hospitals, clinics, home care, and hospice agencies in both rural and urban communities. Our compassionate and talented team of more than 38,000 includes employees, physicians, Medical Staff, and volunteers driven in pursuit of one mission: living God's love by inspiring health, wholeness and hope.
RN Utilization Review Part-time
Capital Health

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

Capital Health Hopewell, VA
$39.40 - $51.47 / hour
Capital Health is the region's leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advanced technology. Capital Health is a dynamic health care resource accredited by the DNV that includes two hospitals, an outpatient center, satellite ED, and an expansive network of primary and specialty care. Capital Health Medical Group is made up of more than 600 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region. Capital Health recognizes that attracting the best talent is key to our strategy and success as an organization. As a result, we aim for flexibility in structuring competitive compensation offers to ensure we can attract the best candidates. The listed pay range or pay rate reflects compensation for a full-time equivalent (1.0 FTE) position. Actual compensation may differ depending on assigned hours and position status (e.g., part-time). Pay Range: $39.40 - $51.47 Scheduled Weekly Hours: 20 Position Overview Performs a variety of utilization and resource management activities to promote quality, clinical and cost effective outcomes. Assesses patients treatment plans, communicates to third party payers, and collaborates with healthcare team members. Performs functions which help to optimize lengths of stay, utilize resources efficiently, and promote cost effective practices without negatively impacting patient care. Adheres to established standards, practices and procedures. MINIMUM REQUIREMENTS Education: Associate's degree in nursing. Graduate of an accredited school of nursing. CPHQ, CCM or CPUR preferred. Experience: Five years' clinical nursing and three years quality management, utilization review or discharge planning experience. Other Credentials: Registered Nurse - NJ Knowledge and Skills: Special Training: Basic computer skills including the working knowledge of Microsoft Office, UR software and EMR. Possesses familiarity with MCG guidelines. Mental, Behavioral and Emotional Abilities: Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form. Usual Work Day: 8 Hours Reporting Relationships Does this position formally supervise employees? No If set to YES, then this position has the authority (delegated) to hire, terminate, discipline, promote or effectively recommend such to manager. ESSENTIAL FUNCTIONS Performs chart review of identified patients to identify quality, timeliness and appropriateness of patient care. Conducts admission reviews for Medicare, Medicaid beneficiaries, as well as private insurers and self pay patients, based on appropriate guidelines. Uses these criteria guidelines to screen for appropriateness for inpatient level of care or observation services based on physician certification (physicians H&P, treatment plan, potential risks and basis for expectation of a 2 midnight stay). Refers cases as appropriate, to the UR physician advisor for review and determination. Gathers clinical information to conduct continued stay utilization review activities with payers on a daily basis. Performs concurrent and retrospective clinical reviews with various payers, utilizing the appropriate guidelines as demonstrated by compliance with all applicable regulations, policies and timelines. Adheres to CMS guidelines for utilization reviews as evidenced by utilization of the relevant guidelines and appropriate referrals to the physician advisor and the UR Committee. Identifies, develops and implements strategies to reduce length of stay and resource consumption. . Confers proactively with admitting physician to provide coaching on accurate level of care determinations at point of hospital entry. Keeps current on all regulatory changes that affect delivery or reimbursement of acute care services. Uses knowledge of national and local coverage determinations to appropriately advise physicians. Understands and applies federal law regarding use of Hospital Initiated Notice of Non-Coverage (HINN) and Lifetime Reserve Days letters. Identifies and records consistently any information on any progression of care or patient flow barriers using the Avoidable Days tool in Utilization software program. Consults with medical staff, care team and case managers as necessary to resolve immediate progression of care barriers through appropriate administrative and medical channels. Engages care team colleagues in collaborative problem solving regarding appropriate utilization of resources. Recognizes and responds appropriately to patient safety and risk factors. Represents Utilization Management at various committees, professional organizations an physician groups as needed. Promotes the use of evidence based protocols and or order sets to influence high quality and cost effective care. Identifies, develops and implements strategies to reduce lengths of stay and resource consumption in patient population. Participates in performance improvement activities. Promotes medical documentation that accurately reflects findings and interventions, presence of complication or comorbidities, and patient's need for continued stay. Identifies and records episodes of preventable delays or avoidable days due to failure of progression of care processes. Maintains appropriate documentation in Utilization software system on each patient to include specific information of all resource utilization activities. Participates actively in daily huddles, patient care conferences, and hospitalist or nurse handoff reports to maintain knowledge about intensity of services and the progression of care. Identifies potentially wasteful or misused resources and recommends alternatives if appropriate by analyzing clinical protocols. Performs other duties as needed. PHYSICAL DEMANDS AND WORK ENVIRONMENT Frequent physical demands include: Sitting , Standing , Walking Occasional physical demands include: Climbing (e.g., stairs or ladders) , Carry objects , Push/Pull , Twisting , Bending , Reaching forward , Reaching overhead , Keyboard use/repetitive motion , Talk or Hear Continuous physical demands include: Lifting Floor to Waist 15 lbs. Lifting Waist Level and Above 15 lbs. Sensory Requirements include: Accurate Near Vision, Accurate Far Vision, Accurate Color Discrimination, Accurate Depth Perception, Accurate Hearing Anticipated Occupational Exposure Risks Include the following: N/A This position is eligible for the following benefits: Medical Plan Prescription drug coverage & In-House Employee Pharmacy Dental Plan Vision Plan Flexible Spending Account (FSA) - Healthcare FSA - Dependent Care FSA Retirement Savings and Investment Plan Basic Group Term Life and Accidental Death & Dismemberment (AD&D) Insurance - Less than 10 years of service - $5,000 - 10+ years of service - $10,000 Supplemental Group Term Life & Accidental Death & Dismemberment Insurance Disability Benefits – Short Term Disability (STD) Employee Assistance Program Commuter Transit Commuter Parking Supplemental Life Insurance - Voluntary Life Spouse - Voluntary Life Employee - Voluntary Life Child Voluntary Legal Services Voluntary Accident, Critical Illness and Hospital Indemnity Insurance Voluntary Identity Theft Insurance Voluntary Pet Insurance Paid Time-Off Program The pay range listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future. When determining base salary and/or rate, several factors may be considered including, but not limited to location, years of relevant experience, education, credentials, negotiated contracts, budget, market data, and internal equity. Bonus and/or incentive eligibility are determined by role and level. The salary applies specifically to the position being advertised and does not include potential bonuses, incentive compensation, differential pay or other forms of compensation, compensation allowance, or benefits health or welfare. Actual total compensation may vary based on factors such as experience, skills, qualifications, and other relevant criteria.
RN Utilization Review Full-time
Baptist Health South Florida

