RN Utilization Review Jobs

RN Case Manager - Utilization Review (Temple Hospital Jeanes Campus)

Utilizing InterQual and other appropriate criteria, responsible for reviewing all admissions and continued stay of patients in conformance with the established criteria set forth in the hospital's utilization management and quality assurance plan. Will determine the medical necessity for admission and continued stays for patients within department's scope of service and to meet the hospital's objectives for assuring a high quality of patient care as well as assuring the effective and efficient utilization of available health services. Identifies appropriate level of care for inpatients and outpatients requiring overnight care. Education Other Graduate Of An Accredited School Of Nursing Required Bachelor's Degree BSN Required Experience 2 years experience in clinical nursing preferably in acute care Preferred General Experience in utilization review, case management, PreCertification, or discharge planning Preferred General Experience and knowledge of Medicare, Medicaid, and commercial insurance guidelines Preferred General Experience and knowledge of MCG and InterQual criteria tools Preferred Licenses PA Registered Nurse License Required or Multi State Compact RN License Required Schedule: M-F 8:00am-4:30pm with every third weekend requirement

Utilization Management Nurse Consultant

CVS Health OH

$29.10 - $62.32 / hour

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours. Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function. Typical office working environment with productivity and quality expectations. Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor. Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment. Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding. Effective communication skills, both verbal and written Required Qualifications - 2+ years of experience as a Registered Nurse in adult acute care/critical care setting - Must have active current and unrestricted RN licensure in state of residence - Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours Preferred Qualifications - 2+ years of clinical experience required in med surg or specialty area - Managed Care experience preferred, especially Utilization Management - Preference for those residing in EST zones Education Associates Degree required BSN preferred Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $29.10 - $62.32 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan . No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 04/30/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

Utilization Management Nurse Consultant

CVS Health IA

$26.01 - $56.14 / hour

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours. Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function. Typical office working environment with productivity and quality expectations. Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor. Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment. Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding. Effective communication skills, both verbal and written Required Qualifications - 2+ years of experience as a Registered Nurse in adult acute care/critical care setting - Must have active current and unrestricted RN licensure in state of residence - Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours Preferred Qualifications - 2+ years of clinical experience required in med surg or specialty area - Managed Care experience preferred, especially Utilization Management - Preference for those residing in CST zones Education Associates Degree required BSN preferred Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $26.01 - $56.14 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan . No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 04/30/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

RN Clinical Review Specialist - Remote

Gentiva Michigan Center, MI

Overview Audit Documentation. Ensure Compliance. Improve Quality Standards. As a Clinical Review Specialist, you will be responsible for completing chart audits and other functions that monitor, improve, and enforce compliance and Quality Assurance standards. You’ll collaborate with local and corporate teams to identify training needs, guide process improvements, and ensure adherence to federal and state regulations—all while supporting exceptional hospice care delivery. As a Clinical Review Specialist, You Will: Conduct proactive, recurring audits to support company infrastructure. Review and analyze documentation in HomeCareHomeBase (HCHB), making recommendations to improve accuracy and compliance. Quantify documentation quality and guide local management in targeted improvement strategies. Adhere to quality assurance, compliance, and departmental plans. Identify skill gaps among hospice agency staff and work with management to arrange appropriate training. Prepare reports and data analysis to support quality improvement initiatives. Assist in HCHB adjustments to prevent recurring deficiencies. Stay current on hospice best practices and recommend beneficial training resources. Support orientation and ongoing education of staff and committees on quality assurance and care standards. Participate in defining factors that influence care quality for hospice patients. Coordinate management calls to review patient chart findings and improvement recommendations. Compile local documentation outcome data and use company-wide insights to enhance QA. Meet or exceed department chart audit productivity expectations. This is a work from home position. To support operational needs and business hours, candidates should reside in one of these states: Alabama, Arkansas, Florida, Georgia, Indiana, Kansas, Michigan, Missouri, North Carolina, Pennsylvania, South Carolina, Tennessee, Texas or Virginia. About You Qualifications – What You’ll Bring: Registered Nurse (RN) currently licensed in the state of residence. Minimum of three years’ Hospice and Home Care experience, including at least one year in clinical record review and QAPI. Experience participating in state surveys. Valid driver’s license and insurance coverage. Strong understanding of documentation requirements to support medical necessity for hospice care. Knowledge of hospice federal and state regulations. Ability to manage confidential information with discretion. Initiative in researching and resolving documentation issues. Skilled at gathering and processing time-sensitive data from multiple sources. Flexible, responsive, and able to adapt to changing priorities in a fast-paced environment. Preferred Experience (Not Required) BSN or equivalent degree Previous experience with HomeCare HomeBase (HCHB) documentation systems. Prior quality assurance leadership experience in a hospice setting. We Offer Benefits for All Hospice Associates (Full-Time & Per Diem): Competitive Pay 401(k) with Company Match Career Advancement Opportunities National & Local Recognition Programs Teammate Assistance Fund Additional Full-Time Benefits: Medical, Dental, Vision Insurance Mileage Reimbursement or Fleet Vehicle Program Generous Paid Time Off + 7 Paid Holidays Wellness Programs (Telemedicine, Diabetes Management, Joint & Spine Concierge Care) Education Support & Tuition Assistance Free Continuing Education Units (CEUs) Company-paid Life & Long-Term Disability Insurance Voluntary Benefits (Pet, Critical Illness, Accident, LTC) Apply today and help support compassionate care that makes every moment count. Legalese This is a safety-sensitive position Employee must meet minimum requirements to be eligible for benefits Where applicable, employee must meet state specific requirements We are proud to be an EEO employer We maintain a drug-free workplace ReqID: 2026-134461 Category: Branch Admin and Clerical Position Type: Full-Time Company: Gentiva

