Registered Nurse (RN) Utilization Review Jobs

RN Utilization Review Full-time
Terre Haute Regional Hospital

Clinical Nurse Reviewer

apartment Terre Haute Regional Hospital location_onNashville, TN
Description Introduction Do you want to join an organization that invests in you as a Clinical Nurse Reviewer? At Parallon, you come first. HCA Healthcare has committed up to 300 million in programs to support our incredible team members over the course of three years. Benefits Parallon offers a total rewards package that supports the health, life, career and retirement of our colleagues. The available plans and programs include: Comprehensive medical coverage that covers many common services at no cost or for a low copay. Plans include prescription drug and behavioral health coverage as well as free telemedicine services and free AirMed medical transportation. Additional options for dental and vision benefits, life and disability coverage, flexible spending accounts, supplemental health protection plans (accident, critical illness, hospital indemnity), auto and home insurance, identity theft protection, legal counseling, long-term care coverage, moving assistance, pet insurance and more. Free counseling services and resources for emotional, physical and financial wellbeing 401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service) Employee Stock Purchase Plan with 10% off HCA Healthcare stock Family support through fertility and family building benefits with Progyny and adoption assistance. Referral services for child, elder and pet care, home and auto repair, event planning and more Consumer discounts through Abenity and Consumer Discounts Retirement readiness, rollover assistance services and preferred banking partnerships Education assistance (tuition, student loan, certification support, dependent scholarships) Colleague recognition program Time Away From Work Program (paid time off, paid family leave, long- and short-term disability coverage and leaves of absence) Employee Health Assistance Fund that offers free employee-only coverage to full-time and part-time colleagues based on income. Learn more about Employee Benefits Note: Eligibility for benefits may vary by location. You contribute to our success. Every role has an impact on our patients’ lives and you have the opportunity to make a difference. We are looking for a dedicated Clinical Nurse Reviewer like you to be a part of our team. Job Summary and Qualifications The Clinical Nurse Reviewer WFH is responsible for performing retrospective medical reviews based on patient eligibility and contract requirements. Responsibilities: Perform a retrospective review of medical records using clinical expertise and Medicaid guidelines to determine medical necessity for emergent inpatient admissions and outpatient services. Perform clinical reviews and maintain clinical documentation in accordance with HCA policy, procedures, and job aids Submit authorization request based on state deadlines using various State portals Review deferred accounts and update according to payer request Review denied account to determine justification for Appeal requests Maintains clinical documentation according to HCA’S documentation policy Meet productivity requirement as established by leadership Assists in the orientation and training of new clinical staff Education: Successful completion of an accredited Licensed Practical/Vocational Nurse Program RN licensure is preferred Experience: A minimum of one-year experience reviewing medical records for medical necessity in a managed care, health plan, and/or hospital setting A minimum of one-year experience with denials and appeals in a clinical setting preferred A minimum of one-year experience in a patient care setting Experience working in a remote setting Work from home roles require employees must have high speed internet 60 MB download and 10 MB upload. Certificate/License: Currently licensed in applicable state Maintains an active LPN/LVN license in good standing " Parallon provides full-service revenue cycle management, or total patient account resolution, for HCA Healthcare. Our services include scheduling, registration, insurance verification, hospital billing, revenue integrity, collections, payment compliance, credentialing, health information management, customer service, payroll and physician billing. We also provide full-service revenue cycle management as well as targeted solutions, such as Medicaid Eligibility, for external clients across the country. Parallon has over 17,000 colleagues, and serves close to 1,000 hospitals and 3,000 physician practices, all making an impact on patients, providers and their communities. HCA Healthcare has been recognized as one of the World’s Most Ethical Companies® by the Ethisphere Institute more than ten times. In recent years, HCA Healthcare spent an estimated 3.7 billion in cost for the delivery of charitable care, uninsured discounts, and other uncompensated expenses. " "Good people beget good people." - Dr. Thomas Frist, Sr. HCA Healthcare Co-Founder We are a family 270,000 dedicated professionals! Our Talent Acquisition team is reviewing applications for our Clinical Reviewer LPN opening. Qualified candidates will be contacted for interviews. Submit your resume today to join our community of caring! We are an equal opportunity employer. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.
RN Utilization Review Full-time
Trident Health System

Clinical Nurse Reviewer

apartment Trident Health System location_onSan Antonio, TX
Description Introduction Do you want to join an organization that invests in you as a Clinical Nurse Reviewer? At Parallon, you come first. HCA Healthcare has committed up to 300 million in programs to support our incredible team members over the course of three years. Benefits Parallon offers a total rewards package that supports the health, life, career and retirement of our colleagues. The available plans and programs include: Comprehensive medical coverage that covers many common services at no cost or for a low copay. Plans include prescription drug and behavioral health coverage as well as free telemedicine services and free AirMed medical transportation. Additional options for dental and vision benefits, life and disability coverage, flexible spending accounts, supplemental health protection plans (accident, critical illness, hospital indemnity), auto and home insurance, identity theft protection, legal counseling, long-term care coverage, moving assistance, pet insurance and more. Free counseling services and resources for emotional, physical and financial wellbeing 401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service) Employee Stock Purchase Plan with 10% off HCA Healthcare stock Family support through fertility and family building benefits with Progyny and adoption assistance. Referral services for child, elder and pet care, home and auto repair, event planning and more Consumer discounts through Abenity and Consumer Discounts Retirement readiness, rollover assistance services and preferred banking partnerships Education assistance (tuition, student loan, certification support, dependent scholarships) Colleague recognition program Time Away From Work Program (paid time off, paid family leave, long- and short-term disability coverage and leaves of absence) Employee Health Assistance Fund that offers free employee-only coverage to full-time and part-time colleagues based on income. Learn more about Employee Benefits Note: Eligibility for benefits may vary by location. You contribute to our success. Every role has an impact on our patients’ lives and you have the opportunity to make a difference. We are looking for a dedicated Clinical Nurse Reviewer like you to be a part of our team. Job Summary and Qualifications The Clinical Nurse Reviewer WFH is responsible for performing retrospective medical reviews based on patient eligibility and contract requirements. Responsibilities: Perform a retrospective review of medical records using clinical expertise and Medicaid guidelines to determine medical necessity for emergent inpatient admissions and outpatient services. Perform clinical reviews and maintain clinical documentation in accordance with HCA policy, procedures, and job aids Submit authorization request based on state deadlines using various State portals Review deferred accounts and update according to payer request Review denied account to determine justification for Appeal requests Maintains clinical documentation according to HCA’S documentation policy Meet productivity requirement as established by leadership Assists in the orientation and training of new clinical staff Education: Successful completion of an accredited Licensed Practical/Vocational Nurse Program RN licensure is preferred Experience: A minimum of one-year experience reviewing medical records for medical necessity in a managed care, health plan, and/or hospital setting A minimum of one-year experience with denials and appeals in a clinical setting preferred A minimum of one-year experience in a patient care setting Experience working in a remote setting Work from home roles require employees must have high speed internet 60 MB download and 10 MB upload. Certificate/License: Currently licensed in applicable state Maintains an active LPN/LVN license in good standing " Parallon provides full-service revenue cycle management, or total patient account resolution, for HCA Healthcare. Our services include scheduling, registration, insurance verification, hospital billing, revenue integrity, collections, payment compliance, credentialing, health information management, customer service, payroll and physician billing. We also provide full-service revenue cycle management as well as targeted solutions, such as Medicaid Eligibility, for external clients across the country. Parallon has over 17,000 colleagues, and serves close to 1,000 hospitals and 3,000 physician practices, all making an impact on patients, providers and their communities. HCA Healthcare has been recognized as one of the World’s Most Ethical Companies® by the Ethisphere Institute more than ten times. In recent years, HCA Healthcare spent an estimated 3.7 billion in cost for the delivery of charitable care, uninsured discounts, and other uncompensated expenses. " "Good people beget good people." - Dr. Thomas Frist, Sr. HCA Healthcare Co-Founder We are a family 270,000 dedicated professionals! Our Talent Acquisition team is reviewing applications for our Clinical Reviewer LPN opening. Qualified candidates will be contacted for interviews. Submit your resume today to join our community of caring! We are an equal opportunity employer. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.
RN Utilization Review Full-time
Trident Health System

Clinical Nurse Reviewer

apartment Trident Health System location_onNashville, TN
Description Introduction Do you want to join an organization that invests in you as a Clinical Nurse Reviewer? At Parallon, you come first. HCA Healthcare has committed up to 300 million in programs to support our incredible team members over the course of three years. Benefits Parallon offers a total rewards package that supports the health, life, career and retirement of our colleagues. The available plans and programs include: Comprehensive medical coverage that covers many common services at no cost or for a low copay. Plans include prescription drug and behavioral health coverage as well as free telemedicine services and free AirMed medical transportation. Additional options for dental and vision benefits, life and disability coverage, flexible spending accounts, supplemental health protection plans (accident, critical illness, hospital indemnity), auto and home insurance, identity theft protection, legal counseling, long-term care coverage, moving assistance, pet insurance and more. Free counseling services and resources for emotional, physical and financial wellbeing 401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service) Employee Stock Purchase Plan with 10% off HCA Healthcare stock Family support through fertility and family building benefits with Progyny and adoption assistance. Referral services for child, elder and pet care, home and auto repair, event planning and more Consumer discounts through Abenity and Consumer Discounts Retirement readiness, rollover assistance services and preferred banking partnerships Education assistance (tuition, student loan, certification support, dependent scholarships) Colleague recognition program Time Away From Work Program (paid time off, paid family leave, long- and short-term disability coverage and leaves of absence) Employee Health Assistance Fund that offers free employee-only coverage to full-time and part-time colleagues based on income. Learn more about Employee Benefits Note: Eligibility for benefits may vary by location. You contribute to our success. Every role has an impact on our patients’ lives and you have the opportunity to make a difference. We are looking for a dedicated Clinical Nurse Reviewer like you to be a part of our team. Job Summary and Qualifications The Clinical Nurse Reviewer WFH is responsible for performing retrospective medical reviews based on patient eligibility and contract requirements. Responsibilities: Perform a retrospective review of medical records using clinical expertise and Medicaid guidelines to determine medical necessity for emergent inpatient admissions and outpatient services. Perform clinical reviews and maintain clinical documentation in accordance with HCA policy, procedures, and job aids Submit authorization request based on state deadlines using various State portals Review deferred accounts and update according to payer request Review denied account to determine justification for Appeal requests Maintains clinical documentation according to HCA’S documentation policy Meet productivity requirement as established by leadership Assists in the orientation and training of new clinical staff Education: Successful completion of an accredited Licensed Practical/Vocational Nurse Program RN licensure is preferred Experience: A minimum of one-year experience reviewing medical records for medical necessity in a managed care, health plan, and/or hospital setting A minimum of one-year experience with denials and appeals in a clinical setting preferred A minimum of one-year experience in a patient care setting Experience working in a remote setting Work from home roles require employees must have high speed internet 60 MB download and 10 MB upload. Certificate/License: Currently licensed in applicable state Maintains an active LPN/LVN license in good standing " Parallon provides full-service revenue cycle management, or total patient account resolution, for HCA Healthcare. Our services include scheduling, registration, insurance verification, hospital billing, revenue integrity, collections, payment compliance, credentialing, health information management, customer service, payroll and physician billing. We also provide full-service revenue cycle management as well as targeted solutions, such as Medicaid Eligibility, for external clients across the country. Parallon has over 17,000 colleagues, and serves close to 1,000 hospitals and 3,000 physician practices, all making an impact on patients, providers and their communities. HCA Healthcare has been recognized as one of the World’s Most Ethical Companies® by the Ethisphere Institute more than ten times. In recent years, HCA Healthcare spent an estimated 3.7 billion in cost for the delivery of charitable care, uninsured discounts, and other uncompensated expenses. " "Good people beget good people." - Dr. Thomas Frist, Sr. HCA Healthcare Co-Founder We are a family 270,000 dedicated professionals! Our Talent Acquisition team is reviewing applications for our Clinical Reviewer LPN opening. Qualified candidates will be contacted for interviews. Submit your resume today to join our community of caring! We are an equal opportunity employer. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.
RN Pediatric Utilization Review Full-time
UNC Health

RN Utilization Manager - Surgery, Women's, & Children's

apartment UNC Health location_onChapel Hill, NC
Description Areas of focus include Surgery, Women's, and Children's at UNCMC. The team: Completes clinical reviews for all areas: pediatric, adult surgical, and postpartum patients Ensures compliance in accordance to government's federal rules and regulations related to patient care and reimbursement Interacts with the Interdisciplinary Team for patient care progression Protects hospital revenue by working with payors for insurance authorizations, denials, and appeals Delivers mandated federal notices to patients/ patient representatives related to their payer source Preferences given to candidates with Medical Surgical bedside experience. 40 hrs/week with flexible schedule options available Primarily on-site with option to work remotely twice monthly Holiday rotation No Nights No on-call Become part of an inclusive organization with over 40,000 teammates, whose mission is to improve the health and well-being of the unique communities we serve. Summary: Works in collaboration with the patient/family, and interdisciplinary team (including physicians, other care providers, and payors), and assesses the patient care progression from acute care episode through post discharge for quality, efficiency, and effectiveness. The Utilization Manager works collaboratively with other Clinical Care Management staff to ensure patient needs are met and care delivery is coordinated across the continuum. The Utilization Manager completes admission, continued stay, and discharge reviews in accordance with federal regulations & the Hospitals? Utilization Management Plan. In addition, the Utilization Manager is responsible for revenue protection by reconciling physician orders, bed billing type, and medical necessity. This may include delivering notifications to patients directly. Interface is completed verbally, via email, data base tasks, or other electronic communication and via telephone. Responsibilities: 1. Clinical Review Process - Uses approved criteria and conducts admission review/status change review within 24 hours of patient admission to the hospital to ensure appropriateness of the setting and timely implementation of the plan of care. Identifies and obtains observation status as appropriate. Partners with physicians, nursing, and other care providers to help ensure timely and accurate documentation of patient data and treatments. Communicates daily with the Case Manager to manage level of care transitions & appropriate utilization of services. Coordinates with the support center to assure third party payor pre-certification and/or re-certifications when required. Utilizes high risk screening criteria to make appropriate referrals to Manager. 2. Discharge Facilitation - Identifies patient/families with the complex psychosocial, on-going medical discharge planning issues, continuing care needs by initiating appropriate case management referrals. Initiates appropriate social work referrals. 3. Utilization Management Process - Performs utilization management assessments and interventions, using collaboration with interdisciplinary team approach, on assigned patients as appropriate to ensure optimal patient outcomes. Using approved criteria, conducts continued stay and quality reviews to monitor the patient's progress along the continuum of care and intervenes as necessary to ensure appropriateness of setting and that the services provided are quality-driven, efficient, and effective. Enters all pertinent review data into the correct computer system in a timely manner. Consults with Physician Advisor as necessary to resolve barriers through appropriate administrative and medical channels. 4. Utilization Outcomes Management - Monitors and guides to trend interdisciplinary documentation and guides medical staff in documentation that will assist in coding accuracy, enhance quality of care, reflect accurate severity of illness and appropriate reimbursement. Facilitates patient movement to appropriate (acuity) level of care including observation status issues through collaboration with patient/family, multidisciplinary team, third party payors and resource center. Provides information regarding denials and approvals to designated entities. Assists in coordination of practice parameter development with the assigned departments/sections/specialties of Medical Staff. Oversees collection and analysis of patient care and financial data relevant to the target case types. Directs delivery of notifications to patients (includes traveling to hospital(s) to deliver notifications. Other Information Other information: Education Requirements: ● Graduation from a state-accredited school of professional nursing ● If hired after October 1, 2015, must be enrolled in an accredited program within four years of employment, and obtain a Bachelor's degree with a major in Nursing or a Master's degree with a major in Nursing within seven years of employment date. Licensure/Certification Requirements: ● Licensed to practice as a Registered Nurse in the state of North Carolina. Professional Experience Requirements: ● Two (2) years of clinical experience in a medical facility and/or comparable Utilization Management experience. Knowledge/Skills/and Abilities Requirements: Job Details Legal Employer: STATE Entity: UNC Medical Center Organization Unit: UNCH Care Mgmt-Medical Center Work Type: Full Time Standard Hours Per Week: 40.00 Salary Range: $35.87 - $51.57 per hour (Hiring Range) Pay offers are determined by experience and internal equity Work Assignment Type: Onsite Work Schedule: Day Job Location of Job: US:NC:Chapel Hill Exempt From Overtime: Exempt: Yes This is a State position employed by UNC Health Care System with UNC Health benefits. If, however, you are presently an employee of another North Carolina agency and currently participate in TSERS or the ORP, you will be eligible to continue participating in those plans at UNC Health. Qualified applicants will be considered without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, status as a protected veteran or political affiliation. UNC Health makes reasonable accommodations for applicants' and employees' religious practices and beliefs, as well as applicants and employees with disabilities. All interested applicants are invited to apply for career opportunities. Please email applicant.accommodations@unchealth.unc.edu if you need a reasonable accommodation to search and/or to apply for a career opportunity.
RN Utilization Review Part-time
John Muir Health

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

apartment John Muir Health location_onConcord, CA
Job Description: The role of the inpatient case manager is one of patient advocate of appropriate utilization of resources. The inpatient case manager applies the process of assessment, planning, implementation, monitoring, evaluation and coordination of care to meet the patient’s health care needs through hospitalization and transition back to the community and does this in coordination with the interdisciplinary health team. The RN Case Manager is expected to function within the full scope of the nursing practice with specialized focus on care coordination, compliance, transition management, education, and utilization management. 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. Work shift : 0800-1630 Days worked per week: Per Diem Hours worked per day: 8 Work Shift: 08.0 - Per Diem Days No Waive (United States of America) Pay Range: $84.77 - $115.51 Hourly Offer amounts are based on demonstrated/relevant experience and/or licensure. Pay will be adjusted to the local market if hired outside of the Bay Area . Note: Positions at JMH which are exempt (not eligible for overtime) under the level of Manager are listed as hourly for compensation purposes on this posting. The work shift will contain the word ‘exempt’ on it. Scheduled Weekly Hours: 0
RN Utilization Review Full-time
Prime Healthcare

RN Case Manager - Utilization Review

apartment Prime Healthcare location_onLynwood, CA
Overview St. Francis Medical Center is one of the leading comprehensive healthcare institutions in Los Angeles. St. Francis provides vital healthcare services for the 700,000 adults and 300,000 children in our community who count on the hospital for high quality and compassionate medical care. St. Francis is recognized for its full range of diagnostic and treatment services in specialties including Cardiovascular, Surgical, Orthopedics, Obstetrics, Pediatrics, Behavioral Health, and Emergency and Trauma Care. In addition, the hospital offers a broad array of education and outreach programs that advance community health. St. Francis Medical Center is a Comprehensive Stroke Center, STEMI Receiving Center, ED Approved for Pediatrics, Geriatric ED, Level III Neonatal ICU, and Level II Trauma Center. Please visit www.stfrancismedicalcenter.com for more information. Join an award-winning team of dedicated professionals committed to compassion, quality, and service! Responsibilities Responsible for the quality and resource management of all patients that are admitted to the facility from the point of their admission and across the continuum of the health care management. Works on behalf of the advocate, promoting cost containment and demonstrates leadership to integrate the health care providers to achieve a perceived seamless delivery of care. The methodology is designed to facilitate and insure the achievement of quality, clinical and cost effective outcomes and to perform a holistic and comprehensive admission and concurrent review of the medical record for the medical necessity, intensity of service and severity of illness. Qualifications EDUCATION, EXPERIENCE, TRAINING 1. Starting April 1 2015. Minimum 5 years work experience post-graduation of an accredited school of nursing and a current state Registered Nurse license.2. Grandfathered prior to April 1, 2015. Minimum 5 years post graduate of an accredited school Of Social Work for Licensed Clinical Social Worker. However, RN Case Manager preferred.3. Five years acute care nursing experience preferred. At least one year experience in case management, discharge planning or nursing management, preferred.4. Current BCLS (AHA) certificate, preferred. 5. Knowledge of Milliman Criteria and InterQual Criteria preferred.6. Experience and knowledge in basic to intermediate computer skills. Pay Transparency St. Francis Medical Center offers competitive compensation and a comprehensive benefits package that provides employees the flexibility to tailor benefits according to their individual needs. Our Total Rewards package includes, but is not limited to, paid time off, a 401K retirement plan, medical, dental, and vision coverage, tuition reimbursement, and many more voluntary benefit options. Benefits may vary based on collective bargaining agreement requirements and/or the employment status, i.e. full-time or part-time. The current compensation range for this role is $47.20 to $63.45. The exact starting compensation to be offered will be determined at the time of selecting an applicant for hire, in which a wide range of factors will be considered, including but not limited to, skillset, years of applicable experience, education, credentials and licensure. Employment Status Full Time Shift Evenings Equal Employment Opportunity Company is an equal employment opportunity employer. Company prohibits discrimination against any applicant or employee based on race, color, sex, sexual orientation, gender identity, religion, national origin, age (subject to applicable law), disability, military status, genetic information or any other basis protected by applicable federal, state, or local laws. The Company also prohibits harassment of applicants or employees based on any of these protected categories. Know Your Rights: https://www.eeoc.gov/sites/default/files/2022-10/EEOC_KnowYourRights_screen_reader_10_20.pdf Privacy Notice Privacy Notice for California Applicants: https://www.primehealthcare.com/wp-content/uploads/2024/04/Notice-at-Collection-and-Privacy-Policy-for-California-Job-Applicants.pdf
RN Utilization Review Full-time
Molina Healthcare

Care Review Clinician (RN) (Must Reside in IL)

apartment Molina Healthcare location_onChicago, IL
$27.73 - $54.06 / hour
JOB DESCRIPTION Job SummaryProvides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines. • Analyzes clinical service requests from members or providers against evidence based clinical guidelines. • Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. • Conducts reviews to determine prior authorization/financial responsibility for Molina and its members. • Processes requests within required timelines. • Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner. • Requests additional information from members or providers as needed. • Makes appropriate referrals to other clinical programs. • Collaborates with multidisciplinary teams to promote the Molina care model. • Adheres to utilization management (UM) policies and procedures. Required Qualifications • At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience. • Registered Nurse (RN). License must be active and unrestricted in state of practice. • Ability to prioritize and manage multiple deadlines. • Excellent organizational, problem-solving and critical-thinking skills. • Strong written and verbal communication skills. • Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications • Certified Professional in Healthcare Management (CPHM). • Recent hospital experience in an intensive care unit (ICU) or emergency room. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $27.73 - $54.06 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
RN Utilization Review Full-time
Molina Healthcare

Medical Review Nurse (RN)

apartment Molina Healthcare location_onLong Beach, CA
Job Description Job Summary Provides support for medical claim and internal appeals review activities - ensuring alignment with applicable state and federal regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Contributes to overarching strategy to provide quality and cost-effective member care. Job Duties Facilitates clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases in which an appeal has been made, or is likely to be made, to ensure medical necessity and appropriate/accurate billing and claims processing. Reevaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of relevant and applicable state and federal regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of services provided, length of stay, level of care, and inpatient readmissions. Validates member medical records and claims submitted/correct coding, to ensure appropriate reimbursement to providers. Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) issues. Identifies and reports quality of care issues. Assists with complex claim review including diagnosis-related group (DRG) validation, itemized bill review, appropriate level of care, inpatient readmission, and any opportunities identified by the payment integrity analytical team; makes decisions and recommendations pertinent to clinical experience. Prepares and presents cases representing Molina, along with the chief medical officer (CMO), for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings. Reviews medically appropriate clinical guidelines and other appropriate criteria with medical directors on denial decisions. Supplies criteria supporting all recommendations for denial or modification of payment decisions. Serves as a clinical resource for utilization management, CMOs, physicians and member/provider inquiries/appeals. Provides training and support to clinical peers. Identifies and refers members with special needs to the appropriate Molina program per applicable policies/protocols. Job Qualifications REQUIRED QUALIFICATIONS: At least 2 years clinical nursing experience, including at least 1 year of utilization review, medical claims review, long-term services and supports (LTSS), claims auditing, medical necessity review and/or coding experience, or equivalent combination of relevant education and experience. Registered Nurse (RN). License must be active and unrestricted in state of practice. Experience demonstrating knowledge of ICD-10, Current Procedural Technology (CPT) coding and Healthcare Common Procedure Coding (HCPC). Experience working within applicable state, federal, and third-party regulations. Analytