Registered Nurse (RN) Utilization Review Jobs

RN Utilization Review Full-time
Gainwell Technologies LLC

Clinical Quality Nurse Reviewer, Sr. Specialist

apartment Gainwell Technologies LLC location_onIrving, TX
$64,500 - $92,200 / YEAR
It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you’ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development. Summary We are seeking a talented individual for a Clinical Quality Nurse Reviewer, Sr. Specialist who is responsible for performing on-going quality assurance audits of the work performed by clinical staff. This person is responsible for complex quality reviews to determine if decision by review staff matches medical records and approved review methodologies. Responsibilities include reviewing documentation to ensure all aspects of the review audit have been addressed properly and accurately. Performing inter-rater reliability assessments and quality assurance auditors for multiple review types including Place of Service, Level of Care, Readmissions, Utilization Management and other specialty reviews. Your role in our mission • Conduct quality assurance checks on complex clinical claim reviews and ensure accuracy of determinations. • Analyze claim data and medical records using approved clinical guidelines; document findings clearly. • Provide detailed quality review results for reporting and trend analysis; help identify quality issues and support remediation efforts, including developing training materials. • Ensure all aspects of the clinical review are fully addressed while meeting production and quality standards. • Support training of new reviewers through monitoring, mentoring, and feedback. • Maintain up-to-date knowledge of clinical guidelines and complete required CEUs to keep RN license active. • Participate in training sessions and meetings to strengthen understanding of clinical policies and procedures. • Cross-train to review multiple claim types to support business needs. • Serve as a subject matter expert and assist with proposals, projects, reporting, and data analysis. • Consistently meet performance expectations and demonstrate strong experience in medical review, chart audits, and quality improvement. What we're looking for Active, unrestricted RN licensure from the United States and in the state of primary home residency, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), required Associate degree required; bachelor’s degree preferred. 5+ years clinical experience in acute setting 3+ years medical record review/auditing experience preferred Expert level experience applying MCG and/or InterQual criteria Excellent written communication skills including ability to write clear, concise, accurate, and fact-based rationales in support of determinations. Ability to analyze and evaluate medical information and to apply clinical review guidelines or judgement to make clinical determinations. Ability to multi-task in a fast-paced production environment. What you should expect in this role Remote within the U.S. Applications for this posting will be accepted until January 12, 2026. The pay range for this position is $64,500.00 - $92,200.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits , and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities. We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings. Gainwell Technologies is an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics.
RN Utilization Review Full-time
Molina Healthcare

Care Review Clinician (RN)

apartment Molina Healthcare location_onLong Beach, CA
JOB DESCRIPTION Job Summary Provides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines. • Analyzes clinical service requests from members or providers against evidence based clinical guidelines. • Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. • Conducts reviews to determine prior authorization/financial responsibility for Molina and its members. • Processes requests within required timelines. • Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner. • Requests additional information from members or providers as needed. • Makes appropriate referrals to other clinical programs. • Collaborates with multidisciplinary teams to promote the Molina care model. • Adheres to utilization management (UM) policies and procedures. Required Qualifications • At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience. • Registered Nurse (RN). License must be active and unrestricted in state of practice. • Ability to prioritize and manage multiple deadlines. • Excellent organizational, problem-solving and critical-thinking skills. • Strong written and verbal communication skills. • Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications • Certified Professional in Healthcare Management (CPHM). • Recent hospital experience in an intensive care unit (ICU) or emergency room. Preferred Experience Previous experience in managed care Prior Auth, Utilization Review / Utilization Management and knowledge of Interqual / MCG guidelines. MULTI STATE / COMPACT LICENSURE Individual state licensures which are not part of the compact states are required for: CA, NV, IL, NY and MI WORK SCHEDULE: Tues - Sat shift will rotate with some holidays. Training will be held Mon - Fri To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $26.41 - $61.79 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
RN Utilization Review Full-time
Baptist Health Care

RN - Case Manager - Case Management - Utilization Review

apartment Baptist Health Care location_onPensacola, FL
Job Description The Case Manager acts as a patient advocate to hospital clients. This is an autonomous role that coordinates, negotiates, procures services, and resources for, and manages the care of patients throughout the continuum of care, which includes arranging post-acute services. The Case Manager is responsible for team building, educating, and consulting interdisciplinary team members. This position provides clinically based case management, therefore requiring someone with a strong clinical background, preferably in the acute care setting. This position requires someone that is flexible and willing to work in all and/or any areas of the hospital. Case Management requires an individual that is adaptable to change and can assume any assignment wherever the need may be. The Case Manager is responsible for discharge planning, and care coordination to facilitate the delivery of quality health care and assists in the identification of appropriate utilization of resources across the continuum of care. Responsibilities Directs, coordinates, and provides case management to patients in caseload. Responsible for preventing delayed discharges of observation patients. Participates in case finding and preadmission evaluation screening to ensure a safe discharge plan. Completes case management assessment of patients and support systems in order to facilitate the most appropriate and timely transition plan. Interacts, communicates, and intervenes with multidisciplinary healthcare team in a purposeful, goal-directed fashion. Works proactively to maximize the effectiveness of resource utilization. Anticipates, initiates, and facilitates problem resolution around issues of resource use and continued hospitalization and discharge planning. Consistently maintains a professional commitment to institutions and department's goals and objectives. Demonstrates flexibility to the department's needs in relation to floor and work schedule and any other internal and external demands on the department. Continually shows commitment to the department by extending one's self when the need arises. Maintains current knowledge of case management, , and discharge planning, as specified by federal, state, and private insurance guidelines. Qualifications Minimum Education Technical Diploma/Certificate Practical Nursing Required or Associates Degree Nursing Required or Minimum Work Experience 3 years Acute Hospital Nursing Experience Preferred 1-3 years Case Mgmt in the Acute Care Setting Preferred Licenses and Certifications Registered Nurse Licensed State of Florida or eligible compact license Upon Hire Required Required Skills, Knowledge and Abilities Demonstrated skills in the areas of negotiation, communication (verbal and written), conflict, interdisciplinary collaboration, management, creative problem solving, and critical thinking. (High proficiency) Knowledge of healthcare financing, community and organizational resources, patient care processes, and data analysis. (Medium proficiency) Knowledge of post-acute care community resources. (Medium proficiency) Demonstrates flexibility via an ability to adapt to changing priorities and regulation. (High proficiency) Excellent verbal and written communication skills required. (Medium proficiency) Proficient computer skills required. (Medium proficiency) Ability to communicate effectively and document information accurately (High proficiency) Excellent communication and interpersonal skills. (High proficiency) Excellent organizational and multitasking skills. (High proficiency) Understanding the implications of new information for both current and future problem-solving and decision-making. (High proficiency) Ability to plan, organize and direct the activities of others. (High proficiency) About Us Baptist Health Care is a not-for-profit health care system committed to improving the quality of life for people and communities in northwest Florida and south Alabama. The organization includes three hospitals, four medical parks, Andrews Institute for Orthopaedic & Sports Medicine, and an extensive primary and specialty care provider network. With more than 4,000 team members, Baptist Health Care is one of the largest non-governmental employers in northwest Florida. Baptist Health Care, Inc. is an Equal Opportunity Employer. BHC maintains and enforces a policy that prohibits discrimination against any workforce members or applicants for employment because of sex, race, age, color, disability, marital status, national origin, religion, genetic information, or other category protected by federal, state or local law.
RN Travel Utilization Review Full-time
Aya Healthcare

Permanent Staff Utilization Review RN job in Albuquerque, NM - Make $39 to $53 per hour

apartment Aya Healthcare location_onAlbuquerque, NM
$39 - $53 / HOUR
Access This Permanent Staff Utilization Review Registered Nurse Job in Albuquerque, NM. Job Details Pay: $39.00 to $53.00 per hour. (This info is approximate. To view complete pay and facility information, please log in to your Aya account or register with us now.) Shift: 3, 12-Hour 07:00 - 19:30 Join Aya for the most career options. Aya Healthcare gives you access to the most jobs — and the most exclusive opportunities — in the industry. We have strong relationships with leading facilities nationwide, and job options to support your personal and professional goals. Whether you want to put down roots with a permanent role, explore the country with a travel job or pick up per diem shifts close to home, Aya’s got you covered. Log In Today And Search jobs View pay & facility details Get real-time job notifications Register now to get started.
RN Utilization Review Full-time
Centene

Clinical Review Nurse - Concurrent Review

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

Clinical Review Nurse - Concurrent Review

apartment Centene location_onIA
$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 Central time zone. This role will support Iowa Medicaid members and requires an Iowa or compact nursing license. The work schedule is Monday - Friday, 8am - 5 pm, with rotating weekend / holiday coverage.** 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 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 Manager/Supervisor Utilization Review Full-time
DCH Health System

Manager Utilization Review/RN

apartment DCH Health System location_onTuscaloosa, AL
Overview Oversees the evaluation of patients for appropriateness of admission type and setting, utilizing a combination of clinical information, screening criteria and third-party information across the DCH System. Serves as the primary educator for all DCH PA's, Case Managers, Social Workers, CDI personnel, Utilization Review Coordinators (URC), in the principles of utilization management and serves as a consultant for issues regarding regulations, compliance, payor specific criteria and the denial management process for the DCH System. Responsibilities Supervises utilization review professional and clerical employees. Establishes, manages, approves, and constantly evaluates staffing levels, performance, assignments, skills, learning needs and deployment of Utilization Review. Responsible to support and participate in DCH System strategies and efforts focused on improving length of stay (LOS) and reducing readmissions. Ensures orientation and training in Utilization Review for Utilization Review Staff. Manages the day to day operations for the DCH System Commercial Utilization Review function. Displays sound managerial judgment in all areas. Supervises and initiates or recommends personnel actions for Utilization Review staff members. Manages departmental budget and productivity standards. Interviews, selects, hires, and retains employees 1 0. Performs compliance requirements as outlined in the Employee Handbook Approves payroll and is responsible for accurate payment of employees 1 2. Is knowledgeable of hospital mission, vision, and values, and performs in a manner to support them. 1 3. Manages the performance of URCts providing feedback and direction. 1 4. Informs staff of any insurance changes involving InterQual guidelines or in providing clinical reviews. 1 5. Functions as a consultant to staff for solving challenging utilization issues throughout the DCH System. 1 6. Analyzes each of the assigned medical records for the purpose of medical necessity and appropriate billing status. Collaborates with Business Office Personnel to identify correct insurance source, initial pre-certification information and provides clinical information as necessary to obtain authorization for payment. Manages utilization of Commercial observation process. Collaborates with the Case Manager to determine patient's appropriateness for acute hospital level of care, Evaluates patient's clinical course to verify patients continued need for acute hospital level of care. Provides third party payers with clinical information as needed to comply with payers' requirements for documentation of medical necessity. Negotiates a resolution of any DCH System disagreement over the need for acute hospital level of care with the insurer. Intervenes with appropriate parties regarding inappropriate admissions, delays in discharge and the overutilization of hospital resources. Intervenes with appropriate individuals regarding delays in service that may have an impact on the quality of patient care and/or length of stay. Refers appropriately to Performance Improvement and Risk Management for patient safety occurrences and sentinel events. Refers cases not meeting acute inpatient criteria to the physician advisor and assists with his/her review of the case. Gathers information for monthly statistical reports, special projects as assigned by the Corporate Director of Case Coordination. Assists in discharge planning by confirming patient's insurance benefits. Updates and documents in the computer system pertinent clinical information by utilizing screening criteria. Maintains records in a complete, detailed and orderly manner. Identifies potentially avoidable days per department policy. Establish appropriate staffing levels, assignments, and deployment of Utilization Review staff. Collaborates with Medical Records and patient Accommodations regarding patient billing status. Collaborates with the Financial Counselors to facilitate the Medicaid application process. Manages the delivery of the denial notification for the DCH Health System. Manages work list of BC/Commercial patients with Hospital acquired conditions/Never Events. Responsible to support and participate in department strategies and efforts focused on improving length of stay (LOS). Responsible to support and participate in department strategies and efforts focused on improving clinical documentation by physicians and staff. Manages the BC/BS's Concurrent Utilization Review program (CURP) for RMC, NMC, and FMC for the DCH System. Liaison between hospital & payers during concurrent and retrospective medical necessity audits for the DCH System. Manages continuation of benefits notices issued by Physician Advisor (i.e. pt. notification business office). Conducts retrospective medical record audits to verify appropriate administration of criteria and reports findings as directed. Conducts special focused reviews as directed. Collaborates with the Compliance Officer to assure accurate billing on cases with ambiguous orders. Supports departmental operations to ensure consistency with health system/departmental policies. Provides service in the most cost-effective manner, without compromising the quality of care, or customer satisfaction. Assists Corporate Director of Care Coordination in planning and implementation of opportunities and new ideas to promote department growth and development. Designs and develops processes related to special projects as assigned by Director. Maintains, monitors, and audits accuracy of outpatient and inpatient appeals and interventions and observation according to department policies based on medical necessity. Develops a working knowledge of IMAC's, eFR, and EPSI computer software. Monitors hospital effectiveness for managing patient billing status, identifies opportunities for improvement and informs leadership through monthly reports. Manages hospital appeals for reconsideration of denied payment by insurance companies. Maintains confidentiality at all times related to both patient and employee information. Manaqer Manages departmental budget Interviews, selects, hires, and retains employees Ensures orientation and training for employees Manages performance Promotes, demotes, or transfers employees to meet organizational needs Executes employee accountability process up to and including termination Manages departmental productivity standards Performs compliance requirements Approves payroll and is responsible for accurate payment of employees Manages front line operations of area of accountability related to meeting/exceeding departmental goats DCH Standards: Maintains performance, patient and employee satisfaction and financial standards as outlined in the performance evaluation. Performs compliance requirements as outtined in the Employee Handbook Must adhere to the DCH Mission, Vision, and Values including creating positive relationships with patients/families, coworkers, colleagues and with self. Performs essential job functions in a manner that ensures the safety of patients, visitors and employees. Identifies and reduces unsafe practices that may result in harm to patients, visitors and employees. Recognizes and takes appropriate action to reduce risks and hazards to promote safety for patients, visitors and employees. Requires use of electronic mail, time and attendance software, learning management software and intranet. Must adhere to all DCH Health System policies and procedures. All other duties as assigned. Qualifications Registered Nurse with current Alabama license; very good organizational and interpersonal skills required. Computer knowledge required At least three years acute hospital Utilization Review experience required Can write legibly and speak and read English. A minimum of five (5) years Utilization Review experience preferred Ability to establish priorities, meet deadlines, and maintains proper productivity. Ability to form positive, collaborative relationships with hospital staff, patients, families and post-acute providers. Ability to problem solve in a proactive, creative manner, using sound judgment based on factual information and clinical knowledge. Excellent leadership skills and to serve as a role model for staff. Ability to lead and actively participate in multidisciplinary teams. Intermediate computer skills. Ability to work independently or within a team structure. Excellent interpersonal skills and communication style. Must be able to read, write legibly, speak, and comprehend English. WORKING CONDITIONS Is able to lift at least 201bs. Ability to tolerate prolonged periods of sitting, or standing and/or walking Ability to reach reasonable distances to handle equipment Good manual and finger dexterity. Hearing and vision must be corrected to within normal range. Good communication skills. Physical presence onsite is essential. Hearing and vision must be normal or corrected to within normal range. Able to perform the duties with or without reasonable accommodation.
RN Utilization Review Full-time
Centene

Utilization Review Clinician - ABA

apartment Centene location_onAZ
$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. 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. This is a remote position however must reside in Arizona. 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. 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: Board Certified Behavior Analyst (BCBA) required 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
Northwestern Medicine

RN Utilization Specialist-Utilization Review Casual Days

apartment Northwestern Medicine location_onPalos Heights, IL
Description The RN Utilization Specialist reflects the mission, vision, and values of NM, adheres to the organization’s Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards. The RN Utilization Specialist (RNUS) is an experienced registered professional nurse with extensive knowledge of patient care, medical treatments, hospital procedures and has expertise in hospital utilization. The RNUS through regular reviews and audits and collaboration with the clinical team, facilitates responsible decisions that promote cost effective health care services as evidenced by appropriate level of care assignment and medical necessity documentation consistent with the patient’s clinical state and intervention plan. The RNUS is a key member of the health care team and as such collaborates with clinicians, responsible for patient care plans, to provide hospital health care benefit coverage information and assist the patients in decisions based on benefits and limitations of coverage plans. The RNUS acts as a change agent to systematically drive change in utilization practices as prioritized by departmental and clinical leadership. As such, the RNUS participates in performance improvement initiatives, implements work process changes, monitors performance, and facilitates necessary changes, under the purview of the Department leadership and in collaboration with practicing clinicians, based on data trends. Responsibilities: Applies medical necessity screening criteria, level of care guidelines, and professional nursing knowledge to ensure that admissions & length of stay are appropriate. Completes initial admission and thereafter continuing stay reviews for all hospitalized patients. Facilitates utilization review concurrent with decisions on hospitalization and may perform duties in the Emergency Department, pre- and post-operative, labor and delivery, external transfer, bed assignment, and / or other access points for hospitalization. Collaborates with the Payor Specialists and third-party payors to effectively communicate all relevant clinical information based on clinical indicators and the plan of care. Acts as a liaison with the clinical care team assuring compliance with managed care contracts and payor guidelines while maintaining quality of care. Partners with operational and medical leadership to identify, develop and implement utilization processes that foster the right care at the right time in the right setting. Monitors data elements inherently related to Utilization through data reporting tools. Effectively resolves utilization dilemmas and as needed uses available escalation pathways (Utilization Medical Director (s) or the Lead Utilization Specialists) to secure further information or expertise to resolve identified issues. Makes appropriate referrals to internal physician advisors and contracted third party review company per Department guidelines. May participate in interdisciplinary discharge planning rounds to facilitate communication with the care team on documentation and orders necessary to assign accurate medical necessity, level of care, and communication with the payor. Interfaces with patients as appropriate to provide education on level of care Increases stakeholder understanding of best practices in utilization and internal performance against benchmarks, through a variety of educational forums. Develops, coordinates, presents, and participates in service-line and clinician education programs. Utilizes standardized reports (metrics/dashboard) and provides updates for physicians and the interdisciplinary team members on a regular basis. Collaborates with the interdisciplinary team to promote the resolution of barriers related to utilization of services and institute changes that improve systems and promote optimal utilization practices. May assist in the reporting of financial indicators including length of stay, resource utilization, denials and appeals. Participates in the development, implementation, evaluation and revision of quality utilization tools in collaboration with the healthcare team. Assists in Recovery Audit Contractor (RAC) and other audit follow up and contributes to appeals on insurance denials as requested. Additional Functions: Maintains current knowledge of federal and state laws and regulations related to utilization Actively participates on departmental and hospital committees and taskforces as assigned Complies with Northwestern Medicine policies on patient confidentiality including HIPPA requirements and Personal Rules of Conduct Facilitates review of high risk cases by the Office of General Counsel, Corporate Compliance and Integrity, Risk Management and informs appropriate members of the healthcare team as to interventions. Coordinates interventions in collaboration with the healthcare team Participates in hospital and department quality improvement initiatives. Qualifications Required: Licensed Registered Nurse in the state of Illinois (IDFPR) Three years of experience in acute inpatient hospital care Organizational, team building, coaching, and conflict management to maximize the achievement of utilization outcomes. Analytical skills necessary to independently collect, analyze, and interpret data, resolve problems requiring innovative solutions. Computer skills including word processing and spreadsheets. Preferred : Bachelor’s Degree in Nursing Equal Opportunity Northwestern Medicine is an equal opportunity employer (disability, VETS) and does not discriminate in hiring or employment on the basis of age, sex, race, color, religion, national origin, gender identity, veteran status, disability, sexual orientation or any other protected status. Background Check Northwestern Medicine conducts a background check that includes criminal history on newly hired team members and, at times, internal transfers. If you are offered a position with us, you will be required to complete an authorization and disclosure form that gives Northwestern Medicine permission to run the background check. Results are evaluated on a case-by-case basis, and we follow all local, state, and federal laws, including the Illinois Health Care Worker Background Check Act. Benefits We offer a wide range of benefits that provide employees with tools and resources to improve their physical, emotional, and financial well-being while providing protection for unexpected life events. Please visit our Benefits section to learn more. Sign-on Bonus Eligibility: Internal employees and rehires who left Northwestern Medicine within 1 year are not eligible for the sign on bonus. Exception: New graduate internal employees seeking their first licensed clinical position at NM may be eligible depending upon the job family.
RN Utilization Review Full-time
University Health Kansas City

Utilization Mgmt Nurse RN - Care Continuity - UH Truman Medical Center (5 days per week; 7:30a-4:00p; Mon-Fri)

apartment University Health Kansas City location_onLee's Summit, MO
If you are a current University Health or University Health Physicians employee and wish to be considered, you must apply via the internal career site. Please log into myWORKDAY to search for positions and apply. Utilization Mgmt Nurse RN - Care Continuity - UH Truman Medical Center (5 days per week; 7:30a-4:00p; Mon-Fri) 101 Truman Medical Center Job Location Work From Home-City Tax Exempt Lees Summit, Missouri Department Care Continuity UHTMC Position Type Full time Work Schedule 7:30AM - 4:00PM Hours Per Week 40 Job Description The Utilization Management Nurse (UM RN) collaborates with members of the healthcare team to ensure optimum delivery of services across the healthcare continuum. The UM RN partners with interdisciplinary teams to improve delivery of patient care through monitoring of healthcare resources for effective and efficient utilization. The UM RN serves as internal consultant to healthcare team members by providing education relevant to clinical, financial and resource outcomes. Baccalaureate degree in Nursing; if candidate does not possess a Baccalaureate in Nursing, then a graduate degree in Nursing is required Registered Nurse licensed in state of Missouri, BSN preferred 2 years clinical experience in acute hospital setting Proficient in the use of window-based computer programs Excellent verbal, written, and interpersonal communication skills Ability to work within a fast-paced team-oriented environment Critical thinking skills, creative problem solving, and proficient organization and planning skills Preferred Qualifications : Utilization Management experience Experience with managed care, performance improvement, TJC, and CMS standards Nationally recognized certification applicable to UM/CM Knowledge of ICD / CPT / DRG’s Experience with analyzing data/statistical information
RN Utilization Review Full-time
Denver Health

Registered Nurse, Utilization Coordinator

apartment Denver Health location_onAlbuquerque, NM
$75,100 - $116,400 / YEAR
We are recruiting for a motivated Registered Nurse, Utilization Coordinator to join our team! We are here for life’s journey. Where is your life journey taking you? Being the heartbeat of Denver means our heart reflects something bigger than ourselves, something that connects us all: Humanity in action, Triumph in hardship, Transformation in health. Department REVENUE INTEGRITY Job Summary Under general supervision, the RN Utilization Review Coordinator will facilitate the appropriate status and level of care. This includes all commercial insurance, Medicare, Medicaid and self-pay. These will be reviewed on a cadence defined in the specific workflow. All Reviews will be done to ensure compliance with all state, federal and third-party payors. They will communicate daily and as needed to the RN Care Coordinator, Clinical Social Worker and healthcare teams. Essential Functions : Status and Level of Care Management • Manages observation status patients to determine appropriateness for discharge or conversion to inpatient admission using approved medical necessity criteria continually throughout the observation stay • Conducts medical necessity reviews on all inpatient admissions, transfers and continued stay patients using approved medical necessity criteria daily • Initiates Condition Code 44 process when applicable • Works with the Clinical Documentation Improvement Specialists and physicians to identify opportunities to improve the accuracy of the documentation as well as identify the working MSDRG and associated geometric mean length of stay • Conducts proactive medical necessity review of cases being referred from the Emergency Room, PACU, transfers and direct admissions from physician offices to ensure appropriate status and level of care placement , as assigned • Uses the criteria software application to document results of criteria application according to the documentation policy, i.e. MCG criteria application, length of stay assignments and variance documentation, etc. • Initiates Physician Advisor referrals for any cases not meeting criteria for the level of care • Ensures compliance with all state, federal and payor medical necessity and certification requirements (40%) Utilization Review for Insurance Companies • Documents clinical information as required for insurance company certification according to required payor timeframe standards • Works collaboratively with the Clerical Support Staff to ensure all insurance reviews are received by the insurance company and a disposition response is received • Documents all insurance certification activities in the assigned locations according to the department documentation standards (40%) Compliance • Ensures compliance with all applicable state and federal regulatory requirements as well as the insurance company rules such as Patient Choice, Important Message from Medicare #2, Condition Code 44, insurance certification processes, etc. • Maintains compliance with established hospital policies, procedures, objectives, safety, environmental and infection control guidelines • Protects Patient Rights as they pertain to the ethical and legal issues of confidentiality during the case management process (20%) Education : Associate's Degree Completion of a nursing education program that satisfied the licensing requirements of the Colorado State Board of Nursing for Registered Nurses. Required Work Experience : 1-3 years Three years clinical experience in a hospital, acute care, home health/hospice, direct care or case management required. Required Licenses : RN-Registered Nurse - DORA - Department of Regulatory Agencies Required Knowledge, Skills and Abilities : Bilingual in English/Spanish preferred. Knowledge and understanding of case management/coordination of care principles, programs, and processes in either a hospital or outpatient healthcare environment. Effectively collaborate with and respond to varied personalities in differing emotional conditions, and maintain professional composure at all times. Strong customer service orientation and aptitude. Problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action. Ability to communicate verbally and in writing complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others. Microsoft Office Suite required. Experience with windows-based computer programs and ability to use computer for data analysis and data display required. Prefer experience with Medical Management platforms used to document care coordination services. Shift Work Type Regular Salary $75,100.00 - $116,400.00 / yr Benefits Outstanding benefits including up to 27 paid days off per year, immediate retirement plan employer contribution up to 9.5%, and generous medical plans Free RTD EcoPass (public transportation) On-site employee fitness center and wellness classes Childcare discount programs & exclusive perks on large brands, travel, and more Tuition reimbursement & assistance Education & development opportunities including career pathways and coaching Professional clinical advancement program & shared governance Public Service Loan Forgiveness (PSLF) eligible employer+ free student loan coaching and assistance navigating the PSLF program National Health Service Corps (NHCS) and Colorado Health Service Corps (CHSC) eligible employer Our Values Respect Belonging Accountability Transparency All job applicants for safety-sensitive positions must pass a pre-employment drug test, once a conditional offer of employment has been made. Denver Health is an integrated, high-quality academic health care system considered a model for the nation that includes a Level I Trauma Center, a 555-bed acute care medical center, Denver’s 911 emergency medical response system, 10 family health centers, 19 school-based health centers, Rocky Mountain Poison & Drug Safety, a Public Health Institute, an HMO and The Denver Health Foundation. As Colorado’s primary, and essential, safety-net institution, Denver Health is a mission-driven organization that has provided billions in uncompensated care for the uninsured. Denver Health is viewed as an Anchor Institution for the community, focusing on hiring and purchasing locally as applicable, serving as a pillar for community needs, and caring for more than 185,000 individuals and 67,000 children a year. Located near downtown Denver, Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer. Denver Health is an equal opportunity employer (EOE). We value the unique ideas, talents and contributions reflective of the needs of our community. Applicants will be considered until the position is filled.
RN Utilization Review Full-time
University Health Kansas City

Utilization Mgmt Nurse RN - Care Continuity - UH Truman Medical Center (5 days per week; 7:30a-4:00p; Mon-Fri)

apartment University Health Kansas City location_onLee's Summit, MO
If you are a current University Health or University Health Physicians employee and wish to be considered, you must apply via the internal career site. Please log into myWORKDAY to search for positions and apply. Utilization Mgmt Nurse RN - Care Continuity - UH Truman Medical Center (5 days per week; 7:30a-4:00p; Mon-Fri) 101 Truman Medical Center Job Location Work From Home-City Tax Exempt Lees Summit, Missouri Department Care Continuity UHTMC Position Type Full time Work Schedule 7:30AM - 4:00PM Hours Per Week 40 Job Description The Utilization Management Nurse (UM RN) collaborates with members of the healthcare team to ensure optimum delivery of services across the healthcare continuum. The UM RN partners with interdisciplinary teams to improve delivery of patient care through monitoring of healthcare resources for effective and efficient utilization. The UM RN serves as internal consultant to healthcare team members by providing education relevant to clinical, financial and resource outcomes. Baccalaureate degree in Nursing; if candidate does not possess a Baccalaureate in Nursing, then a graduate degree in Nursing is required Registered Nurse licensed in state of Missouri, BSN preferred 2 years clinical experience in acute hospital setting Proficient in the use of window-based computer programs Excellent verbal, written, and interpersonal communication skills Ability to work within a fast-paced team-oriented environment Critical thinking skills, creative problem solving, and proficient organization and planning skills Preferred Qualifications : Utilization Management experience Experience with managed care, performance improvement, TJC, and CMS standards Nationally recognized certification applicable to UM/CM Knowledge of ICD / CPT / DRG’s Experience with analyzing data/statistical information
RN Utilization Review Full-time
DCH Health System

Utilization Review Care Manager, RN

apartment DCH Health System location_onTuscaloosa, AL
Overview Evaluates patients for appropriateness of admission type and setting, utilizing a combination of clinical information, medical necessity standards, and/or and InterQual guidelines. The Utilization Review Nurse utilizes clinical knowledge to support the coordination and documentation and communication of medical services and/or benefits. The Utilization Nurse also serves on the liaison between the physicians, patients, payers and care managers regarding termination of benefits, denial notification, and expedited appeals. Has access to highly sensitive, confidential information. Responsibilities Evaluates medical records for appropriateness of admission status utilizing a combination of clinical information, screening criteria, and third party information. Collaborates with business office, care managers, attending physicians, and physician advisors as needed. Works with Patient Registration\Financial Counselor (s) to identify correct insurance source and proper billing. Verifies patient admission information for each assigned patient within 24 hours of patient’s admission (next business day) or per payer guidelines. Collaborates with the Case Manager to identify referrals to Financial Counselors. Negotiates resolution of disagreements over the need for acute hospital level of care with the insurer. Educates staff and physicians about managed care principles, observation status, and reimbursement rules. Maintains records in a complete, detailed, and orderly manner. Identifies Potential Avoidable Days per department policy. Conducts self-auditing of medical records for status accuracy and provides peer consultation regarding cases in which patients are failing to progress and/or experiencing significant deviation from the plan of care. Collaborates with case managers and social workers for patients with complex, clinical, financial and psycho-social needs. Reviews physician orders and patient progression and intervenes with care coordination as needed. Collaborates with other departments to eliminate barriers, as necessary. Builds trusting relationships with attending physician, patient and/or family and other members of the healthcare team. Establishes a caring relationship with patients and their caregivers, promotes patient engagement and guides patients/families through the transition phase Gathers information for statistical monitors, plus special projects within the Care Management Department. Updates and documents in Expanse and Cortex, pertinent clinical information by utilizing screening criteria and assigns next review date. Responsible to support and participate in department strategies and efforts focused on improving length of stay (LOS) and reduction of avoidable readmissions. Responsible to support and participate in department strategies and efforts focused on improving clinical documentation by physicians. Identifies and reports Quality and Risk Management concerns and enters risk events in Midas. Is knowledgeable of hospital mission, vision, and values and performs in a manner to support them. Reviews an average of 25 patients per day. Delivers denial letters from all payers to the beneficiary or proper representative; explain appeal rights. Must be able to successfully complete the Interrater Reliability Tool for InterQual Level of Care Acute Criteria. (Adult and Pediatric) after successful orientation. DCH Standards Maintains performance, patient and employee satisfaction and financial standards as outlined in the performance evaluation. Performs compliance requirements as outlined in the Employee Handbook Must adhere to the DCH Behavioral Standards including creating positive relationships with patients/families, coworkers, colleagues and with self. Requires use of electronic mail, time and attendance software, learning management software, and intranet. Must adhere to all DCH Health System policies and procedures. All other duties as assigned. Qualifications Anyone hired after July, 2011 must meet the following: Minimum of Registered Nurse with current Alabama license. Minimum 2 years experience as an RN preferred. Minimum of at least 2 years as care management and/or utilization management experience preferred. Minimum of 2 years of Med Surgical experience preferred; Utilization Review experience preferred. Expected to work under minimal management supervision Efficient use of basic computer skills Ability to multi task, prioritize and effectively adapt to a fast paced changing environment Sedentary work involving periods of sitting, talking, and listening. Work requires sitting for extended periods, talking on the phone, and typing on the computer. Work requires the ability to perform close inspection of computer generated documents as well as a PC monitor. Typical office working environment with productivity and quality expectations. Ability to establish priorities, meet deadlines, and maintain proper productivity. Ability to form positive, collaborative relationships with hospital staff, patients, families, and payers. Ability to problem solve in a proactive, creative manner, using sound judgment based on factual information and clinical knowledge. Ability to effectively negotiate with internal and external providers of patient care services. Ability to develop leadership skills and to serve as a role model for clinical staff. Ability to actively participate in multidisciplinary teams. Ability to work independently or within a team structure. Excellent interpersonal skills, communication style, and organization. Must be able to read, write legibly, speak, and comprehend English. WORK CONTEXT Ability to form positive, collaborative relationships with physicians, colleagues, hospital staff, patients, families, and external contacts. Ability to provide guidance and direction to subordinates, including performance standards and monitoring performance. Ability to encourage and build mutual trust, respect, and cooperation among team members. Ability to communicate with people outside the organization and represent the organization to the public, government, and other external sources. Ability to work independently or within a team structure. May be exposed to environmental cleaning chemicals PHYSICAL FACTORS Requires Light work. Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly to move objects. If the use of arm and/or leg controls requires exertion of forces greater than that for sedentary work and the worker sits most of the time, the job is rated for light work. Ability to tolerate prolonged periods of sitting or standing and/or walking. Ability to reach reasonable distances to handle equipment. Good manual and finger dexterity. Must be able to perform the duties with or without reasonable accommodation. Hearing and vision must be normal or corrected to within normal range. Physical presence onsite is essential.
RN Psych Utilization Review Full-time
PeaceHealth

RN Admissions/Utilization Behavioral Health - Care Management, 1.0 FTE, Day

apartment PeaceHealth location_onBellingham, WA
$44.34 - $80.37 / HOUR
Description Job Description PeaceHealth is seeking a RN Admissions/Utilization Behavioral Health - Care Management for a Full Time, 1.00 FTE, Day position. The salary range for this job opening at PeaceHealth is $44.34 – $80.37. The hiring rate is dependent upon several factors, including but not limited to education, training, work experience, terms of any applicable collective bargaining agreement, seniority, etc. This position is represented by a collective bargaining agreement. There may be more than one opening on this posting. Hiring bonus and relocation assistance may be available. Job Summary Responsible for promoting effective utilization and monitoring of healthcare resources. This position will assume an informal leadership role with the multidisciplinary team to achieve optimal clinical, financial, and satisfaction outcomes. Essential Functions Acts as intermediary between the hospital and third party payors to ensure patients receive appropriate medically necessary inpatient psychiatric and medical services, so that the organization receives appropriate and optimal reimbursement. Understand and adhere to payer standards. Obtain voluntary admission authorization. Monitor accepted admissions from off hours and follow-up on payer authorization. Complete UR Admission review and Concurrent review processes. Ensure best use of limited inpatient resources by confirming accepted patients meet medical necessity criteria and will benefit from hospitalization. Ensure that all disciplines document to payer standards and demonstrate the need for continued hospitalization. Manage concurrent denials and some post discharge denials, submitting reconsideration clinical documentation. Assist provider in coordinating Peer to Peer with payer, as appropriate. Collaborate with PFS, UR Leaders, Payer contracting to ensure efficient work process in obtaining authorizations. Guide discussion with treatment team to improve quality, decrease cost and improve patient satisfaction. Document avoidable days. Verify patients on Single Bed Certifications and oversee UR process related to SBC encounter. ITA- monitor for change of status and notify payer. Provide admission support to Behavioral Health unit/ED/SECU as needed. Assist MSW with initial assessments, as appropriate. Ensure delivery of appropriate Medicare Notices. Assist MSW CM with medical transitions of care discharge planning such as medication pre-authorization, referrals to home health, procurement of DMW, SNF referrals, appt scheduling etc. Performs other duties as assigned. Qualifications Education Required: Degree from an Accredited School of Nursing Preferred: Bachelor of Science in Nursing Experience Strongly Preferred: Prior admission coordination or care management experience. Strongly Preferred: Working knowledge of psychiatric diagnostics. Preferred: Third party reimbursement knowledge. Preferred: Utilization Review experience. Credentials Required: Registered Nurse in state of practice Preferred: Psychiatric/Mental Health Clinical Nurse Specialist Skills Strong psychiatric nursing background. (Required) Must possess strong medical and psychiatric assessment, problem solving and prioritization skills and working knowledge of DSM 5 Revised. (Required) Excellent interpersonal skills required; must be professional in working closely with all customers such as referral sources, physicians, staff, patients and families. (Required) Good organizational skills and demonstrated ability to multi-task in a fast-paced environment. (Required) Ability to take direction from multiple sources and manage competing demands effectively. (Required) Requires excellent communication skills with the ability to communicate with people who have disabling conditions, or who have cultural differences, as well as clinicians less proficient with the needs of people with behavior issues. (Required) Proficient use of computers including MS Office applications and other applicable software applications. (Required) Working Conditions Lifting Consistently operates computer and other office equipment. Exerting up to 10 pounds of force occasionally and/or negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects. Sedentary work. Environmental Conditions Predominantly operates in an office environment. Some time spent on site in medical/hospital setting. Mental/Visual Ability to communicate and exchange accurate information. The worker is required to have close visual acuity to perform an activity such as: preparing and analyzing data and figures; transcribing; viewing a computer terminal; extensive reading. PeaceHealth is committed to the overall wellbeing of our caregivers: physical, emotional, financial, social, and spiritual. We offer caregivers a competitive and comprehensive total rewards package. Some of the many benefits included in this package are full medical/dental/vision coverage; 403b retirement plan employer base and matching contributions; paid time off; employer-paid life and disability insurance with additional buyup coverage options; tuition and continuing education reimbursement; wellness benefits, and expanded EAP and mental health program. See how PeaceHealth is committed to For full consideration of your skills and abilities, please attach a current resume with your application. EEO Affirmative Action Employer/Vets/Disabled in accordance with applicable local, state, or federal laws.
RN Utilization Review Full-time
Adventist Health

RN, Care Manager, Utilization Management (Part Time, Every Weekend)

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

Lead Clinical Review Nurse - Correspondence

apartment Centene location_onNV
$35.49 - $63.79 / 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. Location: Position is remote. Prefer candidate to live in PST time zone. Schedule: Looking for someone who will work Tuesday-Saturday. 8-5 PST. Position Purpose: Oversees correspondence letters based and supports overall team needs. Reviews outcomes in accordance with National Committee for Quality Assurance (NCQA) standards. Works with senior management to identify and implement opportunities for improvement. Oversees the clinical review of outcomes including creating and editing correspondence letters with the correspondence team based on determinations in accordance with National Committee for Quality Assurance (NCQA) standards Manages the audits of correspondence to ensure they are processed in accordance with Federal, State, and NCQA standards Provides expert insight and guidance on the clinical review process of correspondence to ensure compliance with all applicable State and Federal regulations Provides subject matter expertise insights to investigate and resolve issues including comprehensive review of clinical documentation, clinical criteria/guidelines, and policy, including insurance rejections due to coding issues and escalates as appropriate to resolve issues in a timely manner Acts as a point of contact for escalated, advanced issues and/or questions related to correspondence with the state, local, and federal agencies including third party payer and providers to ensure issues are resolved in a timely manner Oversees clinical quality and process improvement initiatives related to clinical quality indicators and financial metrics Manages data needed to identify trends and provide recommendations to senior management of process improvements within utilization management Manages and oversees cases to ensure timely resolution and logs of actions and/or decisions are appropriately documented Provides training and education to the interdepartmental teams on training needed within the utilization management team based on trends Partners with leadership to improve processes and procedures to prevent recurrences based on industry best practices Provides guidance, subject matter expertise and training as needed 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 5 – 7 years of related experience. Expert knowledge of Medicare and Medicaid regulations preferred. Expert knowledge of utilization management processes preferred. License/Certification: LPN - Licensed Practical Nurse - State Licensure required- Compact License Location: Position is remote. Prefer candidate to live in PST time zone. Schedule: Looking for someone who will work Tuesday-Saturday. 8-5 PST. Pay Range: $35.49 - $63.79 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
RN Psych Utilization Review Full-time
Centene

Utilization Review Clinician - Behavioral Health

apartment Centene location_onLA
$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. Position Purpose: Performs a clinical review and assesses care related to mental health and substance abuse. Monitors and determines if level of care and services related to mental health and substance abuse are medically appropriate. Evaluates member’s treatment for mental health and substance abuse before, during, and after services to ensure level of care and services are medically appropriate Performs prior authorization reviews related to mental health and substance abuse to determine medical appropriateness in accordance with regulatory guidelines and criteria Performs concurrent review of behavioral health (BH) inpatient to determine overall health of member, treatment needs, and discharge planning Analyzes BH member data to improve quality and appropriate utilization of services Provides education to providers members and their families regrading BH utilization process Interacts with BH healthcare providers as appropriate to discuss level of care and/or services Engages with medical directors and leadership to improve the quality and efficiency of care Formulates and presents cases in staffing and integrated rounds 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 2 – 4 years of related experience. License to practice independently, and/or have obtained the state required licensure as outlined by the applicable state required. Master’s degree for behavioral health clinicians required. Clinical knowledge and ability to review and/or assess treatment plans related to mental health and substance abuse preferred. Knowledge of mental health and substance abuse utilization review process preferred. Experience working with providers and healthcare teams to review care services related to mental health and substance abuse 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 RN - Registered Nurse - State Licensure and/or Compact State Licensure required For Fidelis Care only: LMSW, LCSW, LMHC, LPC, LMFT, LMHP or RN 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
Centene

Utilization Review Nurse I

apartment Centene location_onNew York, NY
$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. Must have an active New York State clinical license; and a NYS Driver's License or Identification card. Position Purpose: The Utilization Review Nurse I provides first level clinical review for all outpatient and ancillary services requiring authorization. Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services. Answers Utilization Management directed telephone calls; managing them in a professional and competent manner. Processes all prior authorizations to completion utilizing appropriate review criteria. Identifies and refers all potential quality issues to the Clinical Quality Management Department, and suspected fraud and abuse cases to Program Integrity. Acts as liaison between the TRICARE beneficiary and the Network Provider. Provides first level RN review for all outpatient and ancillary prior authorization requests for medical appropriateness and medical necessity using appropriate criteria, referring those requests that fail review to the medical director for second level review and determination. Completes data entry and correspondence as necessary for each review. Conducts rate negotiation with non-network providers, utilizing appropriate CMAC, DRG, HCPC reimbursement methodologies. Documents rate negotiation accurately for proper claims adjudication. Acts as liaison between the TRICARE beneficiary and the provider, facility and the MTF to utilize appropriate and cost effective medical resources within the direct care and purchased care system. Identifies and refers potential cases to Disease Management, Case Management, Demand Management and Transitional Care. Refers all potential quality issues and grievances to Clinical Quality Management and suspected fraud and abuse to Program Integrity. Performs other duties as assigned Complies with all policies and standards Education/Experience: Graduate of Nursing program; BSN desired or Graduate in Clinical Psychology or Clinical Social Work. Three years clinical experience in a health care environment; managed care experience desired. For Fidelis Care only: NYS RN, OT or PT 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 Other
Dartmouth Hitchcock Medical Center

Registered Nurse (RN) - Utilization Review, Per Diem

apartment Dartmouth Hitchcock Medical Center location_onLebanon, NH
Overview Works with physicians and multidisciplinary team members to develop a plan of care for assigned patients. Ensures patient is progressing towards desired outcomes by monitoring care through assessments and/or patient records. Identifies and resolves barriers that hinder effective patient care. Actively involved in discharge planning process. **UR specific experience preferred Responsibilities Works with Medical Director and appropriate physician(s) to establish Dartmouth-Hitchcock (D-H) ambulatory and inpatient procedure list, updates and maintains list. Reviews reservation forms and the log of emergent and urgent admissions daily. Identifies areas that require intervention and education around the use of definitions. Reviews “one day stays” to assess appropriate use of level of care (LOC) determinations. Works with individual physicians and office staff when they are experiencing discrepancies with pre-certifications. Assumes responsibility for the oversight of inpatient denials, including, but not limited to, reviewing denial letters, collaborating with the Medical Director and appropriate physicians to determine the decision to appeal or accept, assisting in the response to Health Plan, etc. Develops and implements communication strategies to keep clinicians and staff informed of changes and current practice. Works closely with others to transition level of care determinations. Provides information to departmental leadership that reflects trends and practices that may need organization, intervention, and change. Collaborates with Health Plans to understand their definitions, articulates the definitions of D-H, and assists in the development of strategies for resolution of differences. Benchmarks with other facilities concerning admission and denial experience and policies. Performs other duties as required or assigned. Qualifications Graduate from an accredited Nursing Program required. Bachelor of Science Degree in Nursing (BSN) with 3 years of experience. Masters of Science Degree in Nursing (MSN) preferred. Strong leadership, communication and computer skills desired. Required Licensure/Certifications Licensed Registered nurse with NH eligibility
RN Utilization Review Full-time
UW Medicine

RN - Second Level Review/Review Coordinator Clinical Documentation Integrity Specialist

apartment UW Medicine location_onWA
$120,000 - $165,600 / YEAR
Job Description UW Medicine - Harborview's Medical Center's Clinical Documentation Department has an outstanding opportunity for a Registered Nurse - Second Level Review/Review Coordinator Clinical Documentation Integrity Specialist. WORK SCHEDULE Full-Time Mondays-Fridays Remote position Department Description This position will also participate in various projects and initiatives within the Clinical Documentation Program. Based on findings, department goals and initiatives and industry expectation, the SLR/Review Coordinator CDIS will participate in the education of the CDI team regarding findings and opportunities for documentation improvement in their record review. This position will assume responsibility for delegating daily assignments when directed by the CDP Operations Manager, as well as participate in quality improvement projects, audits and other duties also assigned by CDP Operations Manager. POSITION HIGHLIGHTS This person will perform duties and conduct interpersonal relationships in a manner that promotes a team approach and collaborative work environment with CDI staff, coders, leadership, and physicians. Primary Job Responsibilities Compliance with internal and external regulations and policies. Self-directed initiative for independent education with current evidenced-based practices. Review target DRGs specified by CDP Operations Manager, which is an evolving workflow. This review may have a focus on various elements including, but not limited to, CC/MCC capture rate and/or risk adjustment review (Vizient/Elixhauser) Ensure that pertinent patient conditions and treatments are documented such that appropriate reimbursement is received for the level of acuity and service rendered to all patients .using an MS-DRG and/or APR-DRG based payer methodology Requirements Bachelor's degree in Nursing (minimum) with current WA or compact RN Licensure 6 + years prior nursing experience in an acute inpatient hospital setting with in-depth knowledge of medical and surgical care Minimum 5 years of CDI experience; CDI leadership/educator experience preferred Risk adjustment experience preferred (Vizient and Elixhauser preferred) Denial/Appeal experience preferred About Harborview Medical Center As the region's only Level I Trauma and verified burn center, Harborview Medical Center is a comprehensive healthcare facility owned by King County and operated by UW Medicine. It is dedicated to providing specialized care for a broad spectrum of patients from throughout the Pacific Northwest, including the most vulnerable residents of King County. It provides exemplary patient care in leading-edge centers of emphasis, including emergency medicine, trauma and burn care, neurosciences, ophthalmology, vascular surgery, HIV/AIDS, rehabilitation, mental health and substance abuse care. We are a Magnet-designated hospital as recognized by the American Nurses Credentialing Center. Harborview employees are committed to the vital role the institution plays in the immediate community, as well as the entire Northwest region. Challenge. Collaboration. Compassion. About Uw Medicine - Where Your Impact Goes Further UW Medicine is Washington’s only health system that includes a top-rated medical school and an internationally recognized research center. UW Medicine’s mission is to improve the health of the public by advancing medical knowledge, providing outstanding primary and specialty care to the people of the region, and preparing tomorrow’s physicians, scientists and other health professionals. All across UW Medicine, our employees collaborate to perform the highest quality work with integrity and compassion and to create a respectful, welcoming environment where every patient, family, student and colleague is valued and honored. Nearly 29,000 healthcare professionals, researchers, and educators work in the UW Medicine family of organizations that includes: Harborview Medical Center, UW Medical Center - Montlake, UW Medical Center - Northwest, Valley Medical Center, UW Medicine Primary Care, UW Physicians, UW School of Medicine, and Airlift Northwest. Become part of our team . Join our mission to make life healthier for everyone in our community. Compensation, Benefits And Position Details Pay Range Minimum: $120,000.00 annual Pay Range Maximum $165,600.00 annual Benefits Other Compensation: For information about benefits for this position, visit https://www.washington.edu/jobs/benefits-for-uw-staff/ Shift Alternate Work Shift (United States of America) Temporary or Regular? This is a regular position FTE (Full-Time Equivalent) 100.00% Union/Bargaining Unit Not Applicable About The UW Working at the University of Washington provides a unique opportunity to change lives – on our campuses, in our state and around the world. UW employees bring their boundless energy, creative problem-solving skills and dedication to building stronger minds and a healthier world. In return, they enjoy outstanding benefits, opportunities for professional growth and the chance to work in an environment known for its diversity, intellectual excitement, artistic pursuits and natural beauty. Our Commitment The University of Washington is committed to fostering an inclusive, respectful and welcoming community for all. As an equal opportunity employer, the University considers applicants for employment without regard to race, color, creed, religion, national origin, citizenship, sex, pregnancy, age, marital status, sexual orientation, gender identity or expression, genetic information, disability, or veteran status consistent with UW Executive Order No. 81. To request disability accommodation in the application process, contact the Disability Services Office at 206-543-6450 or dso@uw.edu. Applicants considered for this position will be required to disclose if they are the subject of any substantiated findings or current investigations related to sexual misconduct at their current employment and past employment. Disclosure is required under Washington state law.
RN Utilization Review Per Diem
Parkland Health (TX)

Registered Nurse (RN) - Utilization Management - PCHP - PRN

apartment Parkland Health (TX) location_onDallas, TX
Interested in a career with both meaning and growth? Whether your abilities are in direct patient care or one of the many other areas of healthcare administration and support, everyone at Parkland works together to fulfill our mission: the health and well-being of individuals and communities entrusted to our care. By joining Parkland, you become part of a diverse healthcare legacy that’s served our community for more than 125 years. Put your skills to work with us, seek opportunities to learn and join a talented team where patient care is more than a job. It’s our passion. Primary Purpose Parkland Community Health Plan's (PCHP's) Utilization Management (UM) Clinician is responsible for processing authorization requests for members requiring physical and/or behavioral healthcare for outpatient and inpatient service. UM responsibilities include but are not limited to processing of prior and concurrent review authorizations, discharge planning and transitions of care. Oversees the application of clinical guidelines in determining appropriateness of requested and continued healthcare services. Ensures that all clinical decisions are completed according to evidence based best practice guidelines and meets regulatory requirements. Seeks Medical Director review of cases not meeting criteria and monitors time frames for decision making and notifications of decision. Minimum Specifications Education Bachelor's degree in Nursing; or Master's Degree in Social Work or a related field required. If serving physical health populations, graduation from an accredited school of nursing is required. Experience 3+ years of acute clinical nursing or medical management experience required. If serving behavioral health populations, at least three 3+ years of clinical social work or behavioral health experience required. 3+ years of experience in Texas Medicaid, Medicaid, or a Medicaid managed care organization or health plan preferred. 1+ year experience with the implementation of utilization management policies, procedures, and protocols for physical health and/or behavioral health services and knowledge of utilization management and case management principles is preferred. Experience managing pediatric population with complex PH/BH conditions preferred. Experience in Texas Medicaid and NCQA is preferred. Certification/Registration/Licensure If primarily serving members with physical health needs, current and unrestricted licensure as a RN in the State of Texas required. If primarily serving members with behavioral health needs, must have and maintain an unrestricted license such as a RN, LPC, LMFT, or LCSW in the State of Texas. Skills or Special Abilities Knowledge of community resources, local service systems including indigent physical health and/or behavioral health systems. Knowledge of utilization management and case management principles. Understanding of utilization management principles, objectives, standards and methods, and of program policies and procedures. For those reviewing BH authorizations, demonstrate knowledge and utilization of evidence-based practices relevant to population served (persons who have experienced trauma, members with substance use disorder, members with serious mental illness or serious emotional disturbance). Competency in prior and concurrent review authorization functions including application of criteria and timelines. Demonstrated ability to analyze clinical information and accurately apply clinical criteria. Excellent verbal and written communication skills including the ability to communicate effectively and professionally across disciplines. Ability to communicate complex information in understandable terms. Proven history of effective communication and counseling skills Strong interpersonal and conflict resolution skills with the ability to establish and maintain effective working relationships across and beyond the organization. Excellent analytical and problem-solving skills. Strong time management and organizational skills with the ability to manage multiple demands and respond to rapidly changing priorities. Ability to write clearly and succinctly with a high level of attention to detail. Proficient computer and Microsoft Office skills. Ability to learn new software programs. Knowledge of Texas Medicaid, National Committee for Quality Assurance (NCQA), the Uniformed Managed Care Contract, and the Uniform Managed Care Manual. - Familiar with InterQual and Texas Medicaid Provider Procedures Manual and utilization guidelines. Solid understanding of managed care and medical terminology. Knowledge of and competence in use of UM software. Foster strong, positive, and effective working relationships with inter-system and intra-system team members, encouraging and supporting interaction among various team members across organizational lines. Responsibilities Care Coordination and Clinical Review Performs clinical utilization reviews of pre-authorization, concurrent and retrospective requests per clinical information submitted by providers using clinical criteria for medical necessity and appropriateness of care. Approves services or forwards requests to the appropriate medical director for further review, as appropriate. Performs utilization management functions competently and adheres to the guidelines for authorization turn-around times. Reviews clinical service requests from members or providers using evidence based clinical guidelines, analyzes clinical information and correctly applies clinical criteria. Requests additional information from members or providers in a timely manner and makes referrals to other clinical programs as needed. Identifies members that are high risk or who have conditions that may need service coordination or disease management and facilitates appropriate referrals. Works collaboratively with provider network and health services team to coordinate member care. Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services. Answers utilization management directed telephone calls, managing them in a professional and competent manner. Conducts ongoing availability, monitoring, and oversight of non-clinical staff activities. Uses effective relationship management, coordination of services, resource management, education, patient advocacy and related interventions to assure appropriate levels of care are received by members. Identifies and utilizes appropriate alternative and non-traditional available resources in managing cases. Documentation Provides accurate and complete documentation along with an explanation of the rationale that was used to approve requests. Documents and maintains clinical information in health management systems ensuring all pertinent information is entered in a timely manner and in accordance with department guidelines. Performs medical necessity documentation to expedite approvals and ensure that appropriate follow up is performed. Regulatory Ensures work is carried out in compliance with regulatory and/or accreditation standards as well as contractual requirements. Professional Accountability Promotes and supports a culturally welcoming and inclusive work environment. Acts with the highest integrity and ethical standards while adhering to Parkland's Mission, Vision, and Values. Adheres to organizational policies, procedures, and guidelines. Completes assigned training, self-appraisal, and annual health requirements timely. Adheres to hybrid work schedule requirements. Attends required meetings and town halls. Recognizes and communicates ethical and legal concerns through the established channels of communication. Demonstrates accountability and responsibility by independently completing work, including projects and assignments on time, and providing timely responses to requests for information. Maintains confidentiality at all times. Performs other work as requested that is reasonably related to the employee's position, qualifications, and competencies. Parkland Health and Hospital System prohibits discrimination based on age (40 or over), race, color, religion, sex (including pregnancy), sexual orientation, gender identity, gender expression, genetic information, disability, national origin, marital status, political belief, or veteran status. As part of our commitment to our patients and employees’ wellness, Parkland Health is a tobacco and smoke-free campus.
RN Utilization Review Full-time
Albany Medical Center

Utilization Review Nurse

apartment Albany Medical Center location_onAlbany, NY
Department/Unit: Care Management/Social Work Work Shift: Day (United States of America) Salary Range: $71,612.39 - $110,999.20 Responsible for Utilization Management, Quality Screening and Delay Management for assigned patients. • Completes Utilization Management and Quality Screening for assigned patients. • Applies MCG criteria to monitor appropriateness of admissions and continued stays, and documents findings based on Departmental standards. • While performing utilization review identifies areas for clinical documentation improvement and contacts appropriate department. • Identifies at-risk populations using approved screening tool and follows established reporting procedures. • Monitors LOS and ancillary resource use on an ongoing basis. Takes actions to achieve continuous improvement in both areas. • Refers cases and issues to Medical Director and Triad Team in compliance with Department procedures and follows up as indicated. • Communicates covered day reimbursement certification for assigned patients. • Discusses payor criteria and issues and a case-by-case basis with clinical staff and follows up to resolve problems with payors as needed. • Uses quality screens to identify potential issues and forwards information to the Quality Department. • Demonstrates proper use of MCG and documentation requirements through case review and inter-rater reliability studies. • Facilitates removal of delays and documents delays when they exist. Reports internal and external delays to the Triad Team. • Collaborates with the health care team and appropriate department in the management of care across the continuum of care by assuring communication with Triad Team and health care team. Minimum Qualifications: • Registered nurse with a New York State current license. • Bachelor's degree preferred. • Minimum of three years clinical experience in an assigned service. • Recent experience in case management, utilization management and/or discharge planning/home care in a high volume, acute care hospital preferred. PRI and • Case Management certification preferred. • Assertive and creative in problem solving, critical thinking skills, systems planning and patient care management. • Self-directed with the ability to adapt in a changing environment. • Basic knowledge of computer systems with skills applicable to utilization review process. • Excellent written and verbal communication skills. • Working knowledge of MCG criteria and ability to implement and utilize. • Understanding of Inpatient versus Outpatient surgery and ICD10-Coding (preferred) and Observation status qualifications. • Ability to work independently and demonstrate organizational and time management skills. • Strong analytic, data management and PC skills. • Working knowledge of Medicare regulatory requirements, Managed Care Plans Thank you for your interest in Albany Medical Center!​ Albany Medical is an equal opportunity employer. This role may require access to information considered sensitive to Albany Medical Center, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that: Access to information is based on a “need to know” and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Med Center policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification.
RN Utilization Review Full-time
John Muir Health

RN Case Manager - MSN - AS Utilization Management - Concord - Full Time - 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. Education: Bachelor's Degree Accredited School of Nursing Required Experience: 3 years Nursing - Medical/Surgical Preferred or 3 years Nursing - Critical Care Preferred 2 years Care Coordination - Case Management Preferred or Equivalent Work Experience 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 know ledge of common diagnoses and procedures and the impact this w ill have to patients/families and their ability to manage their care outside of the hospital. Specialized know ledge 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 know ledge of geriatrics and the impact to health and function in the aged as w ell as a working know ledge 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, Allscripts, InterQual, and Microsoft Outlook. Days worked per week: 5/4 Work schedule: Week 1- Tues-Sat & Week 2- Wed-Sat Work Shift: 08.0 - 08:00 - 16:30 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: 36
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 Full-time
Texas Health Resources

Clinical Reviews, Denial and Appeals RN - Full time

apartment Texas Health Resources location_onArlington, TX
25012327 Clinical Reviews, Denial and Appeals RN Bring your passion to THR so we are Better + Together Work location : Remote (Local candidates only) Work hours : Monday – Friday from 8:00am – 4:30pm Clinical Review And Denials Department Highlights Flexible schedule Remote work environment Collaborative team approach Work/life balance Opportunities for advancement Opportunities for tuition reimbursement for approved degrees Here’s What You Need Associates Degree in Nursing required Bachelor’s Degree in Nursing preferred 3 years Inpatient clinical nursing experience in an acute hospital setting required and 1 year UM experience including knowledge and application of Milliman or InterQual criteria required Case management experience preferred Denials and Appeals experience preferred RN license to practice in the state of Texas upon hire required What You Will Do Communicates and collaborates as needed with physicians, Care Management staff, Business Office, Nursing, and ancillary departments to proactively address patient care issues and denials management Conducts the necessary research for appealing denied days/stays through electronic record review. Requires access to Care Connect patient records for all THR hospitals. Collaborates with physicians when needed to develop comprehensive and effective appeal strategies for medical necessity denials. Reviews clinical documentation in order to determine if medical necessity criteria were met. Prepares appeal letters and notifications to appropriate parties and hospital departments within the specified time frames and files appeal per contracted agreement. Tracks, monitors, manage clinical denials and appeals and appeal outcomes for reporting as requested. Reports denial trends to the respective departments are used for educational corrective action. Develops and maintains relationships with other departments related to appeals and denial management. Serves as an educator and resource to the Care Management Staff, Physicians and other hospital disciplines as required/designated regarding Medicare, Medicaid and Commercial payer guidelines. Reviews Medicare one day stays and conducts medical necessity internal audits (100% one day stays) Additional perks of being a Texas Health employee Benefits include 401k, PTO, medical, dental, Paid Parental Leave, flex spending, tuition reimbursement, Student Loan Repayment Program as well as several other benefits. Delivery of high quality of patient care through nursing education, nursing research and innovations in nursing practice. Strong Unit Based Council (UBC). A supportive, team environment with outstanding opportunities for growth Entity Highlights At Texas Health Resources, our mission is “to improve the health of the people in the communities we serve”. Our award-winning culture is a tribute to our amazing employees. We’re thrilled to be a 2023 FORTUNE Magazine’s “100 Best Companies to Work For®” for the 9th year in a row! We strive to create an atmosphere of respect, integrity, compassion and excellence for all. We’re committed to diversity in our workforce, and our mission to serve spreads across ethnic, cultural, economic and generational boundaries. Join us and to do your life’s best work here! Explore our Texas Health careers site for info like Benefits, Job Listings by Category, recent Awards we’ve won and more. Do you still have questions or concerns? Feel free to email your questions to recruitment@texashealth.org.