RN Clinical Review Specialist - Remote

Gentiva Orlando, FL

Overview Audit Documentation. Ensure Compliance. Improve Quality Standards. As a Clinical Review Specialist, you will be responsible for completing chart audits and other functions that monitor, improve, and enforce compliance and Quality Assurance standards. You’ll collaborate with local and corporate teams to identify training needs, guide process improvements, and ensure adherence to federal and state regulations—all while supporting exceptional hospice care delivery. As a Clinical Review Specialist, You Will: Conduct proactive, recurring audits to support company infrastructure. Review and analyze documentation in HomeCareHomeBase (HCHB), making recommendations to improve accuracy and compliance. Quantify documentation quality and guide local management in targeted improvement strategies. Adhere to quality assurance, compliance, and departmental plans. Identify skill gaps among hospice agency staff and work with management to arrange appropriate training. Prepare reports and data analysis to support quality improvement initiatives. Assist in HCHB adjustments to prevent recurring deficiencies. Stay current on hospice best practices and recommend beneficial training resources. Support orientation and ongoing education of staff and committees on quality assurance and care standards. Participate in defining factors that influence care quality for hospice patients. Coordinate management calls to review patient chart findings and improvement recommendations. Compile local documentation outcome data and use company-wide insights to enhance QA. Meet or exceed department chart audit productivity expectations. This is a work from home position. To support operational needs and business hours, candidates should reside in one of these states: Alabama, Arkansas, Florida, Georgia, Indiana, Kansas, Michigan, Missouri, North Carolina, Pennsylvania, South Carolina, Tennessee, Texas or Virginia. About You Qualifications – What You’ll Bring: Registered Nurse (RN) currently licensed in the state of residence. Minimum of three years’ Hospice and Home Care experience, including at least one year in clinical record review and QAPI. Experience participating in state surveys. Valid driver’s license and insurance coverage. Strong understanding of documentation requirements to support medical necessity for hospice care. Knowledge of hospice federal and state regulations. Ability to manage confidential information with discretion. Initiative in researching and resolving documentation issues. Skilled at gathering and processing time-sensitive data from multiple sources. Flexible, responsive, and able to adapt to changing priorities in a fast-paced environment. Preferred Experience (Not Required) BSN or equivalent degree Previous experience with HomeCare HomeBase (HCHB) documentation systems. Prior quality assurance leadership experience in a hospice setting. We Offer Benefits for All Hospice Associates (Full-Time & Per Diem): Competitive Pay 401(k) with Company Match Career Advancement Opportunities National & Local Recognition Programs Teammate Assistance Fund Additional Full-Time Benefits: Medical, Dental, Vision Insurance Mileage Reimbursement or Fleet Vehicle Program Generous Paid Time Off + 7 Paid Holidays Wellness Programs (Telemedicine, Diabetes Management, Joint & Spine Concierge Care) Education Support & Tuition Assistance Free Continuing Education Units (CEUs) Company-paid Life & Long-Term Disability Insurance Voluntary Benefits (Pet, Critical Illness, Accident, LTC) Apply today and help support compassionate care that makes every moment count. Legalese This is a safety-sensitive position Employee must meet minimum requirements to be eligible for benefits Where applicable, employee must meet state specific requirements We are proud to be an EEO employer We maintain a drug-free workplace ReqID: 2026-134461 Category: Branch Admin and Clerical Position Type: Full-Time Company: Gentiva

RN Clinical Review Specialist - Remote

Gentiva Little Rock, AR

Overview Audit Documentation. Ensure Compliance. Improve Quality Standards. As a Clinical Review Specialist, you will be responsible for completing chart audits and other functions that monitor, improve, and enforce compliance and Quality Assurance standards. You’ll collaborate with local and corporate teams to identify training needs, guide process improvements, and ensure adherence to federal and state regulations—all while supporting exceptional hospice care delivery. As a Clinical Review Specialist, You Will: Conduct proactive, recurring audits to support company infrastructure. Review and analyze documentation in HomeCareHomeBase (HCHB), making recommendations to improve accuracy and compliance. Quantify documentation quality and guide local management in targeted improvement strategies. Adhere to quality assurance, compliance, and departmental plans. Identify skill gaps among hospice agency staff and work with management to arrange appropriate training. Prepare reports and data analysis to support quality improvement initiatives. Assist in HCHB adjustments to prevent recurring deficiencies. Stay current on hospice best practices and recommend beneficial training resources. Support orientation and ongoing education of staff and committees on quality assurance and care standards. Participate in defining factors that influence care quality for hospice patients. Coordinate management calls to review patient chart findings and improvement recommendations. Compile local documentation outcome data and use company-wide insights to enhance QA. Meet or exceed department chart audit productivity expectations. This is a work from home position. To support operational needs and business hours, candidates should reside in one of these states: Alabama, Arkansas, Florida, Georgia, Indiana, Kansas, Michigan, Missouri, North Carolina, Pennsylvania, South Carolina, Tennessee, Texas or Virginia. About You Qualifications – What You’ll Bring: Registered Nurse (RN) currently licensed in the state of residence. Minimum of three years’ Hospice and Home Care experience, including at least one year in clinical record review and QAPI. Experience participating in state surveys. Valid driver’s license and insurance coverage. Strong understanding of documentation requirements to support medical necessity for hospice care. Knowledge of hospice federal and state regulations. Ability to manage confidential information with discretion. Initiative in researching and resolving documentation issues. Skilled at gathering and processing time-sensitive data from multiple sources. Flexible, responsive, and able to adapt to changing priorities in a fast-paced environment. Preferred Experience (Not Required) BSN or equivalent degree Previous experience with HomeCare HomeBase (HCHB) documentation systems. Prior quality assurance leadership experience in a hospice setting. We Offer Benefits for All Hospice Associates (Full-Time & Per Diem): Competitive Pay 401(k) with Company Match Career Advancement Opportunities National & Local Recognition Programs Teammate Assistance Fund Additional Full-Time Benefits: Medical, Dental, Vision Insurance Mileage Reimbursement or Fleet Vehicle Program Generous Paid Time Off + 7 Paid Holidays Wellness Programs (Telemedicine, Diabetes Management, Joint & Spine Concierge Care) Education Support & Tuition Assistance Free Continuing Education Units (CEUs) Company-paid Life & Long-Term Disability Insurance Voluntary Benefits (Pet, Critical Illness, Accident, LTC) Apply today and help support compassionate care that makes every moment count. Legalese This is a safety-sensitive position Employee must meet minimum requirements to be eligible for benefits Where applicable, employee must meet state specific requirements We are proud to be an EEO employer We maintain a drug-free workplace ReqID: 2026-134461 Category: Branch Admin and Clerical Position Type: Full-Time Company: Gentiva

Utilization Management Registered Nurse

Spectrum Healthcare Resources Cheyenne, WY

$39 - $48 / hour

Job Description Spectrum Healthcare Resources has an excellent opportunity for a civilian Utilization Management Registered Nurse at FE Warren Air Force Base in Cheyenne, WY. Full-time opportunity Monday - Friday (0700-1700) No weekends, on-call or holidays required Provide care and resources to military community Full complement of benefits to include health, dental and vision insurance, PTO, 11 Paid Holidays, 401(k) and more Pay range is $39-48/hour Job Requirements: BSN Degree 6 years of clinical nursing experience and 1 year of utilization management experience required Knowledge, skills and computer literacy to interpret and apply medical care criteria, such as InterQual or Milliman Ambulatory Care Guidelines. Experience in performing prospective, concurrent, and retrospective reviews to justify medical necessity for medical care to aid in collection and recovery from multiple insurance carriers. Current RN license in Wyoming Job duties: Monitor specialty care referrals for appropriateness, covered benefit, and authorized surgery/medical procedures, laboratory, radiology, pharmacy, and general hospital procedures and regulations to analyze medical referrals/appointments. Receives and makes patient telephone calls and computer/written correspondence regarding specialty clinic appointments and referrals. Develops and implements a comprehensive Utilization Management plan/program for beneficiaries within MTF’s goals and objectives. Company Overview: At Spectrum, we utilize over thirty-five years of experience providing optimal solutions for federal agencies that are both innovative and cost-effective. We hold ourselves to the highest standard to ensure successful outcomes for the facilities and health care professionals we serve. As a Joint Commission Certified Healthcare Resource, dependability and service are the driving forces of our mission. EOE/Disabled/Veterans Location : Location US-WY-Cheyenne Recruiter : Full Name: First Last Lauren Larkin Direct phone number 571-410-2088 Recruiter : Email Lauren_Larkin@spectrumhealth.com

Utilization Management Registered Nurse

Spectrum Healthcare Resources Cheyenne, WY

Job Description Spectrum Healthcare Resources has a potential opportunity for a civilian Utilization Management Registered Nurse at FE Warren Air Force Base in Cheyenne, WY. Full-time opportunity Monday through Friday, 40 hours per week Outpatient setting, providing care to our Active Duty Air Men and Women No on-call responsibilities Full complement of benefits to include health, dental and vision insurance, paid time off, 11 Paid Holidays, 401k and more Job Requirements: The Position will have the following requirements: Degree: Baccalaureate of Science in Nursing Program from an approved National League of Nursing. Education: Graduate from a college or university accredited by Accreditation Commission for Education in Nursing (ACEN), the Commission on Collegiate Nursing Education (CCNE). Experience: Six years of clinical nursing experience is required. One year of previous experience in Utilization Management is required. Full time employment in a nursing field within the last 36 months is mandatory. Knowledge, skills and computer literacy to interpret and apply medical care criteria, such as InterQual or Milliman Ambulatory Care Guidelines. Must possess experience in performing prospective, concurrent, and retrospective reviews to justify medical necessity for medical care to aid in collection and recovery from multiple insurance carriers. Review process includes Direct Care and Purchase Care System referrals, ward rounds for clinical data collection, contacting providers to inform them of dollars lost for missing documentation, and providing documentation for appeals resolution. Must possess experience in performing prospective, concurrent, and retrospective reviews to justify medical necessity for medical care to aid in collection and recovery from multiple insurance carriers. Review process includes Direct Care and Purchase Care System referrals, ward rounds for clinical data collection, contacting providers to inform them of dollars lost for missing documentation, and providing documentation for appeals resolution. The Contractor must have a working knowledge of Ambulatory Procedure Grouping (APGs), Diagnostic Related Grouping (DRGs), International Classification of Diseases-Version 9 (ICD), and Current Procedural Terminology-Version 4 (CPT-4) coding. Licensure: Current, full, active, unrestricted license to practice as a Registered Nurse in Wyoming Job duties include but not limited to: Coordinate patient care in collaboration with a wide array of healthcare professionals. Facilitate the achievement of optimal outcomes in relation to clinical care, quality and cost effectiveness. Monitors specialty care referrals for appropriateness, covered benefit, and authorized surgery/medical procedures, laboratory, radiology, pharmacy, and general hospital procedures and regulations to analyze medical referrals/appointments. If unsure coordinates with TRICARE Regional Office Clinical Liaison Nurse and MTF Liaison to remedy errors or uncertainty. Assist with orientation and training of other Medical Management staff and assist in providing, assessing, and improving a wide variety of customer service relations. Assists Flight Commander to ensure Health Service Inspection standards are met at the operational level. Receives and makes patient telephone calls and computer/written correspondence regarding specialty clinic appointments and referrals. Routinely monitors referral management Composite Health Care System (CHCS) queue to ensure patients are being called that do not utilize the Referral Management Center walk-in service. Company Overview: Spectrum Healthcare Resources (SHR) was established in 1988 to deliver systems and processes designed to meet the unique needs of Military and VA Health Systems. SHR is a leading organization that provides physician and clinical staffing and management services to United States Military Treatment Facilities, VA clinics and other Federal Agencies through various contracting vehicles. A Joint Commission Health Care Staffing Services firm, SHR is the military staffing division of TeamHealth, a Nationwide organization that serves 850 civilian and military hospitals with a team of 9,600 affiliated health care professionals. Spectrum Healthcare Resources is an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status, or any other characteristic protected by law. Location : Location US-WY-Cheyenne Recruiter : Full Name: First Last Betty Fisk Direct phone number 314-744-4130 Recruiter : Email betty_fisk@spectrumhealth.com

ED Case Management Utilization RN, Per Diem Day

Kaiser Permanente Irwindale, CA

Job Summary: Works collaboratively with an MD to coordinate and screen for the appropriateness of admissions and Continued stays. Makes recommendations to the physicians for alternate levels of care when the patient does not meet the medical necessity for Inpatient hospitalization. Interacts with the family, patient and other disciplines to coordinate a safe and acceptable discharge plan. Functions as an indirect caregiver, patient advocate and manages patients in the most cost effective way without compromising quality. Transfers stable non-members to planned Health care facilities. Responsible for complying with AB 1203, Post Stabilization notification. Complies with other duties as described. Must be able to work collaboratively with the Multidisciplinary team, multitask and in a fast pace environment. Essential Responsibilities: Plans, develops, assesses and evaluates care provided to members. Collaborates with physicians, other members of the multidisciplinary health care team and patient/family in the development, implementation and documentation of appropriate, individualized plans of care to ensure continuity, quality and appropriate resource use. Recommends alternative levels of care and ensures compliance with federal, state and local requirements. Assesses high risk patients in need of post-hospital care planning. Develops and coordinates the implementation of a discharge plan to meet patients identified needs; communicates the plan to physicians, patient, family/caregivers, staff and appropriate community agencies. Reviews, monitors, evaluates and coordinates the patients hospital stay to assure that all appropriate and essential services are delivered timely and efficiently. Participates in the Bed Huddles and carries out recommendations congruent with the patients needs. Coordinates the interdisciplinary approach to providing continuity of care, including Utilization management, Transfer coordination, Discharge planning, and obtaining all authorizations/approvals as needed for outside services for patients/families. Conducts daily clinical reviews for utilization/quality management activities based on guidelines/standards for patients in a variety of settings, including outpatient, emergency room, inpatient and non-KFH facilities. Acts as a liaison between in-patient facility and referral facilities/agencies and provides case management to patients referred. Refers patients to community resources to meet post hospital needs. Coordinates transfer of patients to appropriate facilities; maintains and provides required documentation. Adheres to internal and external regulatory and accreditation requirements and compliance guidelines including but not limited to: TJC, DHS, HCFA, CMS, DMHC, NCQA and DOL. Educates members of the healthcare team concerning their roles and responsibilities in the discharge planning process and appropriate use of resources. Provides patients with education to assist with their discharge and help them cope with psychological problems related to acute and chronic illness. Per established protocols, reports any incidence of unusual occurrences related to quality, risk and/or patient safety which are identified during case review or other activities. Reviews, analyses and identifies utilization patterns and trends, problems or inappropriate utilization of resources and participates in the collection and analysis of data for special studies, projects, planning, or for routine utilization monitoring activities. Coordinates, participates and or facilitates care planning rounds and patient family conferences as needed. Participates in committees, teams or other work projects/duties as assigned.

Utilization Review Registered Nurse (RN) - 40 hrs/wk, Days

MaineGeneral Health Augusta, ME

Job Summary: MaineGeneral Health is seeking an experienced Utilization Review Registered Nurse (RN) to join our collaborative team. In this role, you will evaluate the medical necessity and appropriateness of patient care, ensuring alignment with clinical guidelines and payer requirements while supporting efficient, high-quality outcomes. If you have a passion for service excellence and enjoy working closely with interdisciplinary teams to optimize patient care and resource utilization, we want to hear from you! Job Description: Position: Utilization Review Registered Nurse (RN) Location: Alfond Center for Health, Augusta Schedule: Full-time (40 hours/week) Shift: Days (8-4:30) Monday - Friday What You'll Do: Reviews admissions and service requests within assigned unit for prospective, concurrent, and retrospective medical necessity and/or compliance with reimbursement policy criteria. Assists multidisciplinary teams with issues related to medical records/documentation, pre-certifications, reimbursement, and claim denials/appeals. Collaborates to assess and coordinate patients' discharge planning needs with members of the healthcare team. Monitors for delays in care and prepares data to reduce length of stay and maximize reimbursement. What You Bring: Active State of Maine Registered Nurse (RN) license, or ability to obtain promptly (required) Prior experience in Utilization Review, Case Management, or Care Coordination (strongly preferred) Strong critical thinking, communication, and organizational skills Ability to work independently while collaborating effectively across teams Why Join MaineGeneral Health: Collaborative, team-focused work environment Meaningful impact on patient outcomes and care efficiency Flexible scheduling within a weekday-only schedule A health system committed to excellence, compassion, and community Scheduled Weekly Hours: 40 Scheduled Work Shift: Day (United States of America) Job Exempt: No Benefits Supporting all aspects of our employees’ wellness – physical, emotional and financial – is a critical component of being a great place to work. With the wide range of benefits and programs available, employees have the resources they need to be well at every stage of life and plan for the future. Physical Wellness: We offer quality health, dental, and vision benefits and wellness programs and resources to provide employees access to resources for a healthy lifestyle and help manage health care costs. Employees have access to industry-leading leave for new parents. A generous earned time plan is offered to all employees - We believe employees need and deserve time away from work to observe holidays, be with family, go on vacation, or simply take care of themselves. Emotional Wellness: When life gets challenging, employees have access to our Employee Assistance Program for employees and anyone in their household. Financial Wellness: Access the wages you’ve already earned before payday with Payactiv, giving you greater flexibility over your finances. Loan Reimbursement is available for this position dependent upon current degree level. Please discuss benefit with the recruiter. Tuition Reimbursement is available to all employees to further develop skills and career. We offer eligible employees up to 2% of eligible pay in 403(b) company-matching contributions plus another 2% in the 401(a) retirement income plan. Three insurance plans are available to protect your family from the sudden loss of income in the event of your death, terminal illness or serious injury from accident. We offer both short-term and long-term disability insurance to replace a portion of your income if you become disabled and cannot work for a period of time. Career Mobility: Helping our employees develop their skills and grow their careers is critical to how we retain our talent and sustain our business. We do this by offering our teammates a variety of leadership-supported programs and learning and development resources for every stage of their professional development. We know that our employees are our most valuable resource they are how we grow our business and care for our community. Equal Opportunity Employer M/F/Vet/Disability Assistive technologies are available. Application assistance for those requesting reasonable accommodation to the career site is available by contacting HR at (207) 861-3440 .

Utilization Management Nurse Consultant - Open to residents in Pacific Standard Time Zone

CVS Health NV

$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. Must Reside in PST Time Zone Position Summary Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours. This is a full-time, remote role. Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care. Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs. Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization. Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function. Typical office working environment with productivity and quality expectations. Work requires the ability to perform close inspection of handwritten and computer generated documents as well as a PC monitor. Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer. Ability to multitask, prioritize and effectively adapt to a fast-paced changing environment. Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding. Effective communication skills, both verbal and written. Required Qualifications Must reside in Pacific Standard Time Zone 2+ years of experience as a Registered Nurse in adult acute care/critical care setting. Must have active current and unrestricted RN licensure in state of residence. Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours. Preferred Qualifications 2+ years of clinical experience required in med surg or specialty area. Managed Care experience preferred, especially Utilization Management. Preference for those residing in PST zones. Education Associates Degree required BSN preferred Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $29.10 - $62.32 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan . No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 04/30/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

NICU RN Clinical Review Nurse Concurrent Review

Centene Los Angeles, CA

$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. ****NOTE: This is a fully remote role with a focus on NICU services. Preference will be given to applicants (1) with active compact nursing licensure, (2) experience in neonatal intensive care unit (NICU), and (3) willingness to work eastern time zone schedule. Additional Details: • Department: PHCO UM NICU • Business Unit: Corporate • Schedule: Monday-Friday 8 am - 5pm ET with rotating weekends (Saturday, Sunday) and holidays **** 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 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 For Health Net of California: RN license 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

NICU RN - Clinical Review Nurse - Concurrent Review

Centene Los Angeles, CA

$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. ****NOTE: This is a fully remote role with a focus on NICU services. Preference will be given to applicants (1) with active compact nursing licensure, (2) experience in neonatal intensive care unit (NICU), and (3) willingness to work eastern time zone schedule. Additional Details: • Department: PHCO UM NICU • Business Unit: Corporate • Schedule: Monday-Friday 8 am - 5pm ET with rotating weekends (Saturday, Sunday) and holidays **** 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 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 For Health Net of California: RN license 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

Utilization Management Nurse Consultant - Fully Remote

CVS Health

$26.01 - $74.78 / hour

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary CVS Health Aetna has an opportunity for a full-time Utilization Management (UM) Nurse Consultant. As a Utilization Management Nurse Consultant, you will utilize clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. You would be responsible for ensuring the member is receiving the appropriate care at the appropriate time and at the appropriate location, while adhering to federal and state regulated turn-around times. This includes reviewing written clinical records. Key Responsibilities of the UM Nurse Consultant (Includes but is not limited to) Reviews services to assure medical necessity, applies clinical expertise to assure appropriate benefit utilization, facilitates safe and efficient discharge planning and works closely with facilities and providers to meet the complex needs of the member. Facilitate the delivery of appropriate benefits and/or healthcare information which determines eligibility for benefits while promoting wellness activities. Develops, implements and supports Health Strategies, tactics, policies and programs that ensure the delivery of benefits and to establish overall member wellness and successful and timely return to work. Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure, and clinical judgment to render coverage determination/recommendation along the continuum of care. Communicates with providers and other parties to facilitate care/treatment. Identifies members for referral opportunities to integrate with other products, services and/or programs. Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization. Required Qualifications Registered Nurse (RN) with current unrestricted US licensure in their state of residence is required. 2+ years clinical practice experience as an RN required. 2+ Years Utilization Management experience. Must be willing to travel to the local office as needed if living within approximately 45 minutes/miles. Preferred Qualifications Bilingual proficiency preferred. 1+ year(s) experience utilizing multiple computer systems and applications including Microsoft Word, Excel, Outlook, and web-based applications. Education Associate’s degree in Nursing required. BSN preferred. Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $26.01 - $74.78 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan . No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 04/03/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

Clinical Review Nurse - Correspondence

Centene MI

$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. Position Purpose: Drafts correspondence letters based on review outcomes in accordance with National Committee for Quality Assurance (NCQA) standards. Works with senior management to identify and implement opportunities for improvement. Performs clinical review of outcomes including creating and editing denial letters with the correspondence team based on denial determinations in accordance with National Committee for Quality Assurance (NCQA) standards Contributes to correspondence letter template creation and maintenance with the correspondence team Investigates denials through comprehensive review of clinical documentation, clinical criteria/guidelines, and policy, including insurance rejections due to coding issues and provides supplemental information to resolve denial claims Assists with issues and/or questions related to correspondence with the state, local, and federal agencies including third party payer to ensure issues are resolved in a timely manner Maintains and monitors cases to ensure timely resolution and logs of actions and/or decisions are appropriately documented Coordinates with interdepartmental teams on training needed within the utilization management team based on trends Provides feedback to leadership to improve clinical processes and procedures to prevent recurrences based on industry best practices Performs other duties as assigned Complies with all policies and standards This is a remote position. Candidates must reside in the Central or Eastern time zones. Work Schedule: Monday through Friday 10:00 AM – 6:30 PM CST or 11:00 AM – 7:30 PM EST The ideal candidate will have prior experience in prior authorization, concurrent review, or utilization review . Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. License/Certification: LPN - Licensed Practical Nurse - State Licensure required and 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

NICU Clinical Review Nurse - Concurrent Review

Centene OK

$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. Remote Role : Seeking RN with NICU experience. Must reside in Oklahoma. Hours: Monday-Friday, 8AM to 5PM 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. 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: RN - Registered Nurse - State Licensure and/or Compact State Licensure 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 - Case Manager - Utilization Review - Full Time - Days

Mohawk Valley Health System Utica, NY

$40.19 - $56.51 / hour

Job Summary The RN - Utilization Management gathers clinical information to determine appropriateness of admission, continued stay, medical necessity, and appropriateness of patient status throughout a patient’s hospital stay. Efficiently processes payer authorization requests to obtain certification from insurance or payers. Collaborates with care managers, providers, discharge planners and other care team members. Core Job Responsibilities Complete initial admission reviews within 24 hours of admission, including reviews for those that were admitted during hours without an access nurse on duty. Ensure the appropriate level of patient care by utilizing expert level of clinical decision making, standard level of care criteria, commercial payor criteria, and attending physician communication and input. Consult with Physician Advisor for the cases not meeting criteria. Ensure that Physician Advisor Medical Necessity documentation is placed on the medical record and is available to the Attending Physician. Coordinate peer to peer telephone calls between insurance representatives/payers and attending physicians or physician advisors as needed to appeal concurrent UR denials. Complete daily utilization review of all observation/outpatient/in-bed patients. Collaborate with Care Manager to determine discharge plan is within observation parameters. Communicate with physicians regarding observation length of stay and plan of care. Assist with ensuring that any status (class) order changes are documented, timed and dated in medical record and are accurate in EPIC. Consult Care Managers for admissions which meet re-admission criteria. Complete Continued Stay reviews on Medicare/Medicaid/Medicare HMO, VA, Hospice, and Self-pay patients. Provide support and/or coverage to the Managed Care Reviewer for commercial UR and continued stay requests. Maintain appropriate computer databases and apply appropriate tools for utilization review. Perform related duties as assigned. Education/Experience Requirements REQUIRED: Graduate of an accredited school of nursing program 3-5 years of applied clinical experience as a RN. 1 year of experience in Hospital Case Management. Knowledge and experience with Care Guidelines, Medical Necessity Criteria and/or other UM criteria sets. Ability to assess medical records and make determinations on length of stay and proper procedures. Knowledge of documentation and billing practices, ability to identify billing problems and research issues at hand. Excellent interpersonal, verbal and written communication skills. Proficient with MS Office (Excel) and Epic EMR. PREFERRED: BSN Licensure/Certification Requirements REQUIRED: NYS License as a Registered Nurse. Disclaimer Qualified applicants will receive consideration for employment without regard to their age, race, religion, national origin, ethnicity, age, gender (including pregnancy, childbirth, et al), sexual orientation, gender identity or expression, protected veteran status, or disability. Successful candidates might be required to undergo a background verification with an external vendor. Job Details Req Id 97475 Department CASE MGMT Shift Days Shift Hours Worked 9.50 FTE 0.93 Work Schedule NYSNA - 9.5 x 4 Employee Status A1 - Full-Time Union 2004 - NYSNA Pay Range $40.19 - $56.51/Hourly

Clinical Care Reviewer II - Multi State License - RN - Behavioral Health

CareSource

$62,700 - $100,400 / year

Job Summary: Clinical Care Reviewer II – Behavioral Health is responsible for processing medical necessity reviews for appropriateness of authorization for behavioral health care services, assisting with discharge planning activities (i.e. outpatient services, home health services) and care coordination for members. Essential Functions: Complete prospective, concurrent and retrospective review of Behavioral Health services Identify, document, communication and coordinate care engaging collaborative care partners to facilitation transition to an appropriate level of care Engage with medical director when additional clinical expertise if needed Maintain knowledge of state and federal regulations, including State Contracts and Provider Agreements, benefits, and accreditation standards Identify and refer quality issues to Quality Improvement Identify and refer appropriate members for Care Management Provide guidance to non-clinical staff Provide guidance and support to LPN staff Attend medical advisement and State Hearing meetings, as requested Assist Team Leader with special projects or research, as requested Perform any other job related duties as requested. Education and Experience: Associates of Science (A.S) in Nursing required or Bachelor of Science (B.S) in Social Work required Three (3) years clinical experience required Utilization Management/Utilization Review experience preferred Medicaid/Medicare/Commercial experience preferred Competencies, Knowledge and Skills: Proficient data entry skills and ability to navigate clinical platforms successfully Working knowledge of Microsoft Outlook, Word, and Excel Effective oral and written communication skills Ability to work independently and within a team environment Attention to detail Proper grammar usage and phone etiquette Time management and prioritization skills Customer service oriented Decision making/problem solving skills Strong organizational skills Change resiliency Licensure and Certification: Current, unrestricted Registered Nurse (RN) Licensure or Licensed Social Worker (LSW) required MCG Certification is required or must be obtained within six (6) months of hire required Working Conditions: General office environment; may be required to sit or stand for extended periods of time Travel is not typically required Compensation Range: $62,700.00 - $100,400.00 CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package. Compensation Type (hourly/salary): Hourly Organization Level Competencies Fostering a Collaborative Workplace Culture Cultivate Partnerships Develop Self and Others Drive Execution Influence Others Pursue Personal Excellence Understand the Business This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds. #LI-JM1

Utilization Management RN

UCHealth Aurora, CO

$38.91 - $60.31 / hour

Description Location: UCHealth UCHlth Admin 2450 Peoria, US:CO:Aurora Department: UCHlth Patient Line Referrals Work Schedule: Full Time, 64.00 hours per pay period (2 weeks) Shift: Days Pay: $38.91 - $60.31 / hour. Pay is dependent on applicant's relevant experience Summary: Ensures that services are delivered and documented in a manner that balances quality of care with efficiency, cost-containment and compliance. Responsibilities: Reviews admissions and service requests within assigned unit for prospective, concurrent, and retrospective medical necessity and/or compliance with reimbursement policy criteria. Provides case management and/or consultation for complex cases. Assists departmental staff with issues related to Milliman (or similar) guidelines, status determination, medical records/documentation, precertification, reimbursement and concurrent denials appeals. Collaborates closely with case managers to make sure status’ and level of care is accurate. Communicates with payers as needed to ensure patient accounts are secured. Assesses and coordinates patient's discharge planning needs with members of the healthcare team. Within scope of job, requires critical thinking skills, decisive judgement and the ability to work with minimal supervision. Must be able to work in a fast-paced environment and take appropriate action. Requirements: Registered NurseBachelor's degree in Nursing. State licensure as a Registered Nurse (RN). 3 years of relevant experience. Preferred: 3 years of utilization or case management experience. BLS through the American Heart Association or the American Red Cross CPR for the Professional Rescuer with card in-hand before start date. BLS or CPR card must be good through sixty days of hire. Employees are our number one asset. UCHealth promotes a culture that invests in professional success and personal well-being through a comprehensive total rewards program. * Recognition Performance bonus: UCHealth offers a 3-Year Incentive Bonus to recognize employee contributions to our success in quality, patient experience, organizational growth, financial goals and tenure. The bonus accumulates annually each October and is paid out in October during the third year of employment. Performance-based pay increase: The Annual Merit Pay Increase recognizes work performance that meets or consistently exceeds performance standards documented through UCHealth's established evaluation process and accounts for increased experience, skills and cost of living. Market reviews: All UCHealth positions are reviewed annually to ensure UCHealth base pay aligns with market standards. Base pay rates are adjusted as needed to stay market competitive. Health and well-being Medical, dental and vision coverage. Access to 24/7 mental health and well-being support for employees and dependents. Discounted gym memberships and fitness resources. Free Care.com membership. Voluntary benefits such as accident insurance, critical illness insurance, group legal plan, identity theft protection, pet insurance, auto and home insurance, and employee discount programs. Time away from work: Paid time off (PTO), paid family and medical leave (inclusive of Colorado FAMLI), leaves of absence. New employees receive an initial PTO load with first paycheck. Employer-provided basic life and accidental death and dismemberment coverage with buy-up coverage options. Employer-provided short-term disability and long-term disability with a buy-up coverage option. Retirement and savings 403(b) plan with employer matching contribution. Additional 457(b) plan may be available. Flexible spending accounts for health care and dependent day care; health savings account available when enrolled in high-deductible (HD) medical plan. Education and career growth UCHealth provides access to academic degrees and certificate programs to promote professional and personal growth. Up to 100% of tuition, books and fees paid for by UCHealth for specific educational degrees. Other programs may qualify for up to $10,000/year pre-paid by UCHealth or up to $5,250/year in the form of tuition reimbursement. Access to LinkedIn Learning, which offers thousands of virtual courses and seminars, and internal professional development opportunities. Employees have access to free assistance navigating the Public Service Loan Forgiveness program and submitting their federal student loans for forgiveness. * Eligibility for some programs is based on an employee's scheduled work hours. We improve lives. In big ways through learning, healing, and discovery. In small, personal ways through human connection. But in all ways, we improve lives. UCHealth always welcomes talent. This position will be open for a minimum of three days and until a top applicant is identified. UCHealth recognizes and appreciates the rich array of talents and perspectives that equal employment and diversity can offer our institution. As an equal opportunity employer, UCHealth is committed to making all employment decisions based on valid requirements. No applicant shall be discriminated against in any terms, conditions or privileges of employment or otherwise be discriminated against because of the individual's race, color, national origin, language, culture, ethnicity, age, religion, sex, disability, sexual orientation, gender, veteran status, socioeconomic status, or any other characteristic prohibited by federal, state, or local law. UCHealth does not discriminate against any qualified applicant with a disability as defined under the Americans with Disabilities Act and will make reasonable accommodations, when the do not impose an undue hardship on the organization. Who We Are (uchealth.org) AF123

Care Review Clinician (RN)

Molina Healthcare Long Beach, CA

$27.73 - $54.06 / hour

JOB DESCRIPTION Job SummaryProvides 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: $27.73 - $54.06 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Care Review Clinician (RN)

Molina Healthcare Long Beach, CA

$27.73 - $54.06 / hour

JOB DESCRIPTION Job SummaryProvides 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: $27.73 - $54.06 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Utilization Management Nurse Consultant (Weekend)

CVS Health PA

$29.10 - $62.32 / hour

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary This is a fulltime remote Utilization Review opportunity. Working hours are four 10hr days including every Weekend , both Saturday and Sunday, and two weekday shifts of 10hrs each (to be determined). Also includes holiday and late rotations. 12.5% Shift Premium applies once M-F training schedule completed and UMNC participating in non-traditional, weekend shift rotation. Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care. Communicates with providers and other parties to facilitate care/treatment. Identifies members for referral opportunities to integrate with other products, services and/or benefit programs. Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization. Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function. UMNC meets set productivity and quality expectations. Effective communication skills, both verbal and written Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding. Ability to multitask, prioritize and effectively adapt to a fast-paced changing environment. Work requires sitting for extended periods, talking on the telephone and typing on the computer. Work from home position: During work hours, Colleagues who are working from home must be available by phone, videoconference, and email in a manner and frequency that is required by the Colleague's Leader. Colleagues must be available from time to time to come into the office or client location on a given day for work-related meetings, training sessions or other events, as directed by their Leader. Required Qualifications Active and unrestricted Registered Nurse in state of residence 3+ years of experience as a Registered Nurse 1+ years of clinical experience in acute setting (ex: ER, triage, ICU, Med/Surg) Willing and able to work four 10hr days including every Weekend, both Saturday and Sunday, and two weekday shifts of 10hrs each (to be determined), also includes Holiday and late rotations. 12.5% Shift Premium applies once M-F training schedule completed and UMNC participating in non-traditional, weekend shift rotation Preferred Qualifications Utilization review experience Experience with LTAC, skilled rehab, or home health Managed Care experience Education Minimum Diploma RN acceptable or Associate degree in Nursing required BSN preferred Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $29.10 - $62.32 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan . No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 04/07/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

Manager, Utilization Management Behavioral Health Nursing

Humana OK

$94,900 - $130,500 / year

Become a part of our caring community The Manager, Utilization Management Behavioral Health Nursing utilizes clinical nursing skills to support the coordination, documentation and communication of behavioral health services and/or benefit administration determinations. The Manager, Utilization Management Behavioral Health Nursing works within specific guidelines and procedures; applies advanced technical knowledge to solve moderately complex problems; receives assignments in the form of objectives and determines approach, resources, schedules and goals. The Manager, Utilization Management Behavioral Health Nursing uses clinical knowledge, communication skills, and independent critical thinking skills towards interpreting criteria, policies, and procedures to provide the best and most appropriate treatment, care or services for members. Coordinates and communicates with providers, members, or other parties to facilitate optimal care and treatment. Nursing license is required. Decisions are typically related to resources, approach, and tactical operations for projects and initiatives involving own departmental area. Requires cross departmental collaboration, andconducts briefings and area meetings; maintains frequent contact with other managers across the department. Use your skills to make an impact Required Qualifications Must reside in the state of Oklahoma Registered Nurse or LPC or LMFT or LMSW is required Minimum 2 years of Utilization Management or case management experience Previous Leadership or management experience, to include leading people/teams in UM practices Preferred Qualifications Advanced degree in nursing, healthcare, or business CMS criteria WAH Internet Statement To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. Satellite, cellular and microwave connection can be used only if approved by leadership. Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense. Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information. HireVue As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule. SSN Alert Humana values personal identity protection. Please be aware that applicants may be asked to provide their Social Security Number, if it is not already on file. When required, an email will be sent from Humana@myworkday.com with instructions on how to add the information into your official application on Humana’s secure website. Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. Scheduled Weekly Hours 40 Pay Range The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc. $94,900 - $130,500 per year This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance. Description of Benefits Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities. About us About Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer at Humana.com and at CenterWell.com. Equal Opportunity Employer It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.

RN Utilization Management - Per diem

St. Peter's Health Partners Albany, NY

$38 - $50.18 / hour

Employment Type: Part time Shift: Day Shift Description: Samaritan Hospital in Troy, NY is looking for an experienced RN to work as a Registered Professional Utilization Management Nurse (UMRN). Shift: 8 hrs The team is willing to help train the right candidate as long as they meet the minimum requirements and have the desire and ability to learn and grow into this wonderful opportunity to progress in their nursing career. We at St. Peter’s Health Partners recognize that nursing is one of the most challenging careers and the most rewarding. We work with nurses to ensure that their professional experiences meet the expectations they had when they chose nursing. We recognize the crucial role you play in the care of every patient treated and we have worked hard to ensure that you find the professional culture, the career support, medical resources and the career opportunities you’re seeking. St. Peter’s Hospital is a member of Trinity Health. Trinity Health employs more than 120,000 colleagues at dozens of hospitals and hundreds of health centers in 21 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions. The selected candidate will : Be responsible for the utilization management, both concurrent and retroactive for inpatient and outpatient services in accordance with the utilization program which meets the requirements of JCAHO and third party payor contracts. Be responsible for the length of stay and level of care to provide effective and efficient health care services that best serve the needs of the patient. Work within and contribute to an environment where the mission is actualized, patient focused outcomes are achieved and high quality professional practice is realized. Minimum requirements: Current and valid NYS RN license Bachelor of Science in nursing, or willingness to purse defined plan for matriculation in program demonstrated by ongoing course work each semester BLS certification 2 years of experience in acute setting or one year in community health Must have some week day availability to orient Preferred requirements: Discharge planning and community resource knowledge Basic knowledge of the utilization management process Working knowledge of recognized industry clinical standards, i.e. Interqual, Milliman Care Guidelines. Maintain the highest level of customer service while completing day to day duties and responsibilities Critical thinking skills to problem solve Excellent time management and organizational skills High level of efficiency to communicate in a fast pace work environment Engage within a team setting to help promote a strong team culture Passion to learn, grow and develop in the nursing field Pay Range: $38.00hr-$50.18hr Pay is based on experience, skills, and education. Exempt positions under the Fair Labor Standards Act (FLSA) will be paid within the base salary equivalent of the stated hourly rates. The pay range may also vary within the stated range based on location. Our Commitment Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. 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 any other status protected by federal, state, or local law.

RN, Utilization Management | Utilization Management

UF Health Lady Lake, FL

Overview Plays a critical role in evaluating patient medical records to ensure the necessity and appropriateness of healthcare services. Involves coordinating with healthcare providers to maintain compliance with utilization management guidelines and optimizing treatment plans for effective patient care and resource utilization. Requires clear communication of authorization decisions and ongoing monitoring to support timely discharge planning. Analyzes utilization data to identify trends and collaborates with interdisciplinary teams to enhance care coordination while ensuring accurate documentation and regulatory compliance. Responsibilities Key Responsibilities Evaluates patient medical records to ensure the necessity and appropriateness of healthcare services. Coordinates with healthcare providers to ensure compliance with utilization management guidelines. Supports the optimization of treatment plans to promote effective patient care and appropriate resource utilization. Communicates authorization decisions clearly and supports timely discharge planning. Analyzes utilization data to identify trends and opportunities to improve care coordination. Collaborates with interdisciplinary teams to ensure accurate documentation and regulatory compliance. Qualifications Education & Experience: Registered Nurse (RN) with a current Florida license required. Three (3) years of critical care nursing experience, or Five (5) years of medical-surgical nursing experience, or Three (3) years of utilization review, case management, or third-party payer experience. Qualifications Active Registered Nurse (RN) license with 3+ years of experience in utilization review or case management. Strong knowledge of healthcare utilization management guidelines and regulatory compliance. Experience evaluating medical necessity and optimizing treatment plans. Excellent communication skills with the ability to clearly convey authorization decisions. Ability to analyze utilization data and support effective care coordination. Strong organizational skills with the ability to manage multiple priorities simultaneously. Ability to work independently and collaboratively with multidisciplinary teams. Strong attention to detail and innovative problem-solving skills. Flexibility to adjust work hours and days based on departmental needs. Motor Vehicle Operator Designation: Employees in this position will not operate vehicles for an assigned business purpose. Note: Please indicate the appropriate operator designation on the Request for Personnel (RFP) form at the time of submission. Licensure/Certification/Registration: Registered Nurse (RN) with a current Florida license required.

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