Pool Utilization Review Registered Nurse, Case Management, Per Diem, Shift Varies (Rotating Weekends)

Baptist Health South Florida Boca Raton, FL
$47 / hour
Baptist Health is the region's largest not-for-profit healthcare organization, with 12 hospitals, over 29,000 employees, 4,500 physicians and 200 outpatient centers, urgent care facilities and physician practices across Miami-Dade, Monroe, Broward and Palm Beach counties. With internationally renowned centers of excellence in cancer, cardiovascular care, orthopedics and sports medicine, and neurosciences, Baptist Health is supported by philanthropy and driven by its faith-based mission of medical excellence. For 26 years, we've been named one of Fortune's 100 Best Companies to Work For, and in the 2025-2026 U.S. News & World Report Best Hospital Rankings, Baptist Health was the most awarded healthcare system in South Florida, earning 63 high-performing honors. What truly sets us apart is our people. At Baptist Health, we create personal connections with our colleagues that go beyond the workplace, and we form meaningful relationships with patients and their families that extend beyond delivering care. Many of us have walked in our patients' shoes ourselves and that shared experience fuels out commitment to compassion and quality. Our culture is rooted in purpose, and every team member plays a part in making a positive impact – because when it comes to caring for people, we're all in. At Baptist Health, we’re committed to supporting our employees at every stage of their journey, both personally and professionally. Our approach is rooted in a “grow our own” philosophy, designed to help our team members build meaningful, long-term careers with us, supported by benefits that make a real difference, including: Career growth and development opportunities , with clear pathways and ongoing support Comprehensive health and wellness resources that go beyond traditional benefits A wellness program that can help employees eliminate their medical plan deductible, reducing out-of-pocket healthcare costs Tuition reimbursement to support continued learning and advancement And so much more Together, these benefits and others reflect our commitment to caring for our people, so they can build fulfilling careers with us while making a meaningful impact every day. Description: The purpose of this position is to conduct initial, concurrent, retrospective chart review for clinical, financial and resource utilization. Coordinates with healthcare Team for optimal efficient patient outcomes, while decreasing length of stay and avoid delays and denied days. They are accountable for a designated patient caseload and provides intervention and coordination to decrease avoidable delays denial of reimbursement. Specific functions within this role include: Screens pre-admission, admission process using established criteria for all points of entry, Facilitates communication between payers, review agencies and healthcare team, Identify delays in treatment or inappropriate utilization and serves as a resource, Coordinates communication with physicians, Identify opportunities for expedited appeals and collaborates resolve payer issues and ensures, maintains effective communication with Revenue Cycle Departments. Estimated pay range for this position is $47.00 / hour depending on shift as applicable. Qualifications: Degrees: Associates. Licenses & Certifications: Registered Nurse. Additional Qualifications: RNs hired prior to 2/2012 (10/1/2017 at Bethesda or 7/1/2019 at BRRH) with an Associates Degree in Nursing are not required to have a BSN to continue their non-leadership role as an RN; however, required to complete the BSN within 3 years of hire. 3 years of hospital clinical experience preferred. Excellent written, interpersonal communication and negotiation skills. Strong critical thinking skills and the ability to perform clinical chart review abstract information efficiently. Strong analytical, data management and computer skills. Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components. Current working knowledge of payer and managed care reimbursement preferred. Ability to work independently and exercise sound judgment in interactions with the health care team and patients/families. Knowledgeable in local, state, and federal legislation and regulations, and ability to tolerate high volume production standards. Minimum Required Experience: . BSN Required 3 years of Nursing experience with 1 year of Hospital or Payor Utilization Review experience required MCG Specialist Certification ISC/HRC required within 12 months of job entry date. EOE, including disability/vets
RN Utilization Review Telehealth Full-time
Astrana Health

UM Review Nurse

Astrana Health Monterey Park, CA
$34 - $47 / hour
UM Review Nurse Department: HS - UM Employment Type: Full Time Location: 1600 Corporate Center Dr., Monterey Park, CA 91754 Reporting To: Phillip Vasquez Compensation: $34.00 - $47.00 / hour Description Astrana Health is looking for a CA-licensed Utilization Review Nurse to assist our Health Services Department. In this position, you will utilize your clinical judgement to approve or deny outpatient medical services for patients based on Medical Necessity Criteria, respective to various Health Plans. This position requires open availability between Monday through Sunday, 8 A - 8 P. You would be scheduled for 5 shifts per week. This is a remote position for CA-licensed nurses. Candidates must live in California. We are seeking nurses with at least one year of outpatient Utilization Management experience in a fast-paced setting. Our Values: Put Patients First Empower Entrepreneurial Provider and Care Teams Operate with Integrity & Excellence Be Innovative Work As One Team What You'll Do Complete prior authorization/retrospective review of elective inpatient admissions, outpatient procedures, post-homecare services, and durable medical equipment Refer cases to Medical Directors as needed/appropriate Maintain knowledge of state and federal regulations and accreditation standards Comply with internal policies and procedures Perform any other job duties as requested Qualifications Active and unrestricted LVN license in CA. At least 1 years of outpatient UM experience Experience with Microsoft applications such as Word, Excel, and Outlook You’ll be Great for this Role If: At least two (2) years of health plan, IPA or MSO experience Strong interpersonal skills Ability to collaborate with co-workers, senior leadership, and other management Experience educating and training staff Environmental Job Requirements and Working Conditions This is a remote position. Our office is located at 1600 Corporate Center Drive in Monterey Park, CA. Candidates who live within a 30 mile radius of the office may be expected to work hybrid. Typical business hours are Monday - Friday from 8:30 AM to 5 PM, however, this position requires open availability between 8 AM - 8 PM PST, M-Su. Your schedule will be compromised of 5 shifts per week. Nurses rotate weekend and holiday coverage. Overtime is required in this position. The national target pay range for this role is $34.00 - $47.00 per hour. Actual compensation will be based on job level, geographic location (current or future), experience, and other job-related factors. Astrana Health is proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based on race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. All employment is decided based on qualifications, merit, and business need. If you require assistance in applying for open positions due to a disability, please email us at humanresourcesdept@astranahealth.com to request an accommodation. Additional Information: The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.
RN Utilization Review Temporary
UF Health

RN, Utilization Management | Utilization Management| Variable | PRN

UF Health Leesburg, FL
Overview Make an impact by supporting the right care at the right time through utilization management excellence. 💻 Work Style: Onsite 📍 Location: Leesburg, FL 🕒 FTE: PRN (.10 FTE) ⏰ Schedule: Variable Plays a critical role in evaluating patient medical records to ensure the necessity and appropriateness of healthcare services. Involves coordinating with healthcare providers to maintain compliance with utilization management guidelines and optimizing treatment plans for effective patient care and resource utilization. Requires clear communication of authorization decisions and ongoing monitoring to support timely discharge planning. Analyzes utilization data to identify trends and collaborates with interdisciplinary teams to enhance care coordination while ensuring accurate documentation and regulatory compliance. Responsibilities Key Responsibilities Evaluates patient medical records to determine the medical necessity and appropriateness of healthcare services. Coordinates with healthcare providers and care teams to ensure compliance with utilization management guidelines and payer requirements. Supports effective treatment planning, patient care coordination, and appropriate resource utilization. Communicates authorization decisions and utilization determinations while supporting timely discharge planning efforts. Analyzes utilization management data and trends to identify opportunities for improved care coordination and operational efficiency. Collaborates with interdisciplinary teams to ensure accurate documentation, regulatory compliance, and quality patient outcomes. Qualifications Education & Licensure Registered Nurse (RN) with a current Florida nursing license required. Experience & Skills Minimum of three (3) years of experience in utilization review, utilization management, or case management required. Knowledge of healthcare utilization guidelines, payer requirements, and regulatory compliance standards. Experience evaluating medical necessity, treatment plans, and appropriate levels of care. Strong communication and collaboration skills related to authorization determinations and care coordination. Demonstrated ability to analyze utilization data, identify trends, and support patient care and discharge planning initiatives.