Registered Nurse (RN) Utilization Review Jobs

RN Manager/Supervisor Utilization Review Full-time
Jackson Health System

Utilization Review Supervisor RN, Central Utilization Review, Full Time, Days

apartment Jackson Health System location_onMiami, FL
Facility Name: Jackson Health System - Central UR Facility Address: 1611 NW 12 Ave., Miami, FL 33136 Shift details: Full Time, Days, 8:00 am - 4:30 pm Mon.-Fri. (Will work one weekend month) -Remote, but will need to visit JHS facilities as needed Why Jackson: Jackson Health System is a nationally and internationally recognized academic medical system offering world-class care to any person who walks through our doors. For more than 100 years, Jackson has evolved into one of the world's top medical providers for all levels of care, no matter if it's for a routine patient visit or for a lifesaving procedure. With more than 2,000 licensed beds, we are also proud of our role as the primary teaching hospital for the University of Miami Miller School of Medicine. Here, the best people come together to deliver Jackson's mission for our diverse communities. Our employees are committed to providing the best CARE by demonstrating compassion, accountability, respect, and expertise in everything we do. Summary The Clinical Resource Coordinator is a professional member of the health care team who has 24hour/7day accountability for the coordination, monitoring and management of patient care resources to promote cost effective delivery of patient care services at the appropriate level while maintaining a standard of quality patient care for all patient populations. The Clinical Resource Coordinator acts as a resource to all levels of staff in defining / implementing and evaluating patient care and nursing practice standards utilizing clinical expertise, the nursing process, current concepts/principles of case management/utilization management/disease management, quality improvement, clinical practice and health care trends. This professional member of the healthcare team maintains compliance with current regulatory standards and new regulatory regulations, clinical and financial, and promotes such compliance as part of daily operations amongst all team members. The Clinical Resource Coordinator performs specific job criteria/performance standards according to prevailing applicable Jackson Health System, professional and regulatory standards. Responsibilities Leads the assessment, planning, implementation, and evaluation for new department models and initiatives. Identifies practice issues, systems issues, and trends utilizing medical criteria, clinical data systems, and protocols. Performs problem-resolution activities to maintain quality patient care. Presents at administrative meetings. Manages Case Management and Social Work metrics and productivity, including but not limited to length of stay (LOS), case mix index (CMI), discharge barriers, resource utilization, discharge planning, and level of care. Provides management oversight of patient throughput, including assessment and evaluation to determine appropriate level of care and admission status (inpatient, observation, outpatient procedure) from point of entry through discharge. Follows up in the outpatient setting for patients enrolled in the CRM Placement EDP program. In the absence of the Manager for Clinical Resource Management, visits facilities to evaluate and determine patient appropriateness for the current level of care as needed. Works in collaboration with the Manager for Clinical Resource Management to transition CRM Placement EDP program patients to the appropriate level of care as needed. Provides management oversight of the Clinical Care Coordinator's performance regarding level of care along the continuum (e.g., medication effectiveness, treatments, pain status, discharge plans) and individualizing the plan of care, including reinforcement of teaching and discharge planning. Maintains leadership visibility, supports service-excellence initiatives, and focuses on improving employee satisfaction. Rounds on patient units to identify barriers to staff performance and discharge barriers. Creates and implements Corrective Action Plans (CAP) for problem resolution and escalation of issues preventing efficient performance. Coordinates day-to-day CRM operations for designated areas, including program development, implementation, outcomes, staffing, liaison with PROS/MCOS/regulatory/community agencies, revenue cycle department, length-of-stay initiatives, Physician Adviser activities, and evidence-based practices. Provides management oversight for referral and problem resolution of complicated discharges. May provide management oversight for referral and problem resolution of complex discharges. Collaborates with family, Attending Physician, Chief Utilization Officer, Utilization Management Committee, and discharge-services providers to ensure a safe discharge plan. Conducts concurrent review of employee schedules to ensure appropriate staffing coverage based on patient census. Collaborates with the Chief Utilization Officer regarding the Utilization Management Committee, case-consultation activities, negotiation of patient placement at the appropriate level of care, and evaluation of the patient's medical plan of care. Demonstrates behaviors of service excellence and CARE values (Compassion, Accountability, Respect, and Expertise). Performs all other related job duties as assigned. Experience Generally requires 3 to 5 years of related experience. Preferred Experience Current experience as utilization review registered nurse. Education BSN or Bachelor's degree in related field is required. Master's degree is preferred. Credentials Must meet and maintain valid and current all unit specific and organizational skills/competencies, certifications/licensures, as required by regulatory and/or nursing standard of practice for the specialty. Jackson Health System is an equal opportunity employer and makes employment decisions without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, disability status, age, or any other status protected by law.
RN Utilization Review Full-time
Cone Health

RN Utilization Review Full Time Days

apartment Cone Health location_onGreensboro, NC
The Utilization Review RN performs admission and continued stay utilization reviews and discharge screening to assure the medical necessity of hospital admission, appropriate level of care, continued stay and supportive services, and to examine delays in the provision of services. Collaborates with attending physicians, advanced practice providers, and/or Department Medical Directors concerning status and/or medical necessity issues. Follows departmental policy to escalate cases to second level review when criteria is in question. The UR RN consistently interacts with physicians, nurses, revenue cycle services, other patient caregivers, and coding professionals to ensure that medical record documentation accurately reflects the level of services rendered to patient and the clinical information utilized in profiling and reporting outcomes is completed. Monitors and evaluates care to ensure care is medically necessary, provided in the appropriate setting, and generated according to governmental and regulatory agency standards. Essential Job Function Conducts initial case reviews within 24 hours of admission and continues reviews as long as the patient is hospitalized, following all relevant regulations. Reviews are documented in EPIC, and clinical information is securely transmitted to carriers, with outcomes communicated to relevant medical and hospital staff. Refers appropriate cases to the Physician Advisor promptly and communicates effectively with peers to ensure patient needs are met. Acts as a liaison between physician and payor regarding non-coverage of benefits or denials. Oversees resource utilization, identifies and addresses issues promptly with the healthcare team, and educates them on payer requirements, denials, and regulatory compliance. Monitors patient status authorizations, documents code 44 processes, and documents avoidable days before discharge. Documents UR processes and supports the healthcare team by providing comprehensive documentation in the EMR/Epic. Maintains clinical/authorization documentation to minimize denials and coordinates with the denials team on appeals. Monitors readmissions, reporting trends and possibilities to the transition of care nurse. Performs other duties as assigned. Education Required: Bachelor’s Degree in Nursing or healthcare-related field Experience Required: 3 years as a Registered Nurse Licensure/Certification/Listing Required:Registered Nurse license in North Carolina or a Compact state
RN Utilization Review Full-time
University of Rochester Medical Center

RN, Utilization Management

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

Utilization Review Nurse Consultant - Oncology and Transplant (Remote)

apartment CVS Health
$29.10 - $62.32 / hour
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Information Schedule: Monday-Friday 11:30am-8:00pm EST Location: 100% Remote (U.S. only) About Us American Health Holding, Inc. (AHH), a division of Aetna/CVS Health, is a URAC-accredited medical management organization founded in 1993. We provide flexible, cost-effective care management solutions that promote high-quality healthcare for members. Position Summary Join a team that’s making a difference in the lives of patients facing complex medical journeys. As a Utilization Management (UM) Nurse Consultant specializing in Oncology and Transplant, you’ll play a vital role in ensuring members receive timely, medically necessary care through thoughtful clinical review and collaboration with providers. This fully remote position offers the opportunity to apply your clinical expertise in a fast-paced, desk-based environment where precision, communication, and compassion intersect. Key Responsibilities Conduct medical necessity reviews for oncology and transplant-related services, both inpatient and outpatient. Collaborate with healthcare providers to gather and assess clinical documentation via phone and electronic systems. Apply evidence-based clinical criteria and guidelines to authorize services or refer cases to Medical Directors when needed. Navigate multiple computer systems efficiently while maintaining accurate and timely documentation. Work primarily in a sedentary setting involving extended periods of sitting, talking, listening, and computer use. Participate in occasional on-call rotations, including some weekends and holidays, per URAC and client requirements. Remote Work Expectations This is a 100% remote role; candidates must have a dedicated workspace free of interruptions. Dependents must have separate care arrangements during work hours, as continuous care responsibilities during shift times are not permitted. Required Qualifications Active, unrestricted RN license in your state of residence with multistate/compact licensure privileges. Ability to obtain licensure in non-compact states as needed. Minimum of 1 year of experience in Oncology and Transplant either in UM, concurrent review, or prior authorization 3+ years of experience in Acute clinical Oncology or Oncology/Transplant. Strong decision-making skills and clinical judgment in independent scenarios. Proficient with phone systems, clinical documentation tools, and navigating multiple digital platforms. Commitment to attend a mandatory 3-week training (Monday–Friday, 8:30am–5:00pm EST) with 100% participation. Preferred Qualifications 1+ years of Managed Care (MCO) preferred. 1+ years of experience working in a high-volume clinical call center environment. NCCN (National Comprehensive Cancer Network) guideline experience/exposure. Remote work experience. Education Associate's degree in nursing (RN) required, BSN preferred. Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $29.10 - $62.32 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan . No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 03/11/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
RN Utilization Review Per Diem
Kaiser Permanente

RN Pre-Service Clinical Review - Per Diem - Must Live in WA or ID

apartment Kaiser Permanente location_onRenton, WA
** Highly Prefer Utilization Management, Case Management, Medical Necessity Review, Preauthorization Work Experience ** Must Live in Washington State or Idaho Job Summary: Reviews coverage requests using established timelines and all relevant clinical information for appropriate coding, medical necessity, care coordination, place of service, and care rendered. Summarizes findings and facilitates appropriate authorization or payment. Prepares information for review by the physician reviewer according to established procedures. Determine if new services are experimental or investigational and whether the service requires a new medical technology assessment by Kaiser Foundation Health Plan of Washington. Identifies potential fraud, waste and abuse and evaluates claims to validate. Essential Responsibilities: Conducts clinical review of coverage request based on the application of medical necessity criteria, understanding of individual coverage contracts and ability to meet Kaiser Foundation Health Plan of Washington, coding rules and other regulatory standards. Uses clinical information available in medical records and treatment summaries as a foundation to complete these reviews. Documents the above review process and decisions for determination of coverage and submits questions or potential denials to the physician review staff. Conducts these reviews while meeting regulatory standards for review timeliness. Conducts audits of claims that are suspended because of potential coding issues or high cost against established coding and billing principles. Provides consultation to requesting providers related to medical review, review criteria and coordination of care. Assures consistency and equity in access to medical benefits. Collects data to ensure appropriate reporting occurs related regulatory guidelines and decision consistency. Participates in the development and maintenance of performance and work force planning data. Supports the development and implementation of new criteria or changes in existing criteria through identification (research on the web) and reporting occurrences. Researches and supports the medical determination for experimental and investigational service requests. Works closely with the referral staff regarding medical necessity; provider relations staff regarding contract terms; and coverage and benefits staff regarding clarity and interpretation of contract language. Contacts the requesting physician by phone when required to provide notification of determination outcomes. Coordinates patient care working with treating providers and Kaiser Foundation Health Plan of Washington Case Managers. Understands and complies with medical protocols, referral processes and claims submission processes.
RN Utilization Review Full-time
Molina Healthcare

Care Review Clinician (RN) - Weekends Required

apartment Molina Healthcare location_onBothell, WA
PST applicants preferred. 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). • Recent hospital experience in an intensive care unit (ICU) or emergency room. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $26.41 - $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
Children's Hospital Colorado

Registered Nurse Utilization Review

apartment Children's Hospital Colorado location_onAurora, CO
$84,558.69 - $126,838.03 / year
Job Overview The Utilization Review RN participates as a member of a multidisciplinary team to support medical necessity reviews, ensure compliance, and actively participate in denial mitigation. It is a collaborative approach that uses pre-established guidelines and criteria to perform review activities to ensure the proper utilization of hospital services and payment of those services by Medicare, Medicaid, and other third-party payors. Department Name: Case Management - Utilization Review Job Status: full time, 40 hours per week, eligible for benefits Shift: Dayshift Monday through Friday 0800-1630 This position will be primarily remote but there may be occasions when you are expected to work onsite at one of the Children’s Hospital Colorado locations. The specific details will be discussed in the interview process, and subject to change at our discretion. Applicants must already reside in Colorado or be willing to relocate prior to starting. This position is eligible for relocation assistance, if relocating from 100 miles or greater. Duties & Responsibilities An employee in this position may be called upon to do any or all the following essential functions. These examples do not include all the functions which the employee may be expected to perform. Assesses all new inpatient admissions for identification of status and medical necessity for admission; communicates clinical review process with appropriate Payors. Assesses the continuity of care in conjunction with the Case Managers regarding the continued medical necessity of hospitalization and the status of the discharge plan; communicates this to the appropriate payors. Coordinates with other members of the healthcare team to help identify and control inappropriate resource utilization. Conducts concurrent admission and continued stay reviews based on appropriate utilization review criteria. Utilizes information provided by Patient Access regarding authorized length of stay and follows up with third-party payors on an ongoing basis, documents communications regarding continued authorizations. Follows up on denials communicated to the department and works with the revenue cycle staff to assist with appeals. Maintains and demonstrates appropriate clinical knowledge to assist physicians in providing documentation of severity of illness and intensity of service to assure that criteria for acute hospitalization are met. Employees are expected to comply with all regulatory requirements, including CMS and Joint Commission Standards. Minimum Qualifications Education: Bachelor of Science in Nursing (BSN) Experience: Three years of recent clinical or case management experience that includes recent UR experience in a hospital or with a Third-Party Payor Certification(s): BLS/CPR from the American Heart Association with at least 6 months left before expiration is required upon hire. Licensure(s): Registered Nurse License Salary Information Pay is dependent on applicant's relevant experience. Annual Salary Range (Based on 40 hours worked per week): $84,558.69 to $126,838.03 Benefits Information Here, you matter. As a Children’s Hospital Colorado team member, you will receive a competitive pay and benefits package designed to take care of your needs that includes base pay, incentives, paid time off, medical/dental/vision insurance, company provided life and disability insurance, paid parental leave, 403b employer match (retirement savings), a robust wellness program, and access to professional development tools, including an education benefit to help you advance your career. As part of our Total Rewards package, Children's Colorado offers an annual employee bonus program that rewards eligible team members based on organizational performance. If organizational goals are met for the year, the bonus is paid out the following April. Children’s Colorado delivers annual base pay increases to eligible team members based on their performance over the previous year. EEO Statement It is our intention that all qualified applicants be given equal opportunity and that selection decisions be based on job-related factors. We do not discriminate on the basis of race, color, religion, national origin, sex, age, disability, or any other status protected by law or regulation. Be aware that none of the questions are intended to imply illegal preferences or discrimination based on non-job-related information. The position is expected to stay open until the posted close date. Please submit your application as soon as possible as the posting is subject to close at any time once a sufficient pool of qualified applicants is obtained. Colorado Residents: In any materials you submit, you may redact or remove age-identifying information such as age, date of birth, or dates of attendance at or graduation from an educational institution. You will not be penalized for redacting or removing this information.
RN Utilization Review Full-time
Centene

Clinical Review Nurse - Concurrent Review

apartment Centene location_onFL
$27.02 - $48.55 / hour
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. Ambetter Marketplace Compact licensed needed No specific state residency required Position Purpose: Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member. Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines Reviews member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities Collaborates with care management on referral of members as appropriate Performs other duties as assigned Complies with all policies and standards Ambetter Marketplace Compact licensed needed No specific state residency required Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience. 2+ years of acute care experience required. Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. License/Certification: LPN - Licensed Practical Nurse - State Licensure required Pay Range: $27.02 - $48.55 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
RN Psych Utilization Review Full-time
CVS Health

Utilization Management Clinician - Independent Behavioral Health or Registered Nurse

apartment CVS Health location_onCA
$66,575 - $142,576 / year
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Behavioral Health Utilization Management Clinician Position Summary Join a team that’s dedicated to helping individuals access the right care at the right time. As a Behavioral Health Utilization Management Clinician, you’ll use your clinical expertise and critical thinking skills to support members across the continuum of care. You’ll collaborate with providers, apply evidence‑based guidelines, and help ensure members receive clinically appropriate and cost‑effective treatment. In this role, you will assess treatment plans across various levels of care, evaluate medical necessity, and make coverage recommendations using established criteria and clinical judgment. You’ll provide triage and crisis support when needed, identify members at risk for poor outcomes, and coordinate referrals to additional programs or services. You’ll also partner with internal teams and external providers to promote high‑quality, effective healthcare and optimal benefit utilization. This is a meaningful opportunity for clinicians who are passionate about improving patient outcomes while working in a fast‑paced, supportive environment. What You’ll Do Use clinical expertise to assess the appropriateness of treatment plans and levels of care. Apply evidence‑based guidelines, medical necessity criteria, and policy standards to coverage determinations. Coordinate, monitor, and evaluate options to support members in accessing appropriate healthcare services. Provide crisis intervention and triage support as needed. Facilitate effective discharge planning and transitions of care. Collaborate with providers and internal partners to ensure seamless, coordinated treatment. Identify at‑risk members and connect them with additional programs, services, or resources. Promote quality, efficiency, and appropriate utilization of benefits. Serve as a clinical resource for colleagues and partners involved in utilization and benefit management. Required Qualifications 3+ years of post‑degree experience in a psychiatric or substance abuse treatment setting. 3+ years of direct clinical practice experience post degree (e.g., hospital, ambulatory, or outpatient care). Active, unrestricted independent clinical behavioral health or registered nurse license in the state of residence; accepted licenses include: Reliable residential broadband service (25 Mbps down / 3 Mbps up) ; Preferred Qualifications 3+ years of managed care or utilization review experience. Strong crisis intervention skills. Proficiency navigating multiple computer systems and electronic platforms. California clinical license or willingness to obtain one. Education Master’s degree in Behavioral/Mental Health , Human Services , or Health Services , or Associate’s degree with RN license and 3+ years of behavioral health experience. Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $66,575.00 - $142,576.00 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan . No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 02/23/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
RN Utilization Review Full-time
Lexington Medical Center

Utilization Review Specialist RN - Onsite

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

RN, Clinical Review Nurse - Prior Authorization

apartment Centene location_onTX
$27.02 - $48.55 / hour
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. Superior Health Plan - Specialty Therapy Services NOTE: Candidates must reside in the state of Texas Position Purpose: Analyzes all prior authorization requests to determine medical necessity of service and appropriate level of care in accordance with national standards, contractual requirements, and a member's benefit coverage. Provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care. Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria Works with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care Coordinates as appropriate with healthcare providers and interdepartmental teams, to assess medical necessity of care of member Escalates prior authorization requests to Medical Directors as appropriate to determine appropriateness of care Assists with service authorization requests for a member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities Collects, documents, and maintains all member’s clinical information in health management systems to ensure compliance with regulatory guidelines Assists with providing education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care to members Provides feedback on opportunities to improve the authorization review process for members Performs other duties as assigned Complies with all policies and standards Education/Experience: · Requires Graduate from an Accredited School of Nursing degree · 2 – 4 years of related experience. · Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred. · Knowledge of Medicare and Medicaid regulations preferred. · Knowledge of utilization management processes preferred. Strongly Preferred Experience: · 4+ years of Registered (RN) experience with direct patient care with PDN/Home Health members/patients License/Certification: · For Superior Health Plan: RN license required · LPN - Licensed Practical Nurse - State Licensure required Pay Range: $27.02 - $48.55 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
RN Utilization Review Full-time
PeaceHealth

RN Utilization Management Reviewer (Per Diem) - Remote (OR, WA or AK)

apartment PeaceHealth location_onVancouver, WA
$48.52 - $72.78 / hour
Description Job Description Join PeaceHealth in advancing compassionate, mission-driven care from wherever you are. PeaceHealth is looking for a skilled and motivated Registered Nurse Utilization Management (UM) Reviewer to join our dedicated team in a Per Diem, Day Shift role. If you enjoy analytical work and are energized by helping ensure patients receive the right care at the right time, this remote opportunity may be the perfect next step in your nursing career. Coverage needed could include weekdays, weekends and holidays. Why You’ll Love This Role As a Utilization Management Reviewer at PeaceHealth, you will play a key part in supporting safe, high-quality, and efficient patient care across our healthcare system. This position centers on concurrent and retrospective UM reviews , leveraging clinical expertise, payer policy knowledge, and technology tools to guide patient status determinations and promote appropriate utilization of hospital resources. You’ll work fully remote*, with PeaceHealth-provided computer equipment—empowered by a collaborative team, supportive leadership, and a strong organizational commitment to diversity, cultural humility, and caregiver well-being. Must reside in Washington, Oregon, or Alaska. PeaceHealth will provide the caregiver with necessary computer equipment. It is the responsibility of the caregiver to provide Internet access. PeaceHealth is committed to the overall wellbeing of our caregivers. Pay Range: $48.52 – $72.78/hour plus a per diem differential. The benefits included in positions less than 0.5 FTE are 403b retirement plan for caregiver contributions; wellness benefits, discount program, and expanded EAP and mental health program. What You’ll Do Coordinate accurate patient status identification and documentation Ensure correct admission status and reimbursement through certification and clinical review Gather additional clinical documentation to validate treatment plans and level of care Collaborate closely with physicians, clinicians, and multidisciplinary teams Apply UM criteria using the Xsolis Dragonfly™ platform and PeaceHealth Care Level Score tools Conduct pre-admission status reviews in the ED, patient access areas, and elective settings Communicate with third-party payers regarding medical necessity and discharge progress Support denial and appeal processes; refer cases for physician advisor review when appropriate Participate in UM Committee work, quality initiatives, and performance improvement Identify DRGs with complications/comorbidities and recommend documentation improvements Promote responsible hospital resource utilization, length-of-stay optimization, and care efficiency Perform other duties as needed to support UM and organizational goals What You Bring Education Required: Bachelor of Science in Nursing (BSN) Preferred: Master of Science in Nursing (MSN) Experience 3+ years of acute care hospital experience with strong clinical knowledge In-depth understanding of Medicare/Medicaid UM regulations, RAC, QIO, MAC, and denial/appeals processes Preferred: Prior experience in utilization management or case management Credentials Active RN license in your state of residence (WA, OR, or AK) Ready to Make a Meaningful Impact? Bring your clinical expertise, attention to detail, and passion for patient advocacy to a mission-driven healthcare system that believes in caring for caregivers as much as patients. For full consideration, please attach a current resume with your application. PeaceHealth is an EEO Affirmative Action Employer/Veterans/Disabled following all applicable state, local, and federal laws.
RN OR Utilization Review Full-time
PeaceHealth

RN Utilization Management Reviewer - Remote (WA, OR, or AK)

apartment PeaceHealth location_onVancouver, WA
$48.52 - $72.78 / hour
Description Job Description Join PeaceHealth in advancing compassionate, mission-driven care from wherever you are. PeaceHealth is looking for a skilled and motivated Registered Nurse Utilization Management (UM) Reviewer to join our dedicated team in a Full Time, Day Shift (1.0 FTE) role. If you enjoy analytical work and are energized by helping ensure patients receive the right care at the right time, this remote opportunity may be the perfect next step in your nursing career. Why You’ll Love This Role As a Utilization Management Reviewer at PeaceHealth, you will play a key part in supporting safe, high-quality, and efficient patient care across our healthcare system. This position centers on concurrent and retrospective UM reviews , leveraging clinical expertise, payer policy knowledge, and technology tools to guide patient status determinations and promote appropriate utilization of hospital resources. You’ll work fully remote*, with PeaceHealth-provided computer equipment—empowered by a collaborative team, supportive leadership, and a strong organizational commitment to diversity, cultural humility, and caregiver well-being. Must reside in Washington, Oregon, or Alaska. PeaceHealth will provide the caregiver with necessary computer equipment. It is the responsibility of the caregiver to provide Internet access. PeaceHealth’s Total Rewards package supports your physical, emotional, financial, social, and spiritual wellbeing . Benefits include: Pay Range: $48.52 – $72.78/hour Full medical, dental, and vision coverage 403(b) retirement plan with employer base and matching contributions Paid time off and paid disability & life insurance (with buy-up options) Tuition reimbursement and continuing education support Robust wellness benefits, EAP, and expanded mental health programs A culture grounded in Inclusivity, Respect for Diversity, and Cultural Humility What You’ll Do Coordinate accurate patient status identification and documentation Ensure correct admission status and reimbursement through certification and clinical review Gather additional clinical documentation to validate treatment plans and level of care Collaborate closely with physicians, clinicians, and multidisciplinary teams Apply UM criteria using the Xsolis Dragonfly™ platform and PeaceHealth Care Level Score tools Conduct pre-admission status reviews in the ED, patient access areas, and elective settings Communicate with third-party payers regarding medical necessity and discharge progress Support denial and appeal processes; refer cases for physician advisor review when appropriate Participate in UM Committee work, quality initiatives, and performance improvement Identify DRGs with complications/comorbidities and recommend documentation improvements Promote responsible hospital resource utilization, length-of-stay optimization, and care efficiency Perform other duties as needed to support UM and organizational goals What You Bring Education Required: Bachelor of Science in Nursing (BSN) Preferred: Master of Science in Nursing (MSN) Experience 3+ years of acute care hospital experience with strong clinical knowledge In-depth understanding of Medicare/Medicaid UM regulations, RAC, QIO, MAC, and denial/appeals processes Preferred: Prior experience in utilization management or case management Credentials Active RN license in your state of residence (WA, OR, or AK) Ready to Make a Meaningful Impact? Bring your clinical expertise, attention to detail, and passion for patient advocacy to a mission-driven healthcare system that believes in caring for caregivers as much as patients. For full consideration, please attach a current resume with your application. PeaceHealth is an EEO Affirmative Action Employer/Veterans/Disabled following all applicable state, local, and federal laws.
RN Utilization Review Full-time
Swedish Health Services

Utilization Review RN

apartment Swedish Health Services location_onSeattle, WA
$52.26 - $81.13 / hour
Description The Utilization Review (UR) Nurse has a strong clinical background blended with a well-developed knowledge and skills in Utilization Management (UM), medical necessity and patient status determination. This individual supports the UM program by developing and maintaining effective, efficient processes for determining the appropriate admission status based on regulatory and reimbursement requirements of commercial and government payers. Providence caregivers are not simply valued – they’re invaluable. Join our team at Swedish Shared Services and thrive in our culture of patient-focused, whole-person care built on understanding, commitment, and mutual respect. Your voice matters here, because we know that to inspire and retain the best people, we must empower them. Required Qualifications Bachelor's Degree in Nursing degree (BSN) from an accredited school of nursing. Upon hire: Washington Registered Nurse License 3 years of Registered nursing experience in the clinical setting. Preferred Qualifications Upon hire: ACM or CCM certification 1 year of Case management experience. Why Join Providence? Our best-in-class benefits are uniquely designed to support you and your family in staying well, growing professionally and achieving financial security. We take care of you, so you can focus on delivering our mission of improving the health and wellbeing of each patient we serve. About Providence At Providence, our strength lies in Our Promise of “Know me, care for me, ease my way.” Working at our family of organizations means that regardless of your role, we’ll walk alongside you in your career, supporting you so you can support others. We provide best-in-class benefits and we foster an inclusive workplace where diversity is valued, and everyone is essential, heard and respected. Together, our 120,000 caregivers (all employees) serve in over 50 hospitals, over 1,000 clinics and a full range of health and social services across Alaska, California, Montana, New Mexico, Oregon, Texas and Washington. As a comprehensive health care organization, we are serving more people, advancing best practices and continuing our more than 100-year tradition of serving the poor and vulnerable. Posted are the minimum and the maximum wage rates on the wage range for this position. The successful candidate's placement on the wage range for this position will be determined based upon relevant job experience and other applicable factors. These amounts are the base pay range; additional compensation may be available for this role, such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities. Providence offers a comprehensive benefits package including a retirement 401(k) Savings Plan with employer matching, health care benefits (medical, dental, vision), life insurance, disability insurance, time off benefits (paid parental leave, vacations, holidays, health issues), voluntary benefits, well-being resources and much more. Learn more at providence.jobs/benefits. Applicants in the Unincorporated County of Los Angeles: Qualified applications with arrest or conviction records will be considered for employment in accordance with the Unincorporated Los Angeles County Fair Chance Ordinance for Employers and the California Fair Chance Act. About The Team Providence Swedish is the largest not-for-profit health care system in the greater Puget Sound area. It is comprised of eight hospital campuses (Ballard, Edmonds, Everett, Centralia, Cherry Hill (Seattle), First Hill (Seattle), Issaquah and Olympia); emergency rooms and specialty centers in Redmond (East King County) and the Mill Creek area in Everett; and Providence Swedish Medical Group, a network of 190+ primary care and specialty care locations throughout the Puget Sound. Whether through physician clinics, education, research and innovation or other outreach, we’re dedicated to improving the wellbeing of rural and urban communities by expanding access to quality health care for all. Providence is proud to be an Equal Opportunity Employer. We are committed to the principle that every workforce member has the right to work in surroundings that are free from all forms of unlawful discrimination and harassment on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law. We believe diversity makes us stronger, so we are dedicated to shaping an inclusive workforce, learning from each other, and creating equal opportunities for advancement. For any concerns with this posting relating to the posting requirements in RCW 49.58.110(1), please click here where you can access an email link to submit your concern. Requsition ID: 413245 Company: Swedish Jobs Job Category: Health Information Management Job Function: Revenue Cycle Job Schedule: Full time Job Shift: Day Career Track: Nursing Department: 3900 SS CASE MANAGEMENT Address: WA Seattle 1730 Minor Ave Work Location: Swedish Metropolitan Park East-Seattle Workplace Type: On-site Pay Range: $52.26 - $81.13 The amounts listed are the base pay range; additional compensation may be available for this role, such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities.
RN Utilization Review Full-time
The Christ Hospital Health Network

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

apartment The Christ Hospital Health Network location_onCincinnati, 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 Manager/Supervisor Utilization Review Full-time
BAYADA Home Health Care

Non-Clinical Coding and OASIS Review Manager, RN, PT, OT, SLP

apartment BAYADA Home Health Care location_onMerchantville, NJ
Please note- Candidates must have COS-C, HCS-O or COQS and HCS-D or BCHH-C in order to be considered, there is no flexibility around this requirement. BAYADA Home Health Care is hiring a full time OASIS Review and Coding Manager. The OASIS and Coding Review Manager provides support to all BAYADA Home Health Care Medicare service offices by monitoring Outcome and Assessment Information Set (OASIS) documentation for quality and adherence to policies and procedures. As a member of the Medicare Case Management (MCM) office, individuals in this role are expected to maintain ongoing communication with BAYADA’s service offices and assist the company in addressing and meeting business and development goals. This is a non-clinical role (Note: Clinical opportunities are also available). BAYADA Perks: This role is fully remote, candidates may be based anywhere in the US Base Salary: $64,000/year depending on qualifications Bonus Opportunity of $500/Quarter based on department metrics BAYADA offers a comprehensive benefits plan that includes the following: Paid holidays, vacation and sick leave, vision, dental and medical health plans, employer paid life insurance, 401k with company match, direct deposit, and employee assistance program To learn more about BAYADA Benefits, click here. Responsibilities: Review clinical information for appropriateness, congruency, and accuracy as it relates to the OASIS and ICD 10 coding while using the Medicare PDGM billing model and CMS guidelines. Review and communicate OASIS edit recommendations to each clinician to promote OASIS accuracy. Perform final review and lock OASIS. Timely review and coding of OASIS documents with productivity maintained at the quarterly target set by the Director of MCM. Prevent or decrease the occasion of Medicare denials by assuring proper coding on the plan of care and accurate OASIS documentation. Provide support and communication to all disciplines within the service. Provide customer service/education and act as a resource to Medicare Certified Offices with regards to CMS guidelines, Home Care Coding, PDGM guidelines and billing related issues. Provide ongoing communication with service offices via e-mail, zoom, or telephone (specific to the service office needs). Communication with service offices monthly and as appropriate with a focus on documentation trends, star ratings and potential revenue impact. Perform related duties, or as required or requested by Manager/Director. Qualifications: Four (4) year college degree preferred. COS-C or HCS-O or COQS OASIS Certification (Required) HCS-D or BCHH-C Home Health Care Coding Certification (Required) Minimum of 1 year experience with coding and OASIS review. Knowledge of OASIS, Home Care and Medicare regulations Excellent organizational, interpersonal and communication skills Process oriented, has meticulous attention to detail, and is able to work as part of a team in a busy, high-energy, fast-paced environment. Completion of coding quiz with passing grade as part of the interview process. Candidates should be available Monday-Friday from 8:30am-5:00pm. Medicare, Coder, OASIS Review, Utilization Review, Quality Assurance, Remote, Home Health Coding As an accredited, regulated, certified, and licensed home health care provider, BAYADA complies with all state/local mandates. BAYADA is celebrating 50 years of compassion, excellence, and reliability. Learn more about our 50th anniversary celebration and how you can join in here. BAYADA Home Health Care, Inc., and its associated entities and joint venture partners, are Equal Opportunity Employers. All employment decisions are made on a non-discriminatory basis without regard to sex, race, color, age, disability, pregnancy or maternity, sexual orientation, gender identity, citizenship status, military status, or any other similarly protected status in accordance with federal, state and local laws. Hence, we strongly encourage applications from people with these identities or who are members of other marginalized communities.
RN Utilization Review Full-time
Meadville Medical Center

REGISTERED NURSE-Utilization Management- Full Time- On Site

apartment Meadville Medical Center location_onMeadville, PA
$5,000 SIGN ON BONUS (for external candidates only) Utilization management (UM ) is the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of the applicable health benefits plan. Prior authorization that allow payers, particularly health insurance companies to manage the cost of health care benefits by assessing its appropriateness before it is provided using evidence-based criteria or guidelines. Strong utilization management process can reduce payment denials. Clinical documentation specialists is designed to improve the physician’s documentation in the patient’s medical record, supporting the appropriate severity of illness, expected risk of mortality and complexity of care of the patient. Clinical documentation is responsible for extensive collaboration with physician is, nursing staff, support staff, other patient caregiver and medical records coding staff. Employee insurance liaison Meadville Medical Center has self-funded insurance. One staff member is assigned to work with Human resources, Highmark Liaison, Medical director and employees. Set process is to call medical procedures out of network and employee needs to request a waiver from our current liaison. The liaison will review the requested procedure with our current medical director. If the request is approved the liaison of UM will notify the employee and out Highmark Liaison. Medical necessity rules will be reviewed, urgency and medical history. The decision will be called to the employee. If it is not favorable, this can be appealed to human resources If this process is not followed, and the employee gets a bill. The liaison will review what was performed. They will review with the medical director and make a decision to override the out of network rules. The liaison support HR represented as needed. Applicate: Curious and Detailed Oriented. Actively seek out new ideas, possibilities, and answers to the tough questions. Pays meticulous attention to detail. Committed to life-long learning UM Process Payors may use different criteria and may require their data set be applied for their population. Utilization management is a strategy for managing cost and quality under the latest CMS reimbursement Reviews precertification requests for medical necessity, referring to the Medical Director those that require additional expertise. Reviews Clinical information for concurrent reviews, extending the length of stay for inpatients as appropriate. Establishes effective rapport with other employees, professional support service staff, customers, clients, patient’s families and physicians. Use effective relationship management, coordination of services, resource management, education, patient advocacy and related interventions. CDS-Inpatients Advanced clinical expertise and extensive knowledge of complex disease processes with a broad clinical experience in an inpatient setting required Pursues a subsequent review of records every 3 days to support and assign a working DRG assignment upon discharge. Formulates queries when it is determined there is missing documentation, conflicting documentation or unclear documentation. Provides on-going education to physicians and essential healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the patient's record. Use of coding nomenclature demonstrated knowledge of ICD-10 classifications, and thorough understanding of the effect coded data has prospective payment, outcome models, utilization, and reimbursement. Participates in the analysis and trending of statistical data for specified patient population; identifies opportunity for improvement. Promotes a partnership with the inpatient-coding professionals to ensure the accuracy of principal diagnosis, procedures and completeness of supporting documentation to determine the working and final DRG, severity of illness and risk of mortality. Acts as a resource person for the interdisciplinary team in order to promote collaboration and coordination of patient care considering age specific, developmental, cultural, and spiritual needs of the patient. Overall department goals Promotes improved quality of care and/or life. Promotes cost effective medical outcomes. Prevents hospitalization when possible and appropriate. Promotes decreased lengths of observation stays or inpatient stays when appropriate. Provides for continuity of care. Assures appropriate levels of care are received by our patients. Participates in rounding on the nursing floors. Works with HIM on coding issues. Provides advice and counsel to precertification staff in physician offices or in house. Identifies appropriate alternative resources and demonstrate creativity in managing each case to fully utilize all available resources. Maintains accurate records of all communications and interventions. Other duties as assigned. MINIMUM EDUCATION, KNOWLEDGE, SKILLS, AND ABILITIES REQUIRED Proof of successful completion of education requirements for board certified registered nurse as defined by the state in which the employee is to practice as well as proof of such licensure in good standing. 5 years’ experience as a Registered Nurse is preferred. Ability to read analyze and interpret documents, reports, technical procedures, governmental regulations and correspondence BLS required. Certification for UM nurse and CDI specialists is encouraged.
RN Utilization Review Full-time
Travelers

Utilization Review Nurse

apartment Travelers location_onBuffalo, NY
Who Are We? Taking care of our customers, our communities and each other. That’s the Travelers Promise. By honoring this commitment, we have maintained our reputation as one of the best property casualty insurers in the industry for over 170 years. Join us to discover a culture that is rooted in innovation and thrives on collaboration. Imagine loving what you do and where you do it. Job Category Claim, Nurse - Medical Case Manager Compensation Overview The annual base salary range provided for this position is a nationwide market range and represents a broad range of salaries for this role across the country. The actual salary for this position will be determined by a number of factors, including the scope, complexity and location of the role; the skills, education, training, credentials and experience of the candidate; and other conditions of employment. As part of our comprehensive compensation and benefits program, employees are also eligible for performance-based cash incentive awards. Salary Range $81,500.00 - $134,500.00 Target Openings 1 What Is the Opportunity? This position is responsible for conducting in-house utilization review with emphasis on determining medical necessity for prospective, concurrent, retrospective and appeal treatment requests for workers compensation claims. Responsible for helping to ensure the appropriate treatment is directly related to the compensable injury and for adhering to multi-jurisdictional Utilization Review criteria. What Will You Do? Interpret routine, complex or unique medical information. Evaluate medical treatment to determine whether it was/is reasonable, necessary and causally related based upon jurisdictional guidelines. Submit accurate billing documentation on all activities as outlined in established guidelines. Engage specialty resources, as needed, to reach final determination of medical necessity. Utilize internal Claim Platform Systems to manage all claim activities on a timely basis. Utilize Preferred Provider Network per jurisdictional guidelines. Research medical information to support the claim review process. Occasional contact with provider to ensure the injured employee is actively participating in a viable treatment plan. Keep claim professional apprised of medical treatment request status. In order to perform the essential functions of this job, acquisition and maintenance of Insurance License(s) may be required to comply with state and Travelers requirements. Generally, license(s) must be obtained within three months of starting the job and obtain ongoing continuing education credits as mandated. Perform other duties as assigned. What Will Our Ideal Candidate Have? Working knowledge of medical causation and relatedness. Working knowledge of jurisdiction-specific medical guidelines. Prior clinical experience. Intermediate medical knowledge of the nature and extent of injuries, periods of disability, and treatment. Intermediate customer service: ability to build and maintain productive relationships with medical providers as well as internal claim handlers. Working knowledge of URAC standards. Intermediate planning & Organizing: ability to establish a plan/course of action and contingencies for self or others to meet current or future goals. Intermediate teamwork: ability to work together in situations when actions are interdependent and a team is mutually responsible to produce a result. Intermediate analytical thinking: Identifies current or future problems or opportunities; analyzes, synthesizes and compares information to understand issues; identifies cause/effect relationships; and explores alternative solutions that support sound decision-making. Intermediate communication skills: Expresses, summarizes and records thoughts clearly and concisely orally and in writing by applying proper content, format, sentence structure, grammar, language and terminology. Basic negotiation: ability to understand alternatives, influence stakeholders and reach a fair agreement through discussion and compromise. Basic principles of investigation: follows a logical sequence of inquiry determine if the treatment request is related to the compensable injury and medically necessary per jurisdictional guidelines. Basic legal knowledge: understanding and application of state, federal and regulatory laws and statutes. Basic worker’s compensation technical ability to apply available resources and technology to manage treatment plans. Demonstrate a clear understanding and ability to work within jurisdictional parameters within their assigned state. What is a Must Have? Registered Nurse; Licensed Practical Nurse or Licensed Vocational Nurse. What Is in It for You? Health Insurance : Employees and their eligible family members – including spouses, domestic partners, and children – are eligible for coverage from the first day of employment. Retirement: Travelers matches your 401(k) contributions dollar-for-dollar up to your first 5% of eligible pay, subject to an annual maximum. If you have student loan debt, you can enroll in the Paying it Forward Savings Program. When you make a payment toward your student loan, Travelers will make an annual contribution into your 401(k) account. You are also eligible for a Pension Plan that is 100% funded by Travelers. Paid Time Off: Start your career at Travelers with a minimum of 20 days Paid Time Off annually, plus nine paid company Holidays. Wellness Program: The Travelers wellness program is comprised of tools, discounts and resources that empower you to achieve your wellness goals and caregiving needs. In addition, our mental health program provides access to free professional counseling services, health coaching and other resources to support your daily life needs. Volunteer Encouragement: We have a deep commitment to the communities we serve and encourage our employees to get involved. Travelers has a Matching Gift and Volunteer Rewards program that enables you to give back to the charity of your choice. Employment Practices Travelers is an equal opportunity employer. We value the unique abilities and talents each individual brings to our organization and recognize that we benefit in numerous ways from our differences. In accordance with local law, candidates seeking employment in Colorado are not required to disclose dates of attendance at or graduation from educational institutions. If you are a candidate and have specific questions regarding the physical requirements of this role, please send us an email so we may assist you. Travelers reserves the right to fill this position at a level above or below the level included in this posting. To learn more about our comprehensive benefit programs please visit http://careers.travelers.com/life-at-travelers/benefits/ .
RN Utilization Review Other
MaineHealth

Care Manager (RN) - Utilization Review

apartment MaineHealth location_onPortland, ME
Description Maine Medical Center Nursing Req #: 67833 This is a Clinical Nurse II vacancy open to candidates with greater than 1 year of RN work experience This is a Bargaining Unit Position Date Posted: 2/9/2026 *Knowledge ofboth Inter-qual and MCG criteria preferred. Previous Care Manager experience preferred* Pleasenote,this position does not include discharge planning Role The CaseManager I is accountable for a designated patient caseload and plans effectivelyin order to meet patient needs, manage the length of stay, and promote efficient utilization of resources. Specific functions within this role include but are not limited to: Facilitation of the collaborative management of patient care across the continuum, intervening as necessary to address barriers totimelyand efficient care delivery,flowand reimbursement Application of process improvement methodologies in evaluating outcomes of care Support and coaching of clinical documentation efforts Coordinating communication with the interdisciplinary care team Must be able todemonstrateknowledge and skills necessary to provide careappropriate tothe patient served. Mustdemonstrateknowledge of the principles of growth and development as it relates to the different life cycles. Summary The purpose of the Case Manager I position is to support the interdisciplinary team in facilitating patient care, with the underlying objective of enhancing the quality of clinical outcomes and patient satisfaction while managing the cost of care and providing timely and accurate information to payors. The role integrates and coordinates utilization management, care facilitation and discharge planning functions. This work is performed under general supervision in accordance with the Maine Medical Center (MMC) institutional policies and Care Management Department policies. The Case Manager I is accountable for a designated patient caseload and plans effectively in order to meet patient needs, manage the length of stay, and promote efficient utilization of resources. Specific functions within this role include but are not limited to: Facilitation of the collaborative management of patient care across the continuum, intervening as necessary to address barriers to timely and efficient care delivery, flow and reimbursement Application of process improvement methodologies in evaluating outcomes of care Support and coaching of clinical documentation efforts Coordinating communication with the interdisciplinary care team Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the patient served. Must demonstrate knowledge of the principles of growth and development as it relates to the different life cycles. Required Minimum Knowledge, Skills, And Abilities (KSAs) Education: BSN or must matriculate into a BSN program within one year of hire and completion attained within 5 years of hire. License/Certifications: Current and valid license to practice as a Registered Nurse in the state of Maine. Professional certification as a Case Manager preferred. Experience: One to three years clinical experience in clinical practice area, three to five years preferred. Excellent interpersonal communication and negotiation skills. Strong analytical, data management and PC skills. Working knowledge of discharge planning, utilization management, case management, performance improvement and managed care reimbursement preferred. Understanding of pre-acute and post-acute venues of care and post-acute community resources preferred. Strong organizational and time management skills. Ability to work independently and exercise sound judgment in interactions with interprofessional team, payors, and patients and their families. Demonstrate commitment to organizational values. Perform duties in a manner to promote quality patient care and customer service/satisfaction, while promoting safety, cost efficiency, and a commitment to the quality process. Additional Information With a career at any of the MaineHealth locations across Maine and New Hampshire, you’ll be working with health care professionals that truly value the people around them – both within the walls of the organization and the communities that surround it. We offer benefits that support an individual's needs for today and flexibility to plan for tomorrow – programs such as paid parental leave, a flexible work policy, student loan assistance, training and education, along with well-being resources for you and your family. MaineHealth remains focused on investing in our care team and developing an inclusive environment where you can thrive and feel supported to realize your full potential. If you’re looking to build a career in a place where people help one another deliver best-in-class care, apply today. If you have questions about this role, please contact nicole.chapman@mainehealth.org
RN Utilization Review Full-time
UNC Health

Utilization Manager (RN)

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

Utilization Management Admissions Liaison RN II

apartment L.A. Care Health Plan location_onLos Angeles, CA
Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job Summary The Utilization Management (UM) Admissions Liaison RN II is primarily responsible for receiving/reviewing admission requests and higher level of care (HLOC) transfer requests from inpatient facilities within regular timelines. Reviews clinical data in real-time and post admission to issue a determination based on clinical criteria for medical necessity. Assures timely, accurate determination and notification of admission and inter-facility transfer requests. Generates approval, modification, and denial communications for inpatient admission requests. Actively monitors for appropriate level of care (inpatient vs. observation) admission in the acute setting. Works with UM leadership, including the Utilization Management Medical Director, on requests where determination requires extended review. Collaborates with the inpatient care team for facilitation/coordination of patient transfers between acute care facilities. Acts as a department resource for medical service requests/referral management and processes. Actively participates in the discharge planning process, including providing clinical review and authorization for alternate levels of care, home health, durable medical equipment, and other discharge needs. Provides support to the inpatient review team as necessary to ensure timely processing of concurrent reviews. Duties Provides the primary clinical point of contact for inpatient acute care hospitals requesting Inpatient care/post-stabilization admission requests, Higher level of care transfers and other emergent transfers or needs. Ensures appropriate determination for admission requests/HLOC transfers based on clinical data presented and established criteria/guidelines, escalating to the medical director if needed. Triages and assesses members for admission needs, including, but not limited to, bed and accepting physician availability. (40%) Establishes and maintains ongoing communication with internal stakeholders and external customers while securing the L.A. Care member's admission or inter-facility transfer. Interfaces with physicians, house supervisors, and other hospital delegates to ensure that telephone triage results in appropriate patient placement. (10%) Applies clinical expertise and the nursing process to triage and prioritize admission acuity, servicing as an expert clinical resource for patient placement while utilizing medical knowledge and experience to facilitate consensus-building and development of satisfactory outcomes (10%) Continually seeks new ways to improve processes and increase efficiencies. Takes the initiative to communicate recommendations to UM Leadership. (5%) Completes all inpatient and discharge planning requests appropriately and timely including, but not limited to: Skilled nursing facility, outpatient needs (home health, physical therapy, infusion), and case management referrals (5%) Performs prospective, concurrent, post-service, and retrospective claim medical review processes. Utilizes clinical judgement, independent analysis, critical-thinking skills, detailed knowledge of medical policies, clinical guidelines and benefit plans to complete reviews and determinations within required turnaround times specific to the case type. Identifies requests needing medical director review or input and presents for second level review (20%) Performs other duties as assigned. (10%) Duties Continued Education Required Associate's Degree in Nursing Education Preferred Bachelor's Degree in Nursing Experience Required: Minimum of 7 years of clinical experience in an acute hospital setting. Previous experience to have a strong understanding of Utilization Management/Case Management practices including, but not limited to, placement (with level of care) criteria (MCG, InterQual), concurrent review, and discharge planning. Preferred: Consistent Critical Care experience (Emergency Department, Intensive Care, Labor & Delivery) background highly desirable. Experience in bed placement decision-making highly desirable. Skills Required: Must be computer literate, with expertise in Outlook, Word, Excel, PowerPoint. Provision of excellent customer service required due to frequent communication with providers and other members of the interdisciplinary team Knowledge of personal computer, keyboarding, and appropriate software to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment. Prepare clear, comprehensive written and oral reports and materials. Excellent time management and priority-setting skills. Maintains strict member confidentiality and complies with all HIPAA requirements. Strong verbal and written communication skills. Preferred: Knowledge of National Committee for Quality Assurance (NCQA) requirements for Utilization Management or CM. Knowledge of Department of Health Care Services (DHCS) or Centers for Medicare and Medicaid Services(CMS) requirements for health plan compliance with UM or CM. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California License Licenses/Certifications Preferred Certified Case Manager (CCM) American Case Management Association (ACM) Required Training Physical Requirements Light Additional Information Required: Attend mandatory department trainings as scheduled Financial Impact: Management of all medical services has a tremendous potential impact on the cost of health care and budget. This position manages determinations to ensure services requested are medically appropriate and provided in the most cost effective manner without compromising quality healthcare delivery. Types of Shift: Day (7:00am - 3:30pm), Evening (3:00pm -11:30 pm), Night (11:00pm -7:30am). Float (Varies)* *All possible shifts. Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. L.A. Care offers a wide range of benefits including Paid Time Off (PTO) Tuition Reimbursement Retirement Plans Medical, Dental and Vision Wellness Program Volunteer Time Off (VTO)
RN Utilization Review Part-time
Grand Lake Health System

Utilization Review Nurse/Case Management

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

Utilization Case Manager (H)

apartment University of Miami Health System location_onMiami, 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 . UMHC-SCCC has an exciting opportunity for a Utilization Case Manager position. The incumbent is to complete ongoing reviews for clinical utilization and identifying the need for continued authorization. The Utilization Case Manager coordinates with the Nurse Case Manager as well as the Healthcare team for optimal patient outcomes, while avoiding potential treatment delays and authorization denials. The Utilization Case Manager is accountable for a designated patient caseload and ensures that all necessary criteria for continued authorization remains in place. At all times the case manager provides communication of progress and or determination to the clinical team and or the patient. CORE JOB FUNCTIONS Adhere and perform timely reviews for services requiring an authorization for continuation of care Follows the authorization process using established criteria as set forth by the payer or clinical guidelines Accurate review of coverage benefits and limitations to determine continued appropriateness of services requested Facilitates interdepartmental communication regarding status of continued authorization in advance of patient’s appointment. Maintains effective communication regarding authorization status and determination to the clinical team and on occasion the patient. Identifies potential delays in treatment by reviewing the treatment plan and proactively communicates with the healthcare team and or patient regarding the potential treatment barrier Maintains knowledge regarding payer reimbursement policies and clinical guidelines. Adheres to University and department level policies and procedures and safeguards University assets. This list of duties and responsibilities is not intended to be all-inclusive and may be expanded to include other duties or responsibilities as necessary. CORE QUALIFICATIONS Bachelor’s degree in relevant field; or equivalent Minimum of 2 years of relevant experience #LI-GD1 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 Full-time
Swedish Health Services

Utilization Review RN

apartment Swedish Health Services location_onSeattle, WA
$51.43 - $79.84 / hour
Description The Utilization Review (UR) Nurse has a strong clinical background blended with a well-developed knowledge and skills in Utilization Management (UM), medical necessity and patient status determination. This individual supports the UM program by developing and maintaining effective, efficient processes for determining the appropriate admission status based on regulatory and reimbursement requirements of commercial and government payers. Providence caregivers are not simply valued – they’re invaluable. Join our team at Swedish Shared Services and thrive in our culture of patient-focused, whole-person care built on understanding, commitment, and mutual respect. Your voice matters here, because we know that to inspire and retain the best people, we must empower them. Required Qualifications Bachelor's Degree in Nursing degree (BSN) from an accredited school of nursing. Upon hire: Washington Registered Nurse License 3 years of Registered nursing experience in the clinical setting. Preferred Qualifications Upon hire: ACM or CCM certification 1 year of Case management experience. Why Join Providence? Our best-in-class benefits are uniquely designed to support you and your family in staying well, growing professionally and achieving financial security. We take care of you, so you can focus on delivering our mission of improving the health and wellbeing of each patient we serve. About Providence At Providence, our strength lies in Our Promise of “Know me, care for me, ease my way.” Working at our family of organizations means that regardless of your role, we’ll walk alongside you in your career, supporting you so you can support others. We provide best-in-class benefits and we foster an inclusive workplace where diversity is valued, and everyone is essential, heard and respected. Together, our 120,000 caregivers (all employees) serve in over 50 hospitals, over 1,000 clinics and a full range of health and social services across Alaska, California, Montana, New Mexico, Oregon, Texas and Washington. As a comprehensive health care organization, we are serving more people, advancing best practices and continuing our more than 100-year tradition of serving the poor and vulnerable. Posted are the minimum and the maximum wage rates on the wage range for this position. The successful candidate's placement on the wage range for this position will be determined based upon relevant job experience and other applicable factors. These amounts are the base pay range; additional compensation may be available for this role, such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities. Providence offers a comprehensive benefits package including a retirement 401(k) Savings Plan with employer matching, health care benefits (medical, dental, vision), life insurance, disability insurance, time off benefits (paid parental leave, vacations, holidays, health issues), voluntary benefits, well-being resources and much more. Learn more at providence.jobs/benefits. Applicants in the Unincorporated County of Los Angeles: Qualified applications with arrest or conviction records will be considered for employment in accordance with the Unincorporated Los Angeles County Fair Chance Ordinance for Employers and the California Fair Chance Act. About The Team Providence Swedish is the largest not-for-profit health care system in the greater Puget Sound area. It is comprised of eight hospital campuses (Ballard, Edmonds, Everett, Centralia, Cherry Hill (Seattle), First Hill (Seattle), Issaquah and Olympia); emergency rooms and specialty centers in Redmond (East King County) and the Mill Creek area in Everett; and Providence Swedish Medical Group, a network of 190+ primary care and specialty care locations throughout the Puget Sound. Whether through physician clinics, education, research and innovation or other outreach, we’re dedicated to improving the wellbeing of rural and urban communities by expanding access to quality health care for all. Providence is proud to be an Equal Opportunity Employer. We are committed to the principle that every workforce member has the right to work in surroundings that are free from all forms of unlawful discrimination and harassment on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law. We believe diversity makes us stronger, so we are dedicated to shaping an inclusive workforce, learning from each other, and creating equal opportunities for advancement. For any concerns with this posting relating to the posting requirements in RCW 49.58.110(1), please click here where you can access an email link to submit your concern. Requsition ID: 413245 Company: Swedish Jobs Job Category: Health Information Management Job Function: Revenue Cycle Job Schedule: Full time Job Shift: Day Career Track: Nursing Department: 3900 SS CASE MANAGEMENT Address: WA Seattle 1730 Minor Ave Work Location: Swedish Metropolitan Park East-Seattle Workplace Type: On-site Pay Range: $51.43 - $79.84 The amounts listed are the base pay range; additional compensation may be available for this role, such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities.
RN Utilization Review Full-time
Molina Healthcare

Care Review Clinician (RN) - BH Experience Required

apartment Molina Healthcare location_onDes Moines, IA
$25.08 - $51.49 / hour
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 outpatient prior authorization/financial responsibility for Molina and its members. • Processes requests within required timelines. • Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner. • Requests additional information from members or providers as needed. • Makes appropriate referrals to other clinical programs. • Collaborates with multidisciplinary teams to promote the Molina care model. • Adheres to utilization management (UM) policies and procedures. Required Qualifications • At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience. • Registered Nurse (RN). License must be active and unrestricted in state of practice. • Ability to prioritize and manage multiple deadlines. • Excellent organizational, problem-solving and critical-thinking skills. • Strong written and verbal communication skills. • Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications • Certified Professional in Healthcare Management (CPHM). • Recent hospital experience in an intensive care unit (ICU) or emergency room. 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: $25.08 - $51.49 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.