Registered Nurse (RN) Utilization Review Jobs

RN Utilization Review Other
MaineHealth

Care Manager (RN) - Utilization Review

apartment MaineHealth location_onPortland, ME
Description Maine Medical Center Nursing Req #: 61670 This is a Clinical Nurse II vacancy open to candidates with greater than 1 year of RN work experience This is a bargaining unit position Date posted: 12/22/2025 For a limited time MaineHealth is offering a $10,000 Sign on bonus for all eligible experienced Registered Nurses with 1-3 years of experience and $20,000 for experienced Registered Nurses with greater than 3 years of experience! Eligible candidates are hired (offer accepted) into a Full or Part time RN position. Bonus amount prorated for Part time hires, per diem hires are ineligible. Current MaineHealth member employees are ineligible; former MaineHealth Members are ineligible until greater than 6 months separation from employment. *Knowledge ofboth Inter-qual and MCG criteria preferred. Previous Care Manager experience preferred* Pleasenote,this position does not include discharge planning Role The CaseManager I is accountable for a designated patient caseload and plans effectivelyin order to meet patient needs, manage the length of stay, and promote efficient utilization of resources. Specific functions within this role include but are not limited to: Facilitation of the collaborative management of patient care across the continuum, intervening as necessary to address barriers totimelyand efficient care delivery,flowand reimbursement Application of process improvement methodologies in evaluating outcomes of care Support and coaching of clinical documentation efforts Coordinating communication with the interdisciplinary care team Must be able todemonstrateknowledge and skills necessary to provide careappropriate tothe patient served. Mustdemonstrateknowledge of the principles of growth and development as it relates to the different life cycles. Summary The purpose of the Case Manager I position is to support the interdisciplinary team in facilitating patient care, with the underlying objective of enhancing the quality of clinical outcomes and patient satisfaction while managing the cost of care and providing timely and accurate information to payors. The role integrates and coordinates utilization management, care facilitation and discharge planning functions. This work is performed under general supervision in accordance with the Maine Medical Center (MMC) institutional policies and Care Management Department policies. The Case Manager I is accountable for a designated patient caseload and plans effectively in order to meet patient needs, manage the length of stay, and promote efficient utilization of resources. Specific functions within this role include but are not limited to: Facilitation of the collaborative management of patient care across the continuum, intervening as necessary to address barriers to timely and efficient care delivery, flow and reimbursement Application of process improvement methodologies in evaluating outcomes of care Support and coaching of clinical documentation efforts Coordinating communication with the interdisciplinary care team Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the patient served. Must demonstrate knowledge of the principles of growth and development as it relates to the different life cycles. Required Minimum Knowledge, Skills, And Abilities (KSAs) Education: BSN or must matriculate into a BSN program within one year of hire and completion attained within 5 years of hire. License/Certifications: Current and valid license to practice as a Registered Nurse in the state of Maine. Professional certification as a Case Manager preferred. Experience: One to three years clinical experience in clinical practice area, three to five years preferred. Excellent interpersonal communication and negotiation skills. Strong analytical, data management and PC skills. Working knowledge of discharge planning, utilization management, case management, performance improvement and managed care reimbursement preferred. Understanding of pre-acute and post-acute venues of care and post-acute community resources preferred. Strong organizational and time management skills. Ability to work independently and exercise sound judgment in interactions with interprofessional team, payors, and patients and their families. Demonstrate commitment to organizational values. Perform duties in a manner to promote quality patient care and customer service/satisfaction, while promoting safety, cost efficiency, and a commitment to the quality process. Additional Information With a career at any of the MaineHealth locations across Maine and New Hampshire, you’ll be working with health care professionals that truly value the people around them – both within the walls of the organization and the communities that surround it. We offer benefits that support an individual's needs for today and flexibility to plan for tomorrow – programs such as paid parental leave, a flexible work policy, student loan assistance, training and education, along with well-being resources for you and your family. MaineHealth remains focused on investing in our care team and developing an inclusive environment where you can thrive and feel supported to realize your full potential. If you’re looking to build a career in a place where people help one another deliver best-in-class care, apply today. If you have questions about this role, please contact nicole.chapman@mainehealth.org
RN Travel Utilization Review Part-time
Aya Healthcare

Travel Utilization Review RN job in Chicago, IL - Make $2,252 to $2,474/week

apartment Aya Healthcare location_onChicago, IL
Aya Healthcare has an immediate opening for the following position: Utilization Review Registered Nurse in Chicago, IL. We’ll work with you to build the healthcare career of your dreams. Whether you want a job close to home or across the country, we’ve got you. Job Details Pay: $2,252/week - $2,474/week Assignment Length: 13-week assignment Shift: 5, 8-Hour 08:00 - 16:00 At least one year of experience required Aya delivers: The most jobs in the industry. We have the largest and most reliable job database, which means the jobs you see are open, updated in real time and ready for you! Competitive advantage over other agencies. Front-of-the-line access through our direct facility relationships — many with quick (even same-day) offers, giving you the best chance of securing your ideal opportunity. Expedited licensing and streamlined compliance. An industry-leading on-time start rate and strong relationships with boards of nursing across the country to accelerate the process in all 50 states. Expert career guidance. A dedicated recruiter to help you achieve your dream career. Travel, per diem, permanent — we have the reach and access to get you the jobs you want, and the expertise to help you realize your long-term goals. A best-in-class support system and an exceptional experience. Enjoy accurate, weekly pay, and an entire team dedicated to your happiness on assignment, 24/7. Plus, you get everything you expect from the largest healthcare staffing company in the industry: Exceptional benefits, including premium medical, dental, vision and life insurance beginning day one of your assignment. Want to take time off? Keep insurance coverage for up to 24 days between assignments. A generous 401(k) match. Paid company housing (we’ll help you bring your pets along, too!) or a generous housing stipend, if eligible. Paid sick time in accordance with all applicable state, federal, and local laws. Aya’s general sick leave policy is that employees accrue one hour of paid sick leave for every 30 hours worked. However, to the extent any provisions of the statement above conflict with any applicable paid sick leave laws, the applicable paid sick leave laws are controlling. The industry’s only clinical ladder program for RNs on assignment. Access to unlimited continuing education units online. Licensure, relocation and other reimbursements, when applicable. Pay listed above includes taxable wages and tax-free expense reimbursements. Aya is an Equal Employment Opportunity ("EEO") Employer and welcomes all to apply.
RN Utilization Review Full-time
Infirmary Health

RN Utilization Review Specialist

apartment Infirmary Health location_onMobile, AL
Overview Qualifications Minimum Qualifications: Associate Degree in Nursing 2 of the most recent 4 years’ working in an acute care setting Proficient in word processing and PC based spreadsheet programs Licensure, Registration, Certification: One of the following: Current Alabama RN license Current Multi State RN License in accordance with Nurse Licensure Compact (NLC) for Alabama* *Infirmary Health abides by the NLC requirements and guidelines for the state of Alabama For specific areas CRRN (Certified Rehabilitation RN) is required (or eligibility) Desired Qualifications: BSN Some background in management, clinical education or case management Desired Licensure, Registration, Certification: National certification applicable to area of clinical practice Responsibilities Improves overall quality and completeness of clinical documentation by performing concurrent review of the medical record to ensure medical necessity and appropriateness of hospital admissions. Provides education to physicians and others to improve the capture of clinical severity for the level of service rendered. Identifies process improvement opportunities and supports the timely and accurate capture of measurements to improve patient outcomes.
RN Utilization Review Per Diem
UNC Health

RN Utilization Manager - Care Management

apartment UNC Health location_onSmithfield, NC
Description Become part of an inclusive organization with over 40,000 teammates, whose mission is to improve the health and well-being of the unique communities we serve. Summary: Works in collaboration with the patient/family, and interdisciplinary team (including physicians, other care providers, and payors), and assesses the patient care progression from acute care episode through post discharge for quality, efficiency, and effectiveness. The Utilization Manager works collaboratively with other Clinical Care Management staff to ensure patient needs are met and care delivery is coordinated across the continuum. The Utilization Manager completes admission, continued stay, and discharge reviews in accordance with federal regulations & the Hospitals? Utilization Management Plan. In addition, the Utilization Manager is responsible for revenue protection by reconciling physician orders, bed billing type, and medical necessity. This may include delivering notifications to patients directly. Interface is completed verbally, via email, data base tasks, or other electronic communication and via telephone. Responsibilities: 1. Clinical Review Process - Uses approved criteria and conducts admission review/status change review within 24 hours of patient admission to the hospital to ensure appropriateness of the setting and timely implementation of the plan of care. Identifies and obtains observation status as appropriate. Partners with physicians, nursing, and other care providers to help ensure timely and accurate documentation of patient data and treatments. Communicates daily with the Case Manager to manage level of care transitions & appropriate utilization of services. Coordinates with the support center to assure third party payor pre-certification and/or re-certifications when required. Utilizes high risk screening criteria to make appropriate referrals to Manager. 2. Discharge Facilitation - Identifies patient/families with the complex psychosocial, on-going medical discharge planning issues, continuing care needs by initiating appropriate case management referrals. Initiates appropriate social work referrals. 3. Utilization Management Process - Performs utilization management assessments and interventions, using collaboration with interdisciplinary team approach, on assigned patients as appropriate to ensure optimal patient outcomes. Using approved criteria, conducts continued stay and quality reviews to monitor the patient's progress along the continuum of care and intervenes as necessary to ensure appropriateness of setting and that the services provided are quality-driven, efficient, and effective. Enters all pertinent review data into the correct computer system in a timely manner. Consults with Physician Advisor as necessary to resolve barriers through appropriate administrative and medical channels. 4. Utilization Outcomes Management - Monitors and guides to trend interdisciplinary documentation and guides medical staff in documentation that will assist in coding accuracy, enhance quality of care, reflect accurate severity of illness and appropriate reimbursement. Facilitates patient movement to appropriate (acuity) level of care including observation status issues through collaboration with patient/family, multidisciplinary team, third party payors and resource center. Provides information regarding denials and approvals to designated entities. Assists in coordination of practice parameter development with the assigned departments/sections/specialties of Medical Staff. Oversees collection and analysis of patient care and financial data relevant to the target case types. Directs delivery of notifications to patients (includes traveling to hospital(s) to deliver notifications. Other Information Other information: Education Requirements: ● Graduation from a state-accredited school of professional nursing ● If hired after October 1, 2015, must be enrolled in an accredited program within four years of employment, and obtain a Bachelor's degree with a major in Nursing or a Master's degree with a major in Nursing within seven years of employment date. Licensure/Certification Requirements: ● Licensed to practice as a Registered Nurse in the state of North Carolina. Professional Experience Requirements: ● Two (2) years of clinical experience in a medical facility and/or comparable Utilization Management experience. Knowledge/Skills/and Abilities Requirements: Job Details Legal Employer: NCHEALTH Entity: Johnston Health Organization Unit: Care Management - Work Type: Per Diem Standard Hours Per Week: 4.00 Salary Range: $35.52 - $51.05 per hour (Hiring Range) Pay offers are determined by experience and internal equity Work Assignment Type: Onsite Work Schedule: Weekend Location of Job: US:NC:Smithfield Exempt From Overtime: Exempt: Yes This position is employed by NC Health (Rex Healthcare, Inc., d/b/a NC Health), a private, fully-owned subsidiary of UNC Heath Care System. This is not a State employed position. Qualified applicants will be considered without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, status as a protected veteran or political affiliation. UNC Health makes reasonable accommodations for applicants' and employees' religious practices and beliefs, as well as applicants and employees with disabilities. All interested applicants are invited to apply for career opportunities. Please email applicant.accommodations@unchealth.unc.edu if you need a reasonable accommodation to search and/or to apply for a career opportunity.
RN Utilization Review Full-time
Capital Health

Utilization Review RN

apartment Capital Health location_onHopewell, VA
Capital Health is the region's leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advanced technology. Capital Health is a five-time Magnet-Recognized health system for nursing excellence and is comprised of 2 hospitals. Capital Health Medical Group is made up of more than 250 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region. Capital Health recognizes that attracting the best talent is key to our strategy and success as an organization. As a result, we aim for flexibility in structuring competitive compensation offers to ensure we can attract the best candidates. The listed pay range or pay rate reflects compensation for a full-time equivalent (1.0 FTE) position. Actual compensation may differ depending on assigned hours and position status (e.g., part-time). Pay Range: $39.40 - $59.19 Scheduled Weekly Hours: 40 Position Overview Performs chart review of identified patients to identify quality, timeliness and appropriateness of patient care. Conducts admission reviews for Medicare, Medicaid beneficiaries, as well as private insurers and self pay patients, based on appropriate guidelines. Uses these criteria guidelines to screen for appropriateness for inpatient level of care or observation services based on physician certification (physicians H&P, treatment plan, potential risks and basis for expectation of a 2 midnight stay). Refers cases as appropriate, to the UR physician advisor for review and determination. Gathers clinical information to conduct continued stay utilization review activities with payers on a daily basis. Performs concurrent and retrospective clinical reviews with various payers, utilizing the appropriate guidelines as demonstrated by compliance with all applicable regulations, policies and timelines. Adheres to CMS guidelines for utilization reviews as evidenced by utilization of the relevant guidelines and appropriate referrals to the physician advisor and the UR Committee. Identifies, develops and implements strategies to reduce length of stay and resource consumption. . Confers proactively with admitting physician to provide coaching on accurate level of care determinations at point of hospital entry. Keeps current on all regulatory changes that affect delivery or reimbursement of acute care services. Uses knowledge of national and local coverage determinations to appropriately advise physicians. Understands and applies federal law regarding the use of Hospital Initiated Notice of Non-Coverage (HINN) and Lifetime Reserve Days letters. Identifies and records consistently any information on any progression of care or patient flow barriers using the Avoidable Days tool in the Utilization software program. Consults with medical staff, care team and case managers as necessary to resolve immediate progression of care barriers through appropriate administrative and medical channels. Engages care team colleagues in collaborative problem solving regarding appropriate utilization of resources. Recognizes and responds appropriately to patient safety and risk factors. Represents Utilization Management at various committees, professional organizations an physician groups as needed. Promotes the use of evidence based protocols and or order sets to influence high quality and cost effective care. Identifies, develops and implements strategies to reduce lengths of stay and resource consumption in the patient population. Participates in performance improvement activities. Promotes medical documentation that accurately reflects findings and interventions, presence of complication or comorbidities, and patient's need for continued stay. Identifies and records episodes of preventable delays or avoidable days due to failure of progression of care processes. Maintains appropriate documentation in the Utilization software system on each patient to include specific information of all resource utilization activities. Participates actively in daily huddles, patient care conferences, and hospitalist or nurse handoff reports to maintain knowledge about intensity of services and the progression of care. Identifies potentially wasteful or misused resources and recommends alternatives if appropriate by analyzing clinical protocols. Maintains related continuing education credits = 15 per calendar year. MINIMUM REQUIREMENTS Education: Minimum of Associate's degree in Nursing. Graduate of an accredited school of nursing. CPHQ, CCM or CPUR preferred. Experience: Three years of clinical nursing or two years quality management, utilization review or discharge planning experience. Other Credentials: Registered Nurse - NJ Knowledge and Skills: Three years of clinical nursing or two years quality management, utilization review or discharge planning experience. CPHQ, CCM or CPUR preferred. Special Training: Basic computer skills including the working knowledge of Microsoft Office, UR software and EMR. Possesses familiarity with MCG guidelines. Mental, Behavioral and Emotional Abilities: Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form. Usual Work Day: 8 Hours PHYSICAL DEMANDS AND WORK ENVIRONMENT Frequent physical demands include: Sitting , Standing , Walking Occasional physical demands include: Climbing (e.g., stairs or ladders) , Carry objects , Push/Pull , Twisting , Bending , Reaching forward , Reaching overhead , Keyboard use/repetitive motion , Talk or Hear Continuous physical demands include: Lifting Floor to Waist 10 lbs. Lifting Waist Level and Above 5 lbs. Sensory Requirements include: Accurate Near Vision, Accurate Far Vision, Accurate Color Discrimination, Accurate Depth Perception, Accurate Hearing Anticipated Occupational Exposure Risks Include the following: N/A This position is eligible for the following benefits: Medical Plan Prescription drug coverage & In-House Employee Pharmacy Dental Plan Vision Plan Flexible Spending Account (FSA) - Healthcare FSA - Dependent Care FSA Retirement Savings and Investment Plan Basic Group Term Life and Accidental Death & Dismemberment (AD&D) Insurance Supplemental Group Term Life & Accidental Death & Dismemberment Insurance Disability Benefits – Long Term Disability (LTD) Disability Benefits – Short Term Disability (STD) Employee Assistance Program Commuter Transit Commuter Parking Supplemental Life Insurance - Voluntary Life Spouse - Voluntary Life Employee - Voluntary Life Child Voluntary Legal Services Voluntary Accident, Critical Illness and Hospital Indemnity Insurance Voluntary Identity Theft Insurance Voluntary Pet Insurance Paid Time-Off Program The pay range listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future. When determining base salary and/or rate, several factors may be considered including, but not limited to location, years of relevant experience, education, credentials, negotiated contracts, budget, market data, and internal equity. Bonus and/or incentive eligibility are determined by role and level. The salary applies specifically to the position being advertised and does not include potential bonuses, incentive compensation, differential pay or other forms of compensation, compensation allowance, or benefits health or welfare. Actual total compensation may vary based on factors such as experience, skills, qualifications, and other relevant criteria.
RN Utilization Review Full-time
Centene

Clinical Review Nurse - Prior Authorization

apartment Centene location_onRemote, OR
$26.50 - $47.59 / 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. **Applicants for this role have the flexibility to work remotely from their home anywhere in the United States. This position does require an Oregon RN or LPN license.** 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: $26.50 - $47.59 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 Manager/Supervisor Full-time
Centene

Supervisor, Utilization Management (RN)

apartment Centene location_onMO
$73,800 - $132,700 / YEAR
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 IS REMOTE WITH POTENTIAL FOR WEEKEND, HOLIDAY AND ON-CALL*** **RN WITH COMPACT LICENSE STRONGLY PREFERRED*** Position Purpose: Supervises Prior Authorization, Concurrent Review, and/or Retrospective Review Clinical Review team to ensure appropriate care to members. Supervises day-to-day activities of utilization management team. Monitors and tracks UM resources to ensure adherence to performance, compliance, quality, and efficiency standards Collaborates with utilization management team to resolve complex care member issues Maintains knowledge of regulations, accreditation standards, and industry best practices related to utilization management Works with utilization management team and senior management to identify opportunities for process and quality improvements within utilization management Educates and provides resources for utilization management team on key initiatives and to facilitate on-going communication between utilization management team, members, and providers Monitors prior authorization, concurrent review, and/or retrospective clinical review nurses and ensures compliance with applicable guidelines, policies, and procedures Works with the senior management to develop and implement UM policies, procedures, and guidelines that ensure appropriate and effective utilization of healthcare services Evaluates utilization management team performance and provides feedback regarding performance, goals, and career milestones Provides coaching and guidance to utilization management team to ensure adherence to quality and performance standards Assists with onboarding, hiring, and training utilization management team members Leads and champions change within scope of responsibility Performs other duties as assigned Complies with all policies and standards Education/Experience: Requires Graduate of an Accredited School Nursing or Bachelor's degree and 4+ years of related experience. Knowledge of utilization management principles preferred. License/Certification: RN - Registered Nurse - State Licensure and/or Compact State Licensure required Pay Range: $73,800.00 - $132,700.00 per year 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 Manager/Supervisor Full-time
Centene

Supervisor, Utilization Management (RN)

apartment Centene location_onIN
$73,800 - $132,700 / YEAR
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 IS REMOTE*** Position Purpose: Supervises Prior Authorization, Concurrent Review, and/or Retrospective Review Clinical Review team to ensure appropriate care to members. Supervises day-to-day activities of utilization management team. Monitors and tracks UM resources to ensure adherence to performance, compliance, quality, and efficiency standards Collaborates with utilization management team to resolve complex care member issues Maintains knowledge of regulations, accreditation standards, and industry best practices related to utilization management Works with utilization management team and senior management to identify opportunities for process and quality improvements within utilization management Educates and provides resources for utilization management team on key initiatives and to facilitate on-going communication between utilization management team, members, and providers Monitors prior authorization, concurrent review, and/or retrospective clinical review nurses and ensures compliance with applicable guidelines, policies, and procedures Works with the senior management to develop and implement UM policies, procedures, and guidelines that ensure appropriate and effective utilization of healthcare services Evaluates utilization management team performance and provides feedback regarding performance, goals, and career milestones Provides coaching and guidance to utilization management team to ensure adherence to quality and performance standards Assists with onboarding, hiring, and training utilization management team members Leads and champions change within scope of responsibility Performs other duties as assigned Complies with all policies and standards Education/Experience: Requires Graduate of an Accredited School Nursing or Bachelor's degree and 4+ years of related experience. Knowledge of utilization management principles preferred. License/Certification: RN - Registered Nurse - State Licensure and/or Compact State Licensure required Pay Range: $73,800.00 - $132,700.00 per year 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
Oceans Healthcare

Utilization Review Coordinator RN

apartment Oceans Healthcare location_onBiloxi, MS
The Utilization Review Coordinator RN is responsible for management of all utilization review and case management activities for the facility’s inpatient, partial hospitalization, and outpatient programs. Conducts concurrent reviews of all medical records to ensure criteria for admission and continued stay are met and documented, and to ensure timely discharge planning. Coordinates information between third party payers and medical/clinical staff members. Interacts with members of the medical/clinical team to provide a flow of communication and a medical record which documents and supports level and intensity of service rendered. All duties to be done in accordance with Joint Commission, Federal and State regulations, Oceans' Mission, policies and procedures and Performance Improvement Standards. Essential Functions: Identifies and reports appropriate use, under-use, over-use and inefficient use of services and resources to ensure high quality patient care is provided in the least restrictive environment and in a cost-effective manner. Conducts review of all inpatient, partial hospitalization, and outpatient records as outlined in the Utilization Review/Case Management plan to (1) determine appropriateness and clinical necessity of admissions, continued stay, and or rehabilitation, and discharge; (2) determine timeliness of assessments and evaluations; i.e. H&Ps, psychiatric evaluation, CIA formulation, and discharge summaries; and (3) identify any under-, over-, and/or inefficient use of services or resources. Reports findings to appropriate disciplines and/or committees; notifies appropriate staff members of any deficiencies noted so corrective actions can be taken in a timely manner; submits monthly report to PI Coordinator of findings and actions recommended to correct identified problems. Coordinates flow of communication between physicians/staff and third party payers concerning reimbursement requisites Attends mini-treatment team and morning status meetings each weekday to obtain third-party payer pre-certification and ongoing certification requirements and to share with those attending any pertinent data from third-party payer contracts. Attends weekly treatment team. Conducts telephone reviews to, and follows through with documentation requests from third party payers. Maintains abstract with updates provided to third party payers. Notifies physicians/staff/patients of reimbursement issues. Initiates and completes appeals process for reimbursement denials; notifies inpatients of denials received. Reports monthly all Hospital Issued Notices of Non-coverage (HINN letter) to QIO. Conducts special retrospective studies/audits when need is determined by M&PS and /or other committee structure. Ensures all authorization and denied information is in HCS at the end of each business day. Performs other duties and projects as assigned.
RN Utilization Review Part-time
Children's Hospital Colorado

Utilization Review Registered Nurse

apartment Children's Hospital Colorado location_onAurora, CO
$84,558.69 - $126,838.03 / YEAR
Summary Job Overview The Utilization Review RN participates as a member of a multidisciplinary team to support medical necessity reviews, ensure compliance, and actively participate in denial mitigation. It is a collaborative approach that uses pre-established guidelines and criteria to perform review activities to ensure the proper utilization of hospital services and payment of those services by Medicare, Medicaid, and other third-party payors. Department Name: Utilization Review Job Status: part time, 24 hours per week, eligible for benefits Shift: Shifts are 8-hour days Friday, Saturday, and Sunday. Start and end times will vary depending on the department needs. This position will be primarily remote but there may be occasions when you are expected to work onsite at one of the CHCO locations. The specific details will be discussed in the interview process, and subject to change at our discretion. This position is eligible for relocation assistance, if relocating from 100 miles or greater. Duties & Responsibilities An employee in this position may be called upon to do any or all the following essential functions. These examples do not include all the functions which the employee may be expected to perform. Assesses all new inpatient admissions for identification of status and medical necessity for admission; communicates clinical review process with appropriate Payors. Assesses the continuity of care in conjunction with the Case Managers regarding the continued medical necessity of hospitalization and the status of the discharge plan; communicates this to the appropriate payors. Coordinates with other members of the healthcare team to help identify and control inappropriate resource utilization. Conducts concurrent admission and continued stay reviews based on appropriate utilization review criteria. Utilizes information provided by Patient Access regarding authorized length of stay and follows up with third-party payors on an ongoing basis, documents communications regarding continued authorizations. Follows up on denials communicated to the department and works with the revenue cycle staff to assist with appeals. Maintains and demonstrates appropriate clinical knowledge to assist physicians in providing documentation of severity of illness and intensity of service to assure that criteria for acute hospitalization are met. Employees are expected to comply with all regulatory requirements, including CMS and Joint Commission Standards. Minimum Qualifications Education: Bachelor of Science in Nursing (BSN) Experience: Three years of recent clinical or case management experience that includes recent UR experience in a hospital or with a Third-Party Payor Licensure(s): Registered Nurse License Salary Information Pay is dependent on applicant's relevant experience. Annual Salary Range (Based on 40 hours worked per week): $84,558.69 to $126,838.03 Benefits Information Here, you matter. As a Children’s Hospital Colorado team member, you will receive a competitive pay and benefits package designed to take care of your needs that includes base pay, incentives, paid time off, medical/dental/vision insurance, company provided life and disability insurance, paid parental leave, 403b employer match (retirement savings), a robust wellness program, and access to professional development tools, including an education benefit to help you advance your career. As part of our Total Rewards package, Children's Colorado offers an annual employee bonus program that rewards eligible team members based on organizational performance. If organizational goals are met for the year, the bonus is paid out the following April. Children’s Colorado delivers annual base pay increases to eligible team members based on their performance over the previous year. EEO Statement It is our intention that all qualified applicants be given equal opportunity and that selection decisions be based on job-related factors. We do not discriminate on the basis of race, color, religion, national origin, sex, age, disability, or any other status protected by law or regulation. Be aware that none of the questions are intended to imply illegal preferences or discrimination based on non-job-related information. The position is expected to stay open until the posted close date. Please submit your application as soon as possible as the posting is subject to close at any time once a sufficient pool of qualified applicants is obtained. Colorado Residents: In any materials you submit, you may redact or remove age-identifying information such as age, date of birth, or dates of attendance at or graduation from an educational institution. You will not be penalized for redacting or removing this information.
RN Utilization Review Full-time
McLaren Health Care

Utilization Management Registered Nurse, Michigan

apartment McLaren Health Care location_onFlint, MI
McLaren Health Plan (MHP) is a company with a culture of high performance and a mission to help people live healthier and more satisfying lives. We are looking for a Utilization Management RN, to join in leading the organization forward. MHP is a Managed Care Organization dedicated to meeting the health care needs of each member. MHP offers multiple product lines, including individual and family plans, and Medicaid and Medicare plans to Michigan residents for every stage of life. McLaren Health Plan is accredited by the National Committee for Quality Assurance (NCQA). MHP values the talents and abilities of all our employees and seeks to foster an open, cooperative and dynamic environment in which employees and the health plan can thrive. As an employee of MHP, you will be a part of a dynamic organization that considers all our employees as leaders in driving the organization forward and delivering quality service to all our members. Position Summary: This position is responsible for utilization management functions.This includes but is not limited toreviewandauthorizationofservices, utilization of medical policy, utilization of standard screening techniques, and utilization of behavioral change techniques.Works with the PCP, the member and managementtopromotethedeliveryofqualityservicesatthemostappropriateand cost-effectivesetting. Performs as the member advocate with emphasis on education regarding managed care, disease management and PCP treatment plans. Monitors member’s utilization patterns for identification of high risk, and under and overuse of services. Collaborates with Medical Director and senior management on complex cases and special projects. Qualifications: Required : RN with a valid unrestrictive license from state employed in state providing services. Two (2) years clinical nursing experience. One (1) year previous experience in Managed Care Utilization Management, Medical Management, Case Management. Preferred: Two (2) years’ experience and knowledge of HMO, PPO, TPA, PHO and Managed Care functions including understanding of claims administration, including CPT-4 codes, revenue codes, HCPCS codes, DRGs, etc. Two (2) years’ experience in Managed Care Utilization Management, Medical Management, Case Management. BSN. Certified Case Manager (CCM) Certification. Additional Information Schedule: Full-time Requisition ID: 25007303 Daily Work Times: 8:30 am - 5:00 pm Hours Per Pay Period: 80 On Call: No Weekends: No
RN Utilization Review Full-time
L.A. Care Health Plan

Utilization Management Nurse Specialist RN II

apartment L.A. Care Health Plan location_onLos Angeles, CA
Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job Summary The Utilization Management Nurse Specialist RN II facilitates, coordinates, and approves medically necessary referrals that meet established criteria. Assures timely and accurate determination and notification of referrals and reconsiderations based on the referral determination status. Generates approval, modification and denial communications, to include member and provider notification of referral determination. Actively monitors for admissions in any inpatient setting. Performs telephonic and/or onsite admission and concurrent review, and collaborates with onsite staff, physicians, providers, member/family interaction to develop and implement a successful discharge plan. Works with the UM Manager and Physician Advisor on case reviews for pre-service, concurrent, post-service and retrospective claims medical review. Monitors and oversees the collection and transfer of data (medical records) and referral requests by Providers. Acts as a department resource for medical service requests /referral management and processes. Receives incoming calls from providers, professionally handles complex calls, researches to identify timely and accurate resolution steps. Follows up with caller to provide response or resolution steps. Answers all inquiries in a professional and courteous manner. Duties Promote and support team engagements, programs and activities to create and ensure a positive and productive workplace environment. Perform telephonic and/or onsite admission and concurrent review, and collaborates with onsite staff, physicians, providers, the member and significant others to develop and implement a successful discharge plan. Process, finalize and facilitate inbound requests that are received from providers. Generate appropriate member and provider communication for all determinations within the required timelines as defined by the most current department policy. Facilitate/review requests for Higher level of care or skilled nursing/discharge planning needs. Research for appropriate facilities, specialty providers and ancillary providers to utilize for all lines of business. Identification of potential areas of improvement within the provider network. Identify and initiate referrals for appropriate members to the various L.A. Care programs/processes and external community based programs or Linked and Carve Out Services (e.g. DDS/CCS/MH). Potential quality of care/potential fraud issues are identified and documented per L.A. Care policy. High risk/high cost cases and reports are maintained and referred to the Physician Advisor/UM Director. Document in platform/system of record. Utilize designated software system to document reviews and/or notes. Receive incoming calls from providers, professionally handle complex calls, research to identify timely and accurate resolution steps. Follow up with caller to provide response or resolution steps. Answer all inquiries in a professional and courteous manner. Perform other duties as assigned. Duties Continued Education Required Associate's Degree in Nursing Education Preferred Bachelor's Degree in Nursing Experience Required: At least 5 years of varied RN clinical experience in an acute hospital setting. At least 2 years of Utilization Management/Case Management experience in a hospital or HMO setting . Preferred: Managed Care experience performing UM and CM at a medical group or management services organization. Experience with Managed Medi-Cal, Medicare, and commercial lines of business. Skills Required: Must be computer literate, with expertise in Outlook, Word, Excel, PowerPoint. Effectively utilizes computer and appropriate software and interacts as needed with L.A. Care Information System. Knowledge of personal computer, keyboarding, and appropriate software to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment. Prepare clear, comprehensive written and oral reports and materials. Provision of excellent customer service required due to frequent communication with providers and other members of the interdisciplinary team Excellent time management and priority-setting skills. Maintains strict member confidentiality and complies with all HIPAA requirements. Strong verbal and written communication skills. Preferred: Knowledge of National Committee for Quality Assurance (NCQA) requirements for Utilization Management or Care Management (CM). Knowledge of Department of Health Care Services (DHCS) or Centers for Medicare and Medicaid Services(CMS) requirements for health plan compliance with UM or CM. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California License Licenses/Certifications Preferred Certified Case Manager (CCM) Required Training Physical Requirements Light Additional Information May work on occasional weekends and some holidays depending on business needs. Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. L.A. Care offers a wide range of benefits including Paid Time Off (PTO) Tuition Reimbursement Retirement Plans Medical, Dental and Vision Wellness Program Volunteer Time Off (VTO)
RN Utilization Review Full-time
Centene

Utilization Review Clinician - ABA

apartment Centene location_onTX
$26.50 - $47.59 / 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. 2 POSITIONS AVAILABLE. THESE POSITIONS ARE REMOTE/WORK FROM HOME SUPPORTING CHILDREN AND ADOLECENTS ABA BEHAVIORAL HEALTH. ABA EXPERIENCE REQUIRED. BCBA STRONGLY PREFERRED. ACTIVE CURRENT STATE LICENSURE IS REQUIRED. WORK SCHEDULE IS MONDAY - FRIDAY 8AM - 5PM EITHER CENTRAL TIME ZONE OR EASTERN TIME ZONE AND VOLUNTARY HOLIDAYS WILL BE PART OF THE WORK SCHEDULE. Position Purpose: Performs reviews of member's care and health status of Applied Behavioral Analysis (ABA) services provided to determine medical appropriateness. Monitors clinical effectiveness and efficiency of member's care in accordance with ABA guidelines. Evaluates member’s care and health status before, during, and after provision of Applied Behavioral Analysis (ABA) services to ensure level of care and services are medically appropriate related to behavioral health (BH) and/or autism spectrum disorder needs and clinical standards Performs prior authorization reviews related to BH to determine medical appropriateness in accordance with ABA regulatory guidelines and criteria Analyzes BH member data to improve quality and appropriate utilization of services Interacts with BH healthcare providers as appropriate to discuss level of care and/or services provided to members receiving Applied Behavior Analysis Services Provides education to members and their families regrading ABA and BH utilization process Provides feedback to leadership on opportunities to improve care services through process improvement and the development of new processes and/or policies Performs other duties as assigned. Complies with all policies and standards. Education/Experience: Requires Graduate of an Accredited School of Nursing or Bachelor's degree and 2-4 years of related experience. For Enterprise Population Health 2+ years providing ABA services as a BCBA License to practice independently, and/or have obtained the state required licensure as outlined by the applicable state (BCBA) required. Master’s degree for behavioral health clinicians required. Behavioral health clinical knowledge and ability to review and/or assess ABA Treatment Plans required. Knowledge of ABA services and BH utilization review process required. Experience working with providers and healthcare teams to review care services related to Applied Behavior Analysis Services preferred. License/Certification: LCSW- License Clinical Social Worker required or LMHC-Licensed Mental Health Counselor required or LPC-Licensed Professional Counselor required or Licensed Marital and Family Therapist (LMFT) required or Licensed Mental Health Professional (LMHP) required or Board Certified Behavior Analyst (BCBA) required RN - Registered Nurse - State Licensure and/or Compact State Licensure RN - Registered Nurse- State Licensure and/or Compact State Licensure with BCBA required or Independent licensure with ABA experience and BCBA preferred. preferred Licensed Behavior Analyst (LBA) where required by state required Pay Range: $26.50 - $47.59 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 Part-time
Baystate Health

RN, Hospital Case Manager/Utilization Management

apartment Baystate Health location_onSpringfield, MA
Note: The compensation range(s) in the table below represent the base salaries for all positions at a given grade across the health system. Typically, a new hire can expect a starting salary somewhere in the lower part of the range. Actual salaries may vary by position and will be determined based on the candidate's relevant experience. No employee will be paid below the minimum of the range. Pay ranges are listed as hourly for non-exempt employees and based on assumed full time commitment for exempt employees. Minimum - Midpoint - Maximum $46.22 - $53.13 - $62.85 Per Diem Hospital Case Manager / Utilization Management The RN Hospital Case Manager is a registered nurse responsible for the coordination of clinical care, quality, and financial outcomes of a designated population of patients. The Hospital Case Manager is responsible for overseeing an efficient plan that will ensure continuity and effective community or post acute reentry. The Hospital Case Manager leads the interdisciplinary team in developing complex discharge plans. Responsibilities: Facilitates patients care plan as called for in the plan of care Leads daily patient care huddles with nursing to direct timely progress along the continuum Works cooperatively as a leading member of the health care team to insure appropriate use of hospital resources, patient satisfaction, and achievement of quality of care. Manages input from all health care professionals and conducts assessments to determine patients health care and transitional needs. Evaluates and ensures appropriateness of admissions and continued stay using evidence based criteria Collaborates and manages outcomes with the payers through ongoing written and verbal communications to appropriate parties Leads discussions with Physician advisors and MD's about safe plan for transitions Leads the team to ensure appropriate utilization of patient resources and directs care to other settings when appropriate Collaborates with community case managers and other health care advisors to ensure a smooth and safe continuum of care plan Conducts extensive assessments and implements interventions for patients at risk for readmissions Manages concurrent denials and works with physicians to overturn for appropriate reimbursement Required Work Experience: BSN Strongly preferred 3-5 years clinical Nursing experience Hospital Case Management, Care Coordination experience strongly preferred Skills and Competencies: Requires a working knowledge of community resources and Utilization/Quality Review standards and activities conducted by third party payers Ability to organize and prioritize workload in order to meet deadlines Must possess excellent interpersonal skills in order to interact with all levels of health care providers, support staff, and third party payers where appropriate Excellent computer skills Must possess excellent interpersonal skills in order to interact with all levels of health care providers, support staff, and third party payers where appropriate Schedule & Location Per Diem Rotating weekends = to approx. 6 weekends a year Rotating holiday = 1 holiday year Baystate Medical Center 759 Chestnut Street Springfield, MA We strive to be the place where we can help you build the career you deserve – apply today – YOU belong at Baystate! Our compensation philosophy We offer competitive total compensation that includes pay, benefits, and other recognition programs for our employees. The base pay range shown above considers the wide range of factors that are considered in making compensation decisions including knowledge/skills; relevant experience and training; education/certifications/licensure; and other business and organizational factors. This base pay range does not include our comprehensive benefits package and any incentive payments that may be applicable to this role. Baystate Health is an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, marital status, national origin, ancestry, age, genetic information, disability, or protected veteran status.
RN Utilization Review Full-time
State of Ohio

Nurse Case Manager - Internal (Medical Review Nurse - PN 20014026)

apartment State of Ohio location_onColumbus, OH
$34.96 / HOUR
What You'll Do Are you a compassionate and detail-oriented nurse looking to make meaningful impact in the lives of children with special care needs? This role offers a dynamic blend of clinical decision-making, case management, community engagement, and administrative support—ideal for nurses who thrive in both independent and collaborative environments. Duties Include: Clinical And Case Management Independently assess medical applications and determine eligibility for CMH services. Authorize or deny diagnostic, treatment, and service coordination based on medical data and program guidelines. Interpret medical plans for treatment and develop appropriate care strategies. Monitor ongoing service needs and effectiveness, ensuring compliance with HIPAA and CMH policies. Coordinate complex treatment plants with other state and federal programs. Evaluate diagnoses and determine appropriate services, including medical equipment, orthotics, prosthetics, and orthodontia. Manage case data and service authorizations. Community Engagement & Education Maintain contact with families, providers, and community partners through phone, written communication and site visits across Ohio. Provide technical assistance and orientation to providers on CMH policies, procedures and billing. Plan and participate in educational workshops, seminars, and nursing care conferences. Resolve service delivery issues and respond to sensitive inquiries professionally and confidentially. Collaborate with nurse case managers and other stakeholders to ensure timely and effective case processing Administrative And Liaison Support Maintain accurate and confidential client records in accordance with national, state and CMH guidelines. Perform administrative tasks such as answering phone, managing documents and operating office equipment. Serve as a liaison to government agencies, private sector partners and other state programs UNUSUAL WORKING CONDITIONS: May require travel Position Qualifications Current and valid license to practice professional nursing as Registered Nurse (i.e., R.N.) in Ohio as issued by Board of Nursing pursuant to Section 4723.03 of Revised Code and all of the following bulleted criteria: 24 mos. exp. in pediatric nursing, which included care of children with special health care needs (i.e., CSHCN) &/or case management of children with multiple health care needs completion of undergraduate core program in nursing to include 1 course in community health nursing or public health nursing & 1 course in research methodologies or equivalent. 1 course or 3 mos. exp. in operation of personal computer. Or Current and valid license to practice professional nursing as Registered Nurse (i.e., R.N.) in Ohio as issued by Board of Nursing pursuant to Section 4723.03 of Revised Code and all of the following bulleted criteria: 24 mos. exp. in pediatric nursing, which included care of children with special health care needs (i.e., CSHCN) &/or case management of children with multiple health care needs. 24 mos. exp. in nursing, which included 3 mos. trg. or 3 mos. exp, in community health or public health nursing & 3 mos. trg. or 3 mos. exp. in data collection & analysis. 1 course or 3 mos. exp. in operation of personal computer. Or Equivalent of Minimum Class Qualifications for Employment noted above may be substituted for the experience required, but not for the mandated licensure. Additional Qualifications Applications of those who meet the minimum qualifications will be further evaluated against the following criteria: Graduate or advanced degree in nursing Experience in pediatric nursing and case management of children/ young adults with special health care needs Experience providing technical assistance/consultation services to a local health department or other provider of child /young adults health services (e.g., hospitals, pediatric clinics, physician's offices, other health care related professionals) Experience in public/community and/or home health nursing Experience reviewing and authorizing medical plans of treatment/requests for services (e.g., may include durable medical equipment/orthotics/prosthetics/orthodontic services/therapies) Certified Nurse Case Manager/ Discharge Planner or Certified Pediatric Nurse Experience in analyzing health related data to prepare reports (e.g., quality assurance/technical reports, medical reports) Experience providing education or training to various groups (e.g., medical groups, nursing staff, parents, young adults) Experience with computer software (e.g., Microsoft Office: Word, PowerPoint) All eligible applications shall be reviewed considering the following criteria: qualifications, experience, education, active disciplinary record, and work record Job Skills: Nursing Technical Skills: Health Administration, Medical Records, Nursing, Public Health, Public Relations Professional Skills: Analyzations, Attention to Detail, Collaboration, Consultation, Verbal Communication, Written Communications Educational Transcript Requirements Official educational transcripts are required for all post-high school educational accomplishments, coursework or degrees claimed on the application. Applicants will be required to submit an official transcript prior to receiving a formal offer of employment. Failure to provide transcripts within five (5) working days of being requested will cause the applicant to be eliminated from further consideration. Please note that a transcript is considered "official" only if it is an original copy from the educational institution and includes an institutional watermark, ink stamp or embossed stamp. Transcripts printed from the institution's website will not be accepted. ODH reserves the right to assess the academic credibility of an educational entity's award of a putative degree. Organization Health Agency Contact Name and Information Gayla. A will contact you if selected for interview. Unposting Date Dec 22, 2025, 11:59:00 PM Work Location Health Department Building Primary Location United States of America-OHIO-Franklin County-Columbus Compensation $34.96 Schedule Full-time Work Hours Monday - Friday; 8am - 5pm Classified Indicator Classified Union 1199 Primary Job Skill Nursing Technical Skills Health Administration, Nursing, Public Health, Public Relations, Medical records Professional Skills Analyzation, Attention to Detail, Collaboration, Consultation, Verbal Communication, Written Communication Agency Overview Nurse Case Manager- Internal (Medical Review Nurse) About Us Our mission at the Ohio Department of Health (ODH) is advancing the health and well-being of all Ohioans. Our agency is committed to building a modern, vibrant public health system that creates the conditions where all Ohioans flourish. The Bureau of Maternal, Child, and Family Health (BMCFH)/ Complex Medical Help (CMH) is organized to support families by improving birth outcomes and the health status of women, infants, children, and youth, including children and youth with complex health care needs. Using data and proven practice, the bureau’s programs support the delivery of direct services, linkages and referrals, population-based supports, program evaluation, education, monitoring and quality oversight, and policy and systems development.
RN Utilization Review Full-time
Catholic Health System

Registered Nurse Utilization Review KMH

apartment Catholic Health System location_onKenmore, NY
Salary: 74,431.50-111,637.50 USD Facility: Kenmore Mercy Hospital Shift: Shift 1 Status: Full Time FTE: 1.000000 Bargaining Unit: ACE Associates Exempt from Overtime: Exempt: Yes Work Schedule: Days with Weekend and Holiday Rotation Hours: 8 am- 4 pm Summary: The Registered Nurse (RN), Utilization Review, as an active member of the Middle Revenue Cycle and interdisciplinary care team, provides comprehensive Utilization Review to patients and families in the hospital setting. Utilizing foundational nursing clinical skills Utilization Review nurse collaborates with the interdisciplinary team to maintain appropriate levels of care and to facilitate movement of the patient through the continuum. The Utilization Review RN identifies and removes barriers for delays of treatment. This individual also works to maintain third-party payer relationships related to Utilization Review Activities. This includes, but is not limited to, concurrent review, responding to inquiries, complaints, and other correspondence, and may include setting up discussions between parties. Knowledge of state and federal laws relating to contracts and utilization review process processes is vital. Responsibilities: EDUCATION BSN degree or RN with a BS in health-related field and working knowledge/experience in documentation utilization review in an acute care/inpatient setting Unrestricted NYS RN license Holds, or will obtain within one year of hire, Certified Case Manager (CCM) Certification in a Nationally Recognized Utilization Review Criteria set is preferred At least 1 year of experience in working with third party payers strongly preferred EXPERIENCE Minimum of three (3) years of experience working in an Acute Care Hospital Setting Proficiency in utilization management and regulatory requirements preferred Experience in working with people who are geographically dispersed preferred Experience in working with third party payers strongly preferred KNOWLEDGE, SKILL AND ABILITY Strong clinical assessment skills and ability to articulate findings in a fast-paced environment. Possess the ability to make independent decisions within the professional scope of practice Possess ability to educate, inform, advocate, promote and facilitate health care options, and demonstrate the willingness to work harmoniously with a team approach Possesses ability to effectively and efficiently utilize technology within daily work with the care team and ability to quickly learn and adapt to new technology tools and software Extensive knowledge of third-party payer guidelines, accreditation and regulatory requirements preferred Knowledge of Managed Care Organization contracts/agreements preferred WORKING CONDITIONS: Willingness to work beyond normal working hours, and in other positions temporarily, and/or at other locations when necessary Variable schedule which may include weekends and holidays. May be requested to travel to multiple hospital and community sites ENVIRONMENT Normal heat, light space, and safe working environment; typical of most office jobs Occasional exposure to one or more mildly unpleasant physical conditions Minimum physical effort required, typical of most office work Significant amount of walking within the acute care facility
RN Utilization Review Part-time
CentraState Healthcare System

Utilization Review Nurse - (RN) - Part Time - Benefit Eligible - Days

apartment CentraState Healthcare System location_onFreehold, NJ
Overview CentraState Healthcare System, headquartered in Freehold, New Jersey, is a leading nonprofit healthcare provider dedicated to serving the community. Its comprehensive network includes CentraState Medical Center, a community-focused hospital, along with an ambulatory campus, two senior living facilities, three free-standing community health pavilions, and a charitable foundation. As the third-largest employer in Monmouth County, CentraState has earned repeated recognition as a Great Place to Work-Certified™ company, reinforcing its reputation as an exceptional workplace. CentraState Medical Center has an employment opportunity available for a Utilization Review Nurse . The Utilization Review RN (UR RN) applies professional nursing judgment and critical thinking skills to assess patients for appropriate levels of care and to mitigate potential denials. This role requires a strong knowledge of evidence-based clinical criteria and federal and state utilization management requirements. The UR RN identifies key clinical information to support hospital admissions and continued stays, collaborates with the care management team to optimize resource utilization, and secures payer approvals. The UR RN also reviews escalated cases that do not meet medical necessity prior to initiating secondary review. Responsibilities Responsibilities include, but are not limited to: Provides timely and thorough clinical information to insurance companies and other intermediaries to secure payer authorizations and avoid denials or reduction in level of care. Performs daily surveillance of observation cases and works with APNs and PA discussing any barriers to progression of care or discharge. Intervenes proactively to avoid denials or delays in authorization. Actively communicates information to other CM team members and interdisciplinary teams regarding progress or payer issues related to continued hospitalization and post-acute service associated with the patients discharge plan. Refers cases and issues to Physician Advisors or Designees in compliance with department procedures with timely follow up as indicated. Assists in identification and collection of avoidable days and management of the expected discharge date. Coordinates with the CM RN and/or CMA to identify and complete the process for CMS required patient notices. Completes and documents utilization reviews, physician advisor referrals and other communications related to assigned cases in accordance with department policy and procedure. Complies with the Condition of Code 44 process, CMS required patient notices and other regulatory requirements within the utilization management process. Maintains proficiency in the application of organization selected clinical review criteria sets evidenced through IRR testing Assists in facilitating and coordinating clinical progression of assigned patients Other duties as assigned by management Qualifications BSN or Bachelor’s Degree in related field or current enrollment in BSN or related Bachelor’s Degree program required. Prior clinical experience in care and management of hospitalized patients. Experience in acute care case management, preferred. Utilization review or case management training from a professional Case Management organization, preferred. RN license required/NJ. Case Management certification preferred. Excellent communication, negotiation, and conflict resolution skills Data and computer skills Knowledge of relevant and state utilization review and appeals requirements Rapid cycle change or clinical performance improvement expertise About Us CentraState Healthcare System, in partnership with Atlantic Health System, is a fully accredited, not-for-profit, community-based health system dedicated to providing comprehensive health services in central New Jersey. Beyond offering a wide range of advanced diagnostic and treatment options, CentraState is committed to being a valuable health partner, focusing on disease prevention, promoting healthy behaviors, and helping individuals of all ages live well. Located in Freehold, CentraState includes a 284-bed acute-care hospital, a dynamic health and wellness campus, two award-winning senior living communities, a charitable foundation, and convenient satellite health pavilions. These pavilions offer primary care, specialty physician practices, and access to outpatient services such as lab work and physical therapy. CentraState is proud to be among the less than two percent of hospitals nationwide to earn Magnet® designation for nursing excellence five times. Additionally, it has been recognized as a Great Place to Work-Certified™ Company by Great Place to Work® for four consecutive years. Joining CentraState means becoming part of a pioneering healthcare facility committed to high-quality, patient-focused care. We invite you to make a difference in our community and advance your career with us. We support our employees with work/life balance initiatives, tuition assistance, career advancement opportunities, and more. Discover why our employees love their jobs and being part of the CentraState family! CentraState Health System offers a competitive and comprehensive Total Rewards package that supports the health, financial security, and well-being of all team members. What We Offer: Medical, Dental, Vision, Prescription Coverage (30 hours per week or above for full-time and part-time team members) Life & AD&D Insurance Long-Term Disability (with options to supplement) 403(b) Retirement Plan with employer match 401(a) Retirement Plan with employer contribution PTO Tuition Reimbursement Well-Being Rewards Employee Assistance Program (EAP) Fertility Coverage, Healthy Pregnancy Program Flexible Spending & Commuter Accounts Pet, Home & Auto, Identity Theft and Legal Insurance Growth Opportunity and Workforce Development Initiatives Continuing Education / Onsite Training A warm, welcoming company culture based upon mutual respect and a collaborative goal of providing excellent patient care Concierge Services with Work & Family Benefits Magnet recognized healthcare facility Compensation Range: $93,600 - $159,120 annually The compensation above reflects the established range from CentraState Healthcare System (CSHS) for this position at the time the job was posted. CSHS considers many factors to determine compensation, including education, experience, skills, licenses, certification, and training. As such, team member compensation may fall outside this range. Additionally, the compensation range reflects base salary and does not include extra shift rates or incentives tied to quality, productivity, etc., as applicable. The benefits outlined also reflect CSHS’ policy at the time of posting. Benefits as are made available to other similarly situated team members of CSHS, although participation is at all times in accordance with and subject to the eligibility and other provisions of such plans and programs. CSHS may modify its benefits plans or programs at any time. CSHS is proud to comply with all pay equity and pay transparency laws.
RN Utilization Review Full-time
Centene

Clinical Review Nurse - Concurrent Review

apartment Centene location_onLos Angeles, CA
$26.50 - $47.59 / 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 position is a M-F 8am to 5pm serving our LA Medicaid inpatient adult and pediatric members. Position Purpose: Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member. Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines Reviews member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities Collaborates with care management on referral of members as appropriate Performs other duties as assigned Complies with all policies and standards Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience. 2+ years of acute care experience required. Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. License/Certification: LPN - Licensed Practical Nurse - State Licensure required For Health Net of California: RN license required Pay Range: $26.50 - $47.59 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
ECU Health

Quality Nurse Specialist II - Peer Review

apartment ECU Health location_onGreenville, NC
Position Summary The Peer Review QNS works closely with medical staff leaders to organize and conduct all Professional Practice Evaluation (PPE) activities, which include Focused Professional Practice Evaluation (FPPE) for initial and additional privileges, Peer Review of clinical activity, professionalism and behavior, and Ongoing Professional Practice Evaluation (OPPE). Responsibilities Synthesize information from relevant resources to demonstrate current practice and identify opportunities for improvement. Identify sources of valid and reliable information and metrics to monitor performance trends. Analyze information from disparate sources. Analyze comparative data, benchmarks, and evidence-based practices for possible adaptation into the organization. Use valid and reliable data to support opportunity recommendations and illuminate key trends for stakeholders. Demonstrate expertise in the use of analytical and statistical tools and techniques including understanding of how process goals are established, measured and monitored; apply techniques and tools to identify variation and its causes; analyze input variable to identify critical factors that must be addressed to achieve optimal process performance. Communicate improvement priorities and results using narrative and visual tools by create graphs and charts that accurately reflect valid interpretation of findings; develop dashboards and scorecards to depict internal metrics and benchmark comparisons; create written and verbal communication to tell a story appropriate to the audience. Design and develop project plans including providing project coordination using project management tools, measurement plans, estimates costs to determine budget, incorporates evidence-based guidelines. Uses change management principles. Communicates project progress to all stakeholders through the project. Promote a safety culture and infrastructure by engaging stakeholders to understand all perspectives when addressing patient safety issues; model behaviors that promotes a safety culture; educate staff; support adoption of high reliability principles; design sustainable actions to improve patient safety. Minimum Requirements Bachelor's degree in applicable field or higher is required. Active RN license 3 years or more experience in healthcare field Certification in specialty preferred within 3 years and maintained thereafter. ECU Health About ECU Health Medical Center ECU Health Medical Center, one of four academic medical centers in North Carolina, is the 974-bed flagship hospital for ECU Health and serves as the primary teaching hospital for The Brody School of Medicine at East Carolina University. ECU Health Medical Center has achieved Magnet® designation twice and provides acute and intermediate care, rehabilitation and outpatient health services to a 29-county region that is home to more than 1.4 million people. General Statement It is the goal of ECU Health and its entities to employ the most qualified individual who best matches the requirements for the vacant position. Offers of employment are subject to successful completion of all pre-employment screenings, which may include an occupational health screening, criminal record check, education, reference, and licensure verification. We value diversity and are proud to be an equal opportunity employer. Decisions of employment are made based on business needs, job requirements and applicant’s qualifications without regard to race, color, religion, gender, national origin, disability status, protected veteran status, genetic information and testing, family and medical leave, sexual orientation, gender identity or expression or any other status protected by law. We prohibit retaliation against individuals who bring forth any complaint, orally or in writing, to the employer, or against any individuals who assist or participate in the investigation of any complaint.
RN Utilization Review Pediatric Full-time
Children's Healthcare of Atlanta

Utilization Review Team Lead (RN)

apartment Children's Healthcare of Atlanta location_onAtlanta, GA
Note: If you are CURRENTLY employed at Children's and/or have an active badge or network access, STOP here. Submit your application via Workday using the Career App (Find Jobs). Work Shift Variable Work Day(s) Saturday, Sunday, Variable Shift Start Time 8:00 AM Shift End Time 5:00 PM Worker Sub-Type Regular Children’s is one of the nation’s leading children’s hospitals. No matter the role, every member of our team is an essential part of our mission to make kids better today and healthier tomorrow. We’re committed to putting you first, and that commitment is at the heart of our company culture: People first. Children always. Find your next career opportunity and make a difference doing what you love at Children’s. Job Description Participates as a team leader to proactively support efforts that ensure effective and efficient utilization review services, clinical reviews, pre-certification, denial analysis, and other revenue functions. Maintains necessary documentation and communication with internal and external customers. Serves as resource for departmental employees when manager/supervisor is not available. This role will focus on account status changes, reviewing denials and serving as resource for Clinical Review Nurses (UR). The schedule is (4) 10-hour days with 2 of those days being Saturday and Sunday. There is opportunity to work remotely. Experience Two years of experience in a healthcare setting; pediatrics preferred Six months of experience in hospital or insurance related utilization review Preferred Qualifications Bachelor of Science in Nursing Previous experience with InterQual and/or MCG programs Previous management or leadership experience Strong clinical skills; PICU or NICU very helpful Education Graduation from an accredited school of nursing Certification Summary Licensure as a Registered Nurse in the single State of Georgia or Multi-State through the Enhanced Nurse Licensure Compact Knowledge, Skills and Abilities Must be able to successfully pass the Basic Windows Skill Assessment at 80% or higher rating within 30 days of employment Job Responsibilities Coordinates and performs activities related to determination of eligibility, precertification, and hospital stay approvals for all unplanned admissions as required by payor. Functions in place of staff as needed. Acts as resource for employees to handle/resolve difficult issues or answer questions. Acts as supervisor upon absence of supervisor. Maintains effective communication strategies so that collaboration and teamwork are enhanced throughout department and Children’s Healthcare of Atlanta. Serves as liaison between utilization review nurses and payors. Researches authorization requests from physician offices. Coordinates and performs activities related to status changes timely and consistently. Participates actively in secondary review process and provides feedback to staff where indicated. Escalates trends to Utilization Review supervisor and clinical educator for quality assurance purposes. Demonstrates competency in utilization review process with successful completion and passing of McKesson Interrater Reliability for both pediatric and adult criteria. Attends meetings with and communicates utilization review initiatives to outside departments, including Managed Care, Patient Accounting, Medical Staff, and Registration. Supports and participates in continuous assessment and improvement of patient care. Participates in Utilization Management committee activities. Provides reporting data to analyze performance of department, especially as relates to correct patient status. Assists supervisor and/or manager with development of staff by being available to teammates, acting as a resource to help complete complicated/complex tasks, providing on the job training to team, and seeking out opportunities to become actively involved in staff workflow and development. Provides supervisor and/or manager feedback on staff performance, educational needs, and workflow status. Children’s Healthcare of Atlanta is an equal opportunity employer committed to providing equal employment opportunities to all qualified applicants and employees without regard to race, color, sex, religion, national origin, citizenship, age, veteran status, disability or any other characteristic covered by applicable law. Primary Location Address 1575 Northeast Expy NE Job Family Nursing-Non Bedside
RN Utilization Review Full-time
The Christ Hospital Health Network

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

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

Utilization Review Nurse | Corporate Utilization Management | PRN | Variable

apartment UF Health location_onLeesburg, FL
Overview FTE-.10 PRN Variable shift The Utilization Review Nurse is responsible for evaluating the appropriateness of hospital admissions, resource utilization, and medical necessity for continued stays. This role facilitates timely discharges, ensures medical documentation accurately reflects patient severity of illness, and provides appropriate interventions and discharge planning services in collaboration with Case Management. Performs other related duties as assigned. Qualifications Education Associate’s Degree required Professional Certification in Case Management (CM) preferred Licensure/Certification/Registration Current Florida nursing license required Case Management (CM) certification preferred Special Skills, Qualifications, and Experience Ability to read, write, speak, and understand English Minimum of five (5) years of clinical experience Current working knowledge of utilization management, performance improvement, and reimbursement issues preferred Experience in utilization review, case management, appeals, denials, and managed care contracting preferred Strong observation, analytical, and problem-solving skills Excellent written and verbal communication skills Ability to effectively communicate with physicians, patients/clients, families, and interdisciplinary staff
RN Utilization Review Full-time
Health & Hospital Corporation

UTILIZATION PAYOR SPECIALIST RN

apartment Health & Hospital Corporation location_onIndianapolis, IN
Division: Eskenazi Health Sub-Division: Hospital Req ID: 24795 Schedule : Full Time Shift : Days Salary Range: Eskenazi Health serves as the public hospital division of the Health & Hospital Corporation of Marion County. Physicians provide a comprehensive range of primary and specialty care services at the 327-bed hospital and outpatient facilities both on and off of the Eskenazi Health downtown campus as well as at 10 Eskenazi Health Center sites located throughout Indianapolis. FLSA Status Exempt Job Role Summary The Utilization Payor Specialist, RN is responsible for working behind the scenes to maximize the quality and cost of efficiency of health services. This position coordinates pre-certifications, re-certifications, the denial management and appeals process, and initial and concurrent reviews. Through regular reviews and audits, the Utilization Payor Specialist ensures that patients receive the care needed without burdening the health care system with unnecessary procedures, ineffective treatments or lengthy hospital stays. #EXPRN Essential Functions and Responsibilities Communicates secondary review decisions determining appropriate patient status provided by secondary reviewer process Communicates and negotiates with payers to obtain approvals for the appropriate care level Serves as a resource on payor requirements for severity and intensity of service determinations for outpatient and acute inpatient admissions Provides timely payor feedback to Case Managers and Social Workers; notifies the Case Manager when additional clinical information may be required that is not currently identified within the electronic medical record or bedside documentation to ensure that services will be approved at the acute level of care as required by the payor Ensures pre-certification/authorizations for post-acute services, initial, concurrent reviews, authorizations not obtained by Patient Registration/Admitting or the doctor's office and clinics for direct admissions and procedures Reviews patient admission for appropriateness and type; refers case to Medical Director/department leadership for review and course of action when case fails to meet admission standards Coordinates and facilitates the most accurate and appropriate patient status for care across the continuum Actively communicates and documents payor issues and concerns regarding the initial level of care, continued stay, denials and discharge plans to the Medical Director/department leadership as appropriate Supports the denial management process and participates in tracking and reporting denials Ensures payor and customer satisfaction through effective communication with the Interdisciplinary Team Obtains payor certification for unplanned admissions, homecare and post-acute services as required Initiates contact with payers for continued stay; reviews utilizing clinical information; pursues additional information as needed Utilizes conflict resolution, critical thinking, and negotiation skills as necessary to ensure timely resolution of issues Identifies concurrent third-party payers denials and notifies Case Managers for immediate intervention and escalation to the Medical Director/department leadership Coordinates denial and appeals process and responds to all third-party payer denials Applies appropriate clinical criteria to complete initial reviews within 24-48 hours of patient presentation Facilitates tracking and payment approval processes for the outpatient parenteral antimicrobial therapy program (OPAT) Assists with coordination, data entry and needed follow up support to the OPAT program Provides post-hospitalization telephonic follow up for OPAT patients in the community for care coordination regarding care outcomes that support the OPAT program Facilitates tracking and payment approval processes for Eskenazi Health inpatient overlaps receiving services at IUH Facilitates tracking and payment approval processes for Eskenazi Health Cardiac send-out receiving services at IUH Reviews claims for both inpatient overlaps and cardiac send-outs and verifies dates of service; provides to Revenue Cycle for adjudication and payment Facilitates tracking and payment approval processes for vendor picc lines to include charge reconciliation in EPIC Provides oversight and maintains readmission initiatives directly related to Target Diagnosis, Bedside education, follow-ups for vendor-automated calls Provides assistance for complex discharge planning placement and programs, departmental projects, authorizations and accounts payable Facilitates referral, tracking and payment approval processes for Eskenazi Health requiring home wound-vac services provided by in-network vendors for specialty clinics and patients discharging home Job Requirements Current Indiana RN nursing license required Four years of clinical nursing experience required Two or more years of Utilization Review experience strongly preferred Knowledge, Skills & Abilities Must demonstrate knowledge of the Utilization Management managed care processes Must demonstrate knowledge of levels of care of Inpatient and Outpatient status Excellent interpersonal, written and verbal communication, and negotiation skills Demonstrated ability to be diplomatic and flexible, and demonstrates a high level of professionalism Ability to cohesively network with the Interdisciplinary Team Accredited by The Joint Commission and named one of the nation’s 150 best places to work by Becker’s Hospital Review for four consecutive years and Forbes list of best places to work for women, and Forbes list of America’s best midsize employers’ Eskenazi Health’s programs have received national recognition while also offering new health care opportunities to the local community. As the sponsoring hospital for Indianapolis Emergency Medical Services, the city’s primary EMS provider, Eskenazi Health is also home to the first adult Level I trauma center in Indiana, the only verified adult burn center in Indiana, the first community mental health center in Indiana and the Eskenazi Health Center Primary Care – Center of Excellence in Women’s Health, just to name a few.
RN Utilization Review Per Diem
John Muir Health

RN-Case Manager - AS Utilization Management - Concord - Per Diem - 8 Hour - Days

apartment John Muir Health location_onConcord, CA
Job Description: The role of the inpatient case manager is one of patient advocate of appropriate utilization of resources. The inpatient case manager applies the process of assessment, planning, implementation, monitoring, evaluation and coordination of care to meet the patient’s health care needs through hospitalization and transition back to the community and does this in coordination with the interdisciplinary health team. The RN Case Manager is expected to function within the full scope of the nursing practice with specialized focus on care coordination, compliance, transition management, education, and utilization management. Job Description Education: Master's Degree Accredited School of Nursing Required ​ Experience: 2 years Case Management or Equivalent Work Experience Preferred 3 years Nursing - Medical/Surgical Preferred 3 years Nursing - Critical Care Preferred Certifications/Licensures: RN Registered Nursing - California Board of Nursing Required BLS Basic Life Support - American Heart Association Required ACM Accredited Case Manager - ACMA American Case Management Association or CCM Certified Case Manager - CCMC Commission for Case Manager Certification Strongly Preferred Skills: Strong written and verbal communication skills. Effectively motivates teams. Strong knowledge of Medicare and Medi-Cal guidelines and benefit resources as applicable to hospitalization and transition planning. Working knowledge of common diagnoses and procedures and the impact this will have to patients/families and their ability to manage their care outside of the hospital. Specialized knowledge may be required for certain areas of practice. Knowledge of individual and family development over the life span, and the influences of cultural and spiritual values in health care. General knowledge of commercial coverage plans and usually covered benefits. Strong understanding of various reimbursement models and impact to care delivery, patient management and reimbursements such as ACOs, DRGs, Full Risk, etc. Strong understanding of the criteria, rules and regulations around Inpatient, Observation and Outpatient levels of patient management. Strong knowledge of geriatrics and the impact to health and function in the aged as well as a working knowledge of chronic/progressive disease states such as CHF, COPD, Diabetes and End Stage Renal Disease, etc. Clear understanding of the role of the inpatient Social Worker and Palliative Care Resources. Ability to plan, organize, manage time and prioritize work in collaboration with others. Ability to work independently and as a part of a multidisciplinary team. Effective problem solving and conflict resolution skills. Ability to work respectfully and creatively with clients of diverse functional abilities, social, economic, and cultural backgrounds to support both client autonomy and client safety. Leadership skills to delegate and provide direction/guidance to staff and hold others accountable. Able to learn and work in a variety of computer programs, including EPIC, MIDAS, Allscripts, and Microsoft Outlook. Work shift (e.g. 0900-1730, 8a-430p, etc.): 0800-1630 Days worked per week: Variable/Per Diem Work Shift: 08.0 - Per Diem Days No Waive (United States of America) Pay Range: $84.77 - $115.51 Hourly Offer amounts are based on demonstrated/relevant experience and/or licensure. Pay will be adjusted to the local market if hired outside of the Bay Area . Note: Positions at JMH which are exempt (not eligible for overtime) under the level of Manager are listed as hourly for compensation purposes on this posting. The work shift will contain the word ‘exempt’ on it. Scheduled Weekly Hours: 0
RN Utilization Review Full-time
Saint Francis Health System

Utilization Management Nurse (RN) (H)

apartment Saint Francis Health System location_onOklahoma City, OK
Current Saint Francis Employees - Please click HERE to login and apply. Full Time #ALDIND **MUST BE LOCAL IN THE TULSA AREA. HYBRID ROLE** Shift: Full time weekend day Friday, Saturday, Sunday 7a-7p. Job Summary: Provides administrative and clinical support to the hospital and treatment teams throughout the review of patients including, but not limited to their placement in various levels of care and receipt of necessary services. The Utilization Management (UM) Registered Nurse will communicate with providers the details of reimbursement issues and participate in treatment teams, Patient Care Committee, and the Utilization Review Staff Committee by providing data and contributing to the improvement of internal processes. Minimum Education: Has completed the basic professional curricula of a school of nursing as approved and verified by a state board of nursing, and holds or is entitled to hold a diploma or degree therefrom or Master's degree in Nursing. Licensure, Registration and/or Certification: Valid multi-state or State of Oklahoma Registered Nurse License. Work Experience: Minimum 2 years of related experience in an acute care setting. Knowledge, Skills and Abilities: Ability to organize and prioritize work in an effective and efficient manner. Effective interpersonal, written, and oral communication skills. Demonstrated ability to integrate the analysis of data to discover facts or develop knowledge, concepts, or interpretations. Ability to be detail oriented as required in the examination of numerical data. Ability to synthesize clinical case data into concise summaries. Working knowledge of Microsoft Word, Excel and Access in the preparation of correspondence and reports. Essential Functions and Responsibilities: Gathers, prepares and supplies required clinical/treatment information needed to obtain authorization within the review interval(s) time requirements. Participates in treatment team and/or Patient Care Committee by providing information about eligibility, benefits, and criteria for the selected level of care. Assists in discharge planning, as needed. Identifies QI Triggers for individual patient situations, reporting them promptly to the UM Manager, appropriate clinicians and Process Improvement/Quality Director. Reviews eligibility and benefits of patients to validate accurate level of care utilization. Investigates and prepares appeals for insurance companies when denial of reimbursement is related to medical necessity or to other treatment issues. Participates in quality-of-care and UM process improvement on an ongoing basis and assists with development of the UR Staff Committee's process improvement goals. Provides staff education to further the goals of UR. Decision Making: The carrying out of non-routine procedures under constantly changing conditions, in conformance with general instructions from supervisor. Working Relationship: Works directly with patients and/or customers. Works with internal customers via telephone or face to face interaction. Works with other healthcare professionals and staff. Works frequently with individuals at Director level or above. Special Job Dimensions: None. Supplemental Information: This document generally describes the essential functions of the job and the physical demands required to perform the job. This compilation of essential functions and physical demands is not all inclusive nor does it prohibit the assignment of additional duties. Utilization Review Management - Yale Campus Location: Virtual Office, Oklahoma 73105 EOE Protected Veterans/Disability