Registered Nurse (RN) Utilization Review Jobs

RN Utilization Review Full-time
CVS Health

Utilization Management Nurse Consultant

CVS Health Harrisburg, PA
$29.10 - $62.32 / hour
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours. Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function. Typical office working environment with productivity and quality expectations. Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor. Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment. Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding. Effective communication skills, both verbal and written Required Qualifications - 2+ years of experience as a Registered Nurse in adult acute care/critical care setting - Must have active current and unrestricted RN licensure in state of residence - Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours Preferred Qualifications - 2+ years of clinical experience required in med surg or specialty area - Managed Care experience preferred, especially Utilization Management - Preference for those residing in ET zones Education Associates Degree required BSN preferred Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $29.10 - $62.32 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan . No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 04/05/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
RN Utilization Review Full-time
Cleveland Clinic

Utilization Review Nurse - Employee Health Plan (EHP)

Cleveland Clinic TN
At Cleveland Clinic Health System, we believe in a better future for healthcare. And each of us is responsible for honoring our commitment to excellence, pushing the boundaries and transforming the patient experience, every day. We all have the power to help, heal and change lives — beginning with our own. That’s the power of the Cleveland Clinic Health System team, and The Power of Every One. Job Title Utilization Review Nurse - Employee Health Plan (EHP) Location Independence Facility Independence West Creek Department Clinical Integration Health Plan Management-Finance Job Code T24041 Shift Days Schedule 8:00am-4:30pm Job Summary Job Details Join the Cleveland Clinic team, where you will work alongside passionate caregivers and provide patient-first healthcare. Cleveland Clinic is recognized as one of the top hospitals in the nation. At Cleveland Clinic, you will receive endless support and appreciation and build a rewarding career with one of the most respected healthcare organizations in the world. As a Utilization Review Nurse, you will provide clinical information to insurance companies to obtain authorization for future and elective surgeries, coordinate peer-to-peer reviews between insurance Medical Directors and Cleveland Clinic physicians and manage all pre-determination cases. This position primarily supports utilization review, with a strong focus on outpatient prior authorization requests. By taking this opportunity, you will join a fun, supportive, motivated, and detail-oriented team that is looking for a nurse with these qualities to join the team. A caregiver in this role works remotely from 8:00 a.m. – 4:30 p.m. A caregiver who excels in this role will: Provide insurance companies with detailed clinical information when required to complete the authorization and pre-certification process. Communicate and attempt to resolve level of service discrepancies between CCF and insurance companies. Coordinate level of service justification directly with physician and communicate directly with third party payers to obtain approval. Complete responses on behalf of physician for denials. Review medical records and communicate with physicians to obtain authorization. Coordinate peer to peer reviews with CCF physicians and the insurance company Medical Director. Reviews are completed for CCF physicians at Main Campus and the community hospitals. Coordinate pre-determinations for specific procedures and maintain confidentiality of all patients' related information. Adhere to all JCAHO and Medicare compliance regulations. Minimum qualifications for the ideal future caregiver include: Graduate of an accredited practical/vocational or professional nursing program Current state licensure as a Licensed Practical Nurse (LPN) or Registered Nurse (RN) Two or more years of experience in coding or a patient care acute facility, preferably at a tertiary care medical center Excellent communications skills required to communicate will all levels in a health care environment Preferred qualifications for the ideal future caregiver include: Utilization Review experience Epic experience Physical Requirements: Requires extensive sitting and dexterity to perform work on a PC. Requires walking for extended periods of time. Good visual acuity through normal or corrected vision. Sedentary Work - Exerting up to 10 pounds of force occasionally (Occasionally: activity or condition exists up to 1/3 of the time) and/or a negligible amount of force frequently (Frequently: activity or condition exists from 1/3 to 2/3 of the time) to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met. Personal Protective Equipment: Follows standard precautions using personal protective equipment as required. The policy of Cleveland Clinic Health System and its system hospitals (Cleveland Clinic Health System) is to provide equal opportunity to all of our caregivers and applicants for employment in our drug free environment. All offers of employment are followed by testing for controlled substances. Cleveland Clinic Health System administers an influenza prevention program. You will be required to comply with this program, which will include obtaining an influenza vaccination on an annual basis or obtaining an approved exemption. Decisions concerning employment, transfers and promotions are made upon the basis of the best qualified candidate without regard to color, race, religion, national origin, age, sex, sexual orientation, marital status, ancestry, status as a disabled or Vietnam era veteran or any other characteristic protected by law. Information provided on this application may be shared with any Cleveland Clinic Health System facility. If applying for a Florida position, please see the following website for more information on the background screening requirements required by the Agency of Health Care Administration: https://info.flclearinghouse.com/ Please review the Equal Employment Opportunity poster . Cleveland Clinic is pleased to be an equal employment opportunity employer.
RN Manager/Supervisor Utilization Review Full-time
State of Ohio

Clinical Review Nurse Supervisor (Medicaid Health Systems Administrator 1)

State of Ohio Columbus, OH
$39.22 / hour
What You Will Do At ODM Office: Legal Counsel Bureau: Program Integrity Classification: Medicaid Health Systems Administrator 1 RN (PN: 20092018) Job Overview The Ohio Department of Medicaid (ODM) is seeking a Registered Nurse (RN) to be a part of our Surveillance/Utilization Review Section (SURS). SURS is charged with helping the agency review utilization of Medicaid services, detect fraud, waste and abuse and recover inappropriate payments to providers. As a Clinical Review Nurse Supervisor your responsibilities will include: Helping to manage an over $ 7million/ year hospital utilization contract Reviewing necessary medical record reviews and making a determination on hospital appeals. Supervising and training RNs, Auditors, and Analysts in identifying fraud, waste, and abuse in the Medicaid program. Participating/leading meetings with external stakeholders including law enforcement Developing and implementing changes to processes and procedures as needed in a team environment Evaluating provider clinical compliance with state and federal Program Integrity rules Evaluating provider medical documentation and billing practices for fraud, waste and abuse Recovering overpayments for medically unnecessary services via administrative procedures and/or referrals to health oversight agencies Responding to provider clinical reconsideration (appeal) requests Consulting on clinical matters with ODM policy units and other state agencies Coordinating clinical Program Integrity efforts with ODM contractors and managed care plans Presenting findings from clinical reviews of provider non-compliance Responding to inquiries from the public, consumers, providers, and other agencies Completion of graduate core program in business, management or public administration, public health, health administration, social or behavioral science or public finance; 12 mos. exp. in the delivery of a health services program or health services project management (e.g., health care data analysis, health services contract management, health care market & financial expertise; health services program communication; health services budget development, HMO & hospital rate development, health services eligibility, health services data base analysis); Current & valid license as registered nurse as issued by Ohio Board of Nursing, pursuant to Sections 4723.03-4723.09 of Ohio Revised Code; Or 12 months experience as Medicaid Health Systems Specialist, 65293, may be substituted for the experience required, but not for the mandated licensure. Note: education & experience is to be commensurate with approved position description on file. Or equivalent of Minimum Class Qualifications for Employment noted above may be substituted for the experience required, but not for the mandated licensure. Technical Skills: Nursing Professional Skills: Collaboration, Confidentiality, Continuous Improvement, Innovation, Verbal Communication, Written Communication Organization Medicaid Agency Contact Name and Information HumanResources@medicaid.ohio.gov Unposting Date Apr 6, 2026, 3:59:00 AM Work Location Lazarus 5 Primary Location United States of America-OHIO-Franklin County-Columbus Compensation $39.22/hour Schedule Full-time Work Hours 8:00 am - 5:00 pm Classified Indicator Classified Union Exempt from Union Primary Job Skill Nursing Technical Skills Nursing Professional Skills Collaboration, Innovation, Verbal Communication, Written Communication, Confidentiality, Continuous Improvement Agency Overview About Us: Investing in opportunities for Ohioans that work for every person and every family in every corner of our state is at the hallmark of Governor DeWine’s agenda for Ohio’s future. To ensure Ohio is “the best place to live, work, raise and family and start a business,” we must have strong schools, a great quality of life, and compassion for those who need our help. Responsibilities Ohio Department of Medicaid plays a unique and necessary role in supporting the governor’s vision. As the single state Medicaid agency responsible for administering high-quality, person-centric healthcare, the department is committed to supporting the health and wellbeing of nearly one in every four Ohioans served. We do so by: Delivering a personalized care experience to more than three million people served. Improving care for children and adults with complex behavioral health needs. Working collectively with our partners and providers to measurably strengthen wellness and health outcomes. Streamlining administrative burdens so doctors and healthcare providers have more time for patient care. Ensuring financial transparency and operational accountability across all Medicaid programs and services.
RN Utilization Review Full-time
Health First

Utilization Management Nurse - Case Management

Health First Melbourne, FL
Job Requirements POSITION SUMMARY The Utilization Review (UR) nurse performs medical necessity reviews on all payer admissions to determine appropriate admission status and documents all information that relates to insurance reimbursement in appropriate reviews. The UR Nurse utilizes advanced clinical skills to facilitate the provision of care including the appropriate length of stay, patient status management, resource utilization and discharge planning for all hospital admissions. The UR Nurse effectively and efficiently manages a diverse workload in a fast-paced, rapidly changing regulatory environment and regularly collaborates with the Medical Staff, Physician Advisors, Case Managers, Revenue Cycle and other multi-disciplinary teams. PRIMARY ACCOUNTABILITIES Screens all admissions for medical necessity and collaborates with the physician to identify and place the patient at the correct level of care and patient type. Coordinates clinical care to include medical necessity, appropriateness of care and resource utilization for admission. Communicates with physicians, office staff, health-care team and physician advisors to determine appropriate status and medical necessity. Documents in the Electronic Medical Record and other applications that initial and concurrent reviews have been appropriately completed. Promotes professional practice through collegial support and interactions. Understands revenue operations and closely partners with charge capture and reimbursement analysts as necessary. Is an active member of the Utilization Management Committee. Work Experience MINIMUM QUALIFICATIONS Education: Associate’s Degree in Nursing Licensure: Current, valid State of Florida RN license or endorsement Certification: Current American Heart Association Basic Life Support Healthcare Provider Completion Card upon hire and maintained Work Experience: At least five (5) years of strong clinical experience in an acute care hospital clinical practice area. Knowledge/Skills/Abilities: Strong analytical, data management and computer skills. Ability to work autonomously and prioritize multiple tasks and role components. Ability to exercise sound judgment in interactions with physicians, payers, and other customers. Must be able to work remotely with adequate technology to support and maintain productivity. PREFERRED QUALIFICATIONS Education: BSN or Master’s Degree in a healthcare field Certification: Current Case Manager Certification (CCM or ACM) Work Experience: Critical, Intermediate or Emergency Department Nursing Knowledge/Skills/Abilities: Current working knowledge of care transitions, utilization management, case management and managed care reimbursement PHYSICAL REQUIREMENTS (Sedentary) Majority of time involves sitting or standing; occasional walking, bending, stooping. Long periods of computer time or at workstation. Light work that may include lifting or moving objects up to 20 pounds with or without assistance. May be exposed to inside environments with varied temperatures, air quality, lighting and/or low to moderate noise. Communicating with others to exchange information. Visual acuity and hand-eye coordination to perform tasks. Workspace may vary from open to confined. May require travel to various facilities within and beyond county perimeter; may require use of personal vehicle. Benefits ABOUT HEALTH FIRST At Health First, diversity and inclusion are essential for our continued growth and evolution. Working together, we strive to build and nurture a culture that recognizes, encourages, and respects the diverse voices of our associates. We know through experience that different ideas, perspectives, and backgrounds create a stronger and more collaborative work environment that delivers better results. As an organization, it fuels our innovation and connects us closer to our associates, customers, and the communities we serve.
RN Utilization Review Full-time
CVS Health

Utilization Management Nurse Consultant - San Antonio, TX Preferred

CVS Health San Antonio, TX
$29.10 - $62.32 / hour
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. As a Utilization Management Nurse Consultant, you will utilize clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. You would be responsible for ensuring the member is receiving the appropriate care at the appropriate time and at the appropriate location, while adhering to federal and state regulated turn-around times. This includes reviewing written clinical records. The UM Nurse Consultant job duties include (not all encompassing): -Reviews services to assure medical necessity, applies clinical expertise to assure appropriate benefit utilization, facilitates safe and efficient discharge planning and works closely with facilities and providers to meet the complex needs of the member. -Facilitate the delivery of appropriate benefits and/or healthcare information which determines eligibility for benefits while promoting wellness activities. -Develops, implements and supports Health Strategies, tactics, policies and programs that ensure the delivery of benefits and to establish overall member wellness and successful and timely return to work. -Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members -Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members -Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure, and clinical judgment to render coverage determination/recommendation along the continuum of care -Communicates with providers and other parties to facilitate care/treatment -Identifies members for referral opportunities to integrate with other products, services and/or programs -Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization -Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function. Required Qualifications: -Must have current unrestricted RN licensure in their state of residence -2+ years clinical practice experience as an RN required -1+ year(s) experience utilizing multiple computer systems and applications including Microsoft Word, Excel, Outlook, and web-based applications -Must be willing to travel to the local office as needed. Preferred Qualifications: - It is preferred that the candidate live within driving distance of San Antonio, TX -Bilingual in Spanish and English -Strong computer skills Education: -Associates Degree in Nursing is minimum required, BSN preferred. Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $29.10 - $62.32 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan . No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 04/04/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
RN Outpatient Utilization Review Full-time
IU Health

Registered Nurse-Ambulatory Referral Review

IU Health Indianapolis, IN
Overview Registered Nurse – Ambulatory Referral Review (Urology Service Line) Position Overview: Join our dynamic healthcare team as a Registered Nurse specializing in Ambulatory Referral Review, supporting the Urology service line. This innovative role leverages your clinical expertise to coordinate and manage patient care referrals from an off-site, system-wide call center. Working Monday through Friday during the day shift with flexible hours, this remote/hybrid position offers a balanced work environment with comprehensive training to ensure your success. Work Environment: This position is primarily remote, with initial hybrid training to ensure seamless onboarding and integration into the team. Key Responsibilities: Utilize the nursing process (assessment, diagnosis, outcome identification, planning, implementation, and evaluation) to review inbound patient care referrals efficiently and accurately. Analyze electronic health records, test results, and clinical documentation in accordance with specialty care protocols and scheduling workflows. Assess patient acuity and prioritize scheduling based on clinical needs. Collaborate closely with specialty physicians and interdisciplinary teams to ensure patients receive timely, appropriate care. Maintain adherence to organizational policies, ensuring quality and compliance in referral management. Qualifications: Associate's Degree is required. Bachelor's Degree is preferred. Requires 0-3 years of relevant experience. 2+ years of Urology experience preferred. Requires that the RN has graduated from a nationally accredited nursing program. Requires an active Registered Nurse (RN) license in the state of Indiana or an active Nurse Licensure Compact (NLC) RN license. Requires basic life support (BLS) certification through the AHA annually. Other advanced life support certifications may be required per unit/department specialty according to patient care policies. Requires the ability to assess patients without face-to-face interaction. Why Join Us? Be part of a forward-thinking healthcare organization dedicated to delivering patient-centered care. This role offers an excellent opportunity to utilize your nursing skills in a specialized, fast-paced environment while enjoying the flexibility of remote work.
RN Utilization Review Full-time
Highmark Health

RN Utilization Review- AHN

Highmark Health
$30.10 - $48.54 / hour
Company : Allegheny Health Network Job Description : GENERAL OVERVIEW: Responsible for obtaining insurance precertification/recertification, functioning as a liaison with third party payers, communicating clinical information to the insurance companies as requested, addressing and resolving any actual or potential denials, and functioning as a member of the care coordination team. ESSENTIAL RESPONSIBILITIES: Obtains or ensures acquisition of appropriate pre-certifications/authorizations from third party payers and placement to appropriate level of care prior to hospitalization utilizing medical necessity criteria and third party payer guidelines. (30%) Obtains or facilitates acquisitions of urgent/emergent authorizations, continued stay authorizations, and authorizations for post-acute services as needed and with compliance with all regulatory and contractual requirements. (30%) Documents, monitors, intervenes/resolves, and reports clinical denials/appeals and retrospective payer audit denials; collaboratively formulates plans of action for denial trends with the care coordination teams, performance improvement teams, physicians/physician advisor, and third party payers, etc. (30%) Maintains a working knowledge of care management, utilization review changes, authorization changes, contract changes, regulatory requirements, etc. Serves as an educational resource to all AHN staff regarding utilization review practice and governmental/commercial payer guidelines.(5%) Adheres to the policies, procedures, rules, regulations, and laws of the hospital and all federal and state regulatory bodies.(5%) Communicates telephonically and electronically with the outpatient providers in an effort to enhance the continuum of care. Assumes responsibility for AHN required continued education and own professional growth. Performs other duties as assigned or required. QUALIFICATIONS: Minimum Bachelor’s degree or relevant experience and/or education as determined by the company in lieu of bachelor's degree Current State of PA RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC) Nationally recognized Care Management Certification within 5 years of start date (3 years for currently employed UR's) 2-3 years nursing experience with 1 year in Utilization Management Preferred Experience in case management, discharge planning and/or the application of InterQual criteria Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job. Compliance Requirement : This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies. As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements. Pay Range Minimum: $30.10 Pay Range Maximum: $48.54 Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets. Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law. We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below. For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org California Consumer Privacy Act Employees, Contractors, and Applicants Notice
RN Utilization Review Full-time
Centene

Clinical Review Nurse - Concurrent Review

Centene
$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. ***This is a fully remote position; however, candidates must reside in the state of New York and maintain active New York State (NYS) RN licensure to be considered. The standard work schedule is Monday through Friday, 8:30 a.m. to 5:00 p.m., with the potential for weekend coverage based on business needs.*** 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 graduation from an accredited school of nursing or a Bachelor’s degree in Nursing (BSN), along with 2–4 years of related nursing experience. A minimum of 2 years of acute care experience is 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: NYS RN Licensure Strongly Preferred Pay Range: $27.02 - $48.55 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
RN Utilization Review Full-time
Centene

Clinical Review Nurse - Concurrent Review (RN)

Centene
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: 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 RN - Registered Nurse - State Licensure and/or Compact State Licensure For State of Nevada required *Must be licensed in Nevada. Location: Position is remote. Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
RN Utilization Review Full-time
CVS Health

Utilization Management Nurse Consultant

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

Utilization Management Nurse Consultant

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

Clinical Review Nurse- Prior Authorization

Centene
$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. Centene is hiring a Remote Clinical Review Nurse – Prior Authorization to support our Duals team . The ideal candidate will have experience reviewing outpatient services , with a background in one or more of the following areas: Imaging services Durable Medical Equipment (DME) Home Health Care Elective inpatient services Multi-State nursing license This role is responsible for conducting clinical reviews for prior authorization requests in accordance with medical necessity guidelines, regulatory requirements, and company policies. This is a remote position with standard business hours, Monday through Friday, 8:00 AM–5:00 PM. Candidates must reside and work within the Mountain or Pacific time zones. This role may also require flexibility for weekend, holiday, and on-call coverage. An alternative schedule of Sunday through Thursday, 9:00 AM–6:00 PM may be required based on business needs. Position Purpose: Analyzes all prior authorization requests to determine medical necessity of service and appropriate level of care in accordance with national standards, contractual requirements, and a member's benefit coverage. Provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care. Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria Works with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care Coordinates as appropriate with healthcare providers and interdepartmental teams, to assess medical necessity of care of member Escalates prior authorization requests to Medical Directors as appropriate to determine appropriateness of care Assists with service authorization requests for a member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities Collects, documents, and maintains all member’s clinical information in health management systems to ensure compliance with regulatory guidelines Assists with providing education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care to members Provides feedback on opportunities to improve the authorization review process for members Performs other duties as assigned Complies with all policies and standards Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience. Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. License/Certification: LPN - Licensed Practical Nurse - State Licensure required Pay Range: $27.02 - $48.55 per hour Pay Range: $27.02 - $48.55 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
RN Utilization Review Full-time
CVS Health

Utilization Management Nurse Consultant

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

RN (Utilization Review)

Sarah Bush Lincoln Mattoon, IL
$66,768 - $103,500.80 / year
Internal Employees: Please ensure that you are logged into Workday and applying through the Jobs Hub before proceeding. RN (Utilization Review) Job Description Utilization Review RN conducts medical certification review for medical necessity for acute care facility and services Uses nationally recognized, evidence-based guidelines approved by medical staff to recommend level of care to the physician and serve as a resource to the medical staff on issues related to admission qualifications, resource utilization, national and local coverage determinations and documentation improvement opportunities. Relays information as requested to the payer sources. Assures the highest quality, most cost effective patient care in the most appropriate setting. Responsibilities Assessment - Collects pertinent data and information relative to the patient's health or the situation. Recognizes normal and abnormal findings when gathering data., Assumes responsibility for remaining current on all regulatory and reimbursement rules and regulations., Concurrently reviews medical necessity, bed status, length of stay and quality of care indicators on all assigned patients. Serves as coordinator for communication with payors and providers to determine the appropriateness of hospital level of care., Confers with attending physician and physician advisor if medically unnecessary inpatient treatment is contemplated., Consults with medical staff, care team, and case managers as necessary to resolve immediate progression-of-care barriers through appropriate administrative and medical channels., Coordinates Medicare appeals with the discharge planner, Director of Utilization Management, Physician Advisor and the QIO., Coordination of Care - Plans and evaluates care in collaboration with appropriate disciplines., Diagnosis - Analyzes assessment data to determine actual or potential diagnosis, problems, and issues., Evaluation - Evaluates progress toward attainment of goals and outcomes. Reports data and outcomes to others as appropriate., Implementation - Implements care or work plan in alignment with the plan and approved safety, infection control, and department/organization standards., Knowledge - In collaboration with leaders, actively pursues required knowledge and skills through orientation activities specific to the position, reading current literature and seeking new learning opportunities., Outcomes Identification - Identifies expected outcomes for a plan individualized to the patient or situations., Planning - Develops a plan that prescribes strategies to attain expected, measurable outcomes., Recognizes and responds appropriately to patient safety/risk factors., Refers all denials, as appropriate, to the Director of Utilization Management and/or Physician Advisor., Relationships - Establishes effective working relationships with peers, physicians, and other members of the health care / work team. Identifies and confers with appropriate resources regarding patient / work decisions., Reviews operating room (OR) schedule 48 hours in advance of scheduled procedures to confirm that all eligible Medicare and Medicaid admissions were identified and the coded procedure is or is not on the Medicare inpatient-only list. Confirms that physician’s admission orders accurately reflect status., Serves as a resource person to physicians, case managers, physician offices, and billing office for coverage and compliance issues., Serves as coordinator for third party payer reviews, certifications and authorizations., Teaching - Employs teaching strategies to promote health and a safe environment., Works closely with physician advisor to review resource utilization data and trends to identify outliers who may benefit from real-time coaching to improve outcomes. Requirements ADN (Required)RN-Registered Nurse - Illinois Department of Financial and Professional Regulation Compensation Estimated Compensation Range $66,768.00 - $103,500.80 Pay based on experience
RN Utilization Review Full-time
CVS Health

Utilization Management Nurse Consultant

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

Registered Nurse - Behavioral Health Unit - Utilization Management

IU Health Muncie, IN
Overview Performs utilization review of inpatient admissions, outpatient surgeries, and ancillary services. Performs precertification, concurrent and retrospective reviews, and coordination of discharge planning. Determines medical necessity and appropriateness of services using clinical review criteria. Collaborates with physicians and other providers to facilitate provision of services throughout the health care continuum. Acts as a member advocate by expediting the care process through the continuum, working in concert with the health care team to maintain high quality and cost effective care delivery. Requires an Associates of Nursing (ASN). Bachelors of Nursing (BSN) preferred. Requires an active Registered Nurse (RN) license in the state of Indiana or an active Nurse Licensure Compact (NLC) RN license. Requires that the RN has graduated from a nationally accredited nursing program. Requires 3-5 years of relevant experience. Basic Life Support certification through the AHA or other advanced life support certifications may be required per unit/department specialty according to patient care policies. Requires proficiency in Microsoft Office and applications. Requires understanding of medical record requirements, regulations and policies.
RN Utilization Review Full-time
MarinHealth

Utilization Review RN II, Care Coordination, Full-Time, Days

MarinHealth Kentfield, CA
$66.03 - $99.04 / hour
ABOUT MARINHEALTH Are you looking for a place where you are empowered to bring innovation to reality? Join MarinHealth, an integrated, independent healthcare system with deep roots throughout the North Bay. With a world-class physician and clinical team, an affiliation with UCSF Health, an ever-expanding network of clinics, and a new state-of-the-art hospital, MarinHealth is growing quickly. MarinHealth comprises MarinHealth Medical Center, a 327-bed hospital in Greenbrae, and 55 primary care and specialty clinics in Marin, Sonoma, and Napa Counties. We attract healthcare’s most talented trailblazers who appreciate having the best of both worlds: the pioneering medicine of an academic medical center combined with an independent hospital's personalized, caring touch. MarinHealth is already realizing the benefits of impressive growth and has consistently earned high praise and accolades, including being Named One of the Top 250 Hospitals Nationwide by Healthgrades, receiving a 5-star Ranking for Overall Hospital Quality from the Centers for Medicare and Medicaid Services, and being named the Best Hospital in San Francisco/Marin by Bay Area Parent, among others. Company: Marin General Hospital dba MarinHealth Medical Center Compensation Range: $66.03 - $99.04 Work Shift: 10 Hour (days) (United States of America) Scheduled Weekly Hours: 40 Job Description Summary: The Utilization Review Nurse is responsible for completion of admission, concurrent and retrospective reviews for designated health plans. This function includes appropriate application of standardized criteria and concurrent documentation. As appropriate, the UR nurse will assess for clinical stability and coordinate transfer back to Marin General for continued care when patients are admitted to non-contracted hospitals. The UR nurse is also responsible for initial RAC review prior to submission to Physician Advisor and will appeal medical necessity denials. Denials submitted to the case management department from Patient Financial Services will be reviewed to determine if the medical record has sufficient medical necessity documentation prior to a written appeal. The UR nurse will escalate cases to the Medical Director (as necessary) to ensure the provision of appropriate and effective patient care. Job Requirements, Prerequisites and Essential Functions: EDUCATION Bachelor of Science degree in Nursing preferred EXPERIENCE 1. Three (3) or more years of experience in an acute patient care setting preferably in medical/surgical or critical care. 2. Substantial recent experience in utilization review and/or discharge planning in an acute care setting is strongly preferred. 3. Experience in applying evidence based criteria related to utilization management. 4. Experience using case management software LICENSURE AND CERTIFICATIONS Registered Nurse Required at hire Basic Life Support Required at hire PREREQUISITE SKILLS 1. Must have the ability to read, write, and follow English verbal and written instructions, and have excellent oral and written communication, interpersonal, problem-solving, conflict resolution, presentation, time management, and positive personal influence and negotiation skills. 2. Able to carry out review function and access medical records. 3. Must have the ability to work independently with a minimum of direction, anticipate and organize work flow, prioritize and follow through on responsibilities. 4. Utilization review/discharge planning services appropriate to patients with complex 5. Strong attention to detail and accuracy is required. 6. Must have the ability to work in a high volume case load environment and deal effectively with rapidly changing priorities. 7. Demonstrated ability to work constructively with a broad spectrum of health care professionals is required. 8. Must be assertive and creative in problem solving, system planning and management. 9. Proficient computer skills are required including use of Electronic Health Record. Microsoft Office Suite Products. Accommodation: Qualified applicants with disabilities may request reasonable accommodation during the application process by contacting Human Resources at 415-925-7040 or TalentAcquisition@mymarinhealth.org . C.A.R.E.S. Standards: MarinHealth seeks candidates ready to model our C.A.R.E.S. standards—Communication, Accountability, Respect, Excellence, Safety—which foster a healing, trust-based environment for patients and colleagues. Health & Immunizations: To protect employees, patients, and our community, MarinHealth requires measles, mumps, varicella, and annual influenza immunizations as a condition of employment (and annually thereafter). COVID-19 vaccination/booster remains strongly recommended. Medical or religious exemptions will be considered consistent with applicable law. Compensation: The posted pay range complies with applicable law and reflects what we reasonably expect to pay for this role. Individual pay is set by skills, experience, qualifications, and internal/market equity, consistent with MarinHealth’s compensation philosophy. Positions covered by collective bargaining agreements are governed by those agreements. Equal Employment: All qualified applicants will receive consideration for employment without regard to race, color, religion, national origin, sexual orientation, gender identity, protected veteran status or disability status, and any other classifications protected by federal, state, and local laws.
RN Utilization Review Per Diem
Kaiser Permanente

Case Manager Utilization RN-Per Diem

Kaiser Permanente Los Angeles, 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.
RN Utilization Review Full-time
Franciscan Health

RN Utilization Review Coordinator

Franciscan Health Mishawaka, IN
Work From Home Work From Home Work From Home, Indiana 46544 The Utilization Review Coordinator performs admission screening for patients in a bed for medical necessity, and reviews for appropriateness of setting and utilization. WHO WE ARE With 12 ministries and access points across Indiana and Illinois, Franciscan Health is one of the largest Catholic health care systems in the Midwest. Franciscan Health takes pride in hiring coworkers that provide compassionate, comprehensive care for our patients and the communities we serve. WHAT YOU CAN EXPECT Schedule: Monday - Friday, 8am - 4:30pm Perform concurrent reviews for appropriateness of utilization to optimize clinical and financial outcomes. Communicate with physicians, patients, members of the Healthcare team, Coordinated Business Office staff, Denial Management staff, and third-party payors to justify the admission or continued stay. Notify appropriate staff members of any admission, service, length of stay, lack of medical necessity criteria, as well as denials/appeals and issuing of letters to patients. Provide Physician, Patient, Family, Staff and Student education. Act as a resource person for the case management department regarding payer rules, regulations, policies and procedures, and utilization issues. Perform admission necessity screening using criteria as established by the various federal, state and private sector programs. QUALIFICATIONS Associate degree in nursing/patient care required Bachelor's Degree in nursing/patient care preferred Registered Nurse (RN - Indiana licensure) required 3 years of nursing/patient care experience required 2 years of Utilization or Case Management experience preferred TRAVEL IS REQUIRED: Never or Rarely JOB RANGE: Utilization Review Coordinator $56971.20-$84749.60 INCENTIVE: Not Applicable EQUAL OPPORTUNITY EMPLOYER It is the policy of Franciscan Alliance to provide equal employment to its employees and qualified applicants for employment as otherwise required by an applicable local, state or Federal law. Franciscan Alliance reserves a Right of Conscience objection in the event local, state or Federal ordinances that violate its values and the free exercise of its religious rights. Franciscan Alliance is committed to equal employment opportunity. Franciscan provides eligible employees with comprehensive benefit offerings. Find an overview on the benefit section of our career site, jobs.franciscanhealth.org .
RN Psych Utilization Review Full-time
Bakersfield Behavioral Healthcare Hospital

Registered Nurse | Admissions Reviewer/Intake

Bakersfield Behavioral Healthcare Hospital Bakersfield, CA
$44 - $61.38 / hour
About Us Bakersfield Behavioral Healthcare Hospital, located in Bakersfield, California, is an acute psychiatric and behavioral 90-bed facility situated on 8.8 acres. We offer inpatient and outpatient services for children, adolescents, and adults needing mental/behavioral health, chemical dependency; and co-occurring disorders treatment through our medically supervised detoxification. Within our Workplace Community, BBHH is striving daily to be one of the BEST PLACES TO WORK not just here in Kern County, but throughout the Behavioral Healthcare Community. By offering amazing benefits, encouraging individual growth and development, and incorporating our CARES values system into our daily operations, we are creating a JUST workplace culture where people enjoy coming to work each day. BBHH CARES about your experience as a candidate and we encourage you to apply to our open positions. Compassion Acceptance Respect Empowerment Sincerity Job Summary Our progressive and dedicated healthcare team strives to change the lives of our patients and provide exceptional care. This RN position is in our Inpatient units. The attention to detail and level of situational awareness required of the staff in the Inpatient Unit is paramount to the success of all patient outcomes. Our CARES values system must be on display in every act of patient care, no matter the circumstances. BBHH is a fast-paced environment that requires critical thinking, teamwork, and excellent communication between staff and patients. We are looking for a Registered Nurse to provide excellent care and to join our Workplace Community in our effort to be the best hospital we can be. POSITION SUMMARY: The Admissions RN (Intake Packet Reviewer) is responsible for conducting comprehensive clinical reviews of referral packets to determine patient eligibility for admission to Bakersfield Behavioral Healthcare Hospital (BBHH). This position evaluates medical history, psychiatric diagnosis, acuity level, risk factors, exclusionary criteria, and medical stability to ensure the hospital can safely and appropriately meet the patient’s needs. The role requires sound clinical judgment, knowledge of psychiatric standards of care, regulatory awareness, and the ability to assess admission risk in alignment with California law, CMS Conditions of Participation, and Joint Commission standards. Some of the fundamentals we're looking for in those who apply to this position include: Someone who demonstrates sound leadership skills and utilizes these skills in organizing the activities and schedules for medical and/or non-medical tasks on the unit. A caring, compassionate human being with a record of consistently showcasing high-quality clinical and interpersonal skills to be an exemplary role model to others Someone capable of displaying basic knowledge of treatment procedures; interventions common to acute psychotic as well as non-violent crisis intervention practice; A person with basic knowledge of abnormal psychology, application of this knowledge to the care of our patients, and fluency in medical terminology in psychiatric care; Someone with thorough familiarity of psych and the use of psychotropic medications, basic teaching and training skills helpful; problem-solving; An organized individual with exceptional organizational and time management skills; crisis intervention skills; Someone with strong written and oral communication skills in the English language; skills in facilitating and/or co-facilitating process-oriented and didactic groups. WHAT WE'RE LOOKING FOR Simply put: HUMANS WHO CARE Though we do need to meet some minimum requirements for the position such a High School Diploma or Equivalent, and a current California RN License we're really looking for people who bring their HEART to work. If you have previous experience in a mental healthcare hospital environment where your attention was focused on the assessments of human behavior, psychiatry, psychology, or other mental healthcare situations, then your application to this position will be moved to the shortlist of candidates. Minimum of two (2) years psychiatric nursing experience (acute inpatient preferred). • Strong knowledge of psychiatric diagnoses, risk stratification, and medical comorbidities. • Demonstrated ability to independently analyze clinical information and exercise sound judgment. • Working knowledge of Title 22, CMS, and Joint Commission standards related to psychiatric facilities. • Strong written documentation skills. • Experience reviewing referral packets or conducting medical necessity reviews. Our patients, our community, and our co-workers RELY on us to be committed to their wellness, Through prevention, intervention, treatment, and education, we can and we will make a difference not just here in Bakersfield, but throughout our extended communities. You should have a current CPR certification when you apply or obtain certification prior to your start date. If you don't have a current CPR certification, just let us know and we'll make sure you get it before you start -- and even cover the cost for you. Additionally, you'll complete a "Handle-With-Care" Physical Restraint Technique Training during your orientation so that you know how and when to engage when such an event occurs. You should know that this position operates on an Alternate Work Schedule of 12-hour shifts from 6:00am to 6:30pm or 6:00pm to 6:30am. SPECIFIC SCHEDULE REQUIREMENTS: Monday 6a-6:30p, Tuesday 6a-6:30p and every other Saturday 6a-6:30p. BBHH encourages ALL qualified candidates to apply. The RN position pays between $44.00-$61.38 per hour based on the experience you bring with you. We look forward to reviewing your application TODAY! Bakersfield Behavioral Healthcare Hospital is proud to offer a suite of benefits to those who join our workplace community. *Benefits eligibility varies based on employment status (full-time, part-time, per diem, temporary, etc.). Some of the benefits you can expect as a Full-Time employee include: Paid Time Off over THREE WEEKS of Paid Time Off in your first year!!! Life Insurance Short-Term Disability Insurance Long-Term Disability Insurance Medical Insurance Dental Insurance Vision Insurance Pet Insurance Accident Insurance 401k Retirement Plan Discounted Meals Employee Assistance Program TUITION Assistance
RN Utilization Review Full-time
Gainwell Technologies LLC

Nurse Reviewer Appeals and Hearings- Remote

Gainwell Technologies LLC TX
$84,000 - $95,000 / year
It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you’ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development. Summary We are seeking a talented individual for a Nurse Reviewer Appeals and Hearings to coordinate and perform all appeal related duties including analyzing and responding appropriately to appeals from providers; reviewing documentation to ensure all aspects of the appeal have been addressed properly and accurately; prepare case files and case summaries for hearings; and participate in in virtual and on-site hearings. Your role in our mission Reviews provider appeals and redeterminations using approved clinical and coding guidelines and documents appeal determinations clearly and concisely. Analyzes and reviews appeal documentation to ensure all aspects of the appeal have been addressed properly and accurately while maintaining production goals and quality standards. Prepares case files and case summaries for hearings and actively participates in hearings in conjunction with the Medical Director. Assist management with training new reviewers to include daily monitoring, mentoring, feedback and education. Maintains current knowledge of clinical criteria guidelines and/or coding guidelines; successfully completes required CEUs to maintain RN license and/or coding certification. Responsible for attending training and scheduled meetings to enhance skills and working knowledge of clinical policies, procedures, rules, and regulations. Actively cross-trains to perform reviews of multiple claim types to provide a flexible workforce to meet client needs. What we're looking for Active, Unrestricted RN license from the United States and in the primary home residency, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), 5+ years clinical experience or 5+ years medical record coding experience required 3+ years utilization review experience or claims auditing required Working knowledge of the appeals and hearings process Experience using MCG or InterQual criteria preferred Excellent written communication skills including ability to write clear, concise, accurate, and fact-based rationales in support of appeal determinations. Excellent oral communication skills with particular emphasis on verbally presenting case summaries and decisions. Ability to multi-task in a fast-paced production environment. What you should expect in this role Work Location: Remote within the United States Travel Requirement: Up to 25% Travel for onsite hearing testimony Applications will be accepted through April 17, 2026. The pay range for this position is $84,000.00 - $95,000.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits , and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities. We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings. Gainwell Technologies is an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. Gainwell Technologies defines “wages” and “wage rates” to include “all forms of pay, including, but not limited to, salary, overtime pay, bonuses, stock, stock options, profit sharing and bonus plans, life insurance, vacation and holiday pay, cleaning or gasoline allowances, hotel accommodations, reimbursement for travel expenses, and benefits.
RN Utilization Review Full-time
St. Luke's University Health Network

RN DRG Downgrades Appeals Review Specialist

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

Utilization Management Nurse Consultant

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

Utilization Management RN

Bryan Health Grand Island, NE
Summary GENERAL SUMMARY: Conducts day-to-day activities for the clinical, financial and utilization coordination of the patient’s hospital experience. Proactively consults with the interdisciplinary team which includes, but is not limited to, hospital patient care staff, physicians, patient support and family to ensure the patient’s hospital stay meets medical necessity and insurance authorizations are obtained in order to facilitate the patient’s and hospitals financial well-being. PRINCIPAL JOB FUNCTIONS: 1. *Commits to the mission, vision, beliefs and consistently demonstrates our core values. 2. *Performs utilization review activities, including concurrent and retrospective reviews as required. 3. *Determines the medical necessity of request by performing first level reviews, using approved evidence based guidelines/criteria. 4. *Collaborates with the patient’s provider and other healthcare team members in managing the patient’s length of stay and determining the continuing medical necessity of continued stays. 5. *Refers cases to reviewing physician when the treatment request does not meet criteria per appropriate algorithm. 6. *Participates in concurrent and retrospective denials and appeals process by researching issues surrounding the denial, participating in all levels of the appeal and process follow-up. 7. *Serves as an internal and external resource regarding appropriate level of care; admission status/classification; Medicare/Medicaid rules, regulations, and policies; 3rd party and managed care contracts; discharge planning; and length of stay. 8. Ensures appropriate resource utilization relevant to the financial, regulatory and clinical aspects of care; proposes alternative treatment to ensure a cost effective and efficient plan of care. 9. *Maintains awareness of financial reimbursement methodology, utilization management, payer/reimbursement practices and regulations and participates in resource stewardship. 10. *Promotes quality improvement initiatives and health care outcomes based on currently accepted clinical practice guidelines and total quality improvement initiatives. 11. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise. 12. Participates in meetings, committees and department projects as assigned. 13. Performs other related projects and duties as assigned. REQUIRED KNOWLEDGE, SKILLS AND ABILITIES: 1. Maintains clinical competency as required for the unit including but not limited to age-specific competencies relative to patient’s growth and developmental needs, annual skill competency verification and mandatory education and competencies. 2. Knowledge of governmental and third party payer regulations and requirements related to patient hospitalization and acute rehabilitation admission, stay and discharge activities, i.e., CMS, CARF, FIM (TM). 3. Knowledge of computer hardware equipment and software applications relevant to work functions. 4. Skill in conflict diffusion and resolution. 5. Ability to communicate effectively both verbally and in writing. 6. Ability to perform crucial conversations with desired outcomes. 7. Ability to establish and maintain effective working relationships with all levels of personnel and medical staff. 8. Ability to problem solve and engage independent critical thinking skills. 9. Ability to maintain confidentiality relevant to sensitive information. 10. Ability to prioritize work demands and work with minimal supervision. 11. Ability to perform crucial conversations with desired outcomes. 12. Ability to maintain regular and punctual attendance. EDUCATION AND EXPERIENCE: Current Registered Nurse licensure from the State of Nebraska or approved compact state of residence as defined by the Nebraska Nurse Practice Act. Minimum of two (2) years recent clinical experience required. Prior care coordination and/or utilization management experience preferred. OTHER CREDENTIALS / CERTIFICATIONS: Basic Life Support (CPR) certification required. Bryan Health recognizes American Heart Association (for healthcare professionals), American Red Cross (for healthcare professionals) and the Military Training Network.
RN Utilization Review Full-time
Molina Healthcare

Care Review Clinician (RN)

Molina Healthcare Long Beach, CA
$30.37 - $59.21 / 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. Must be licensed in CA. 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: $30.37 - $59.21 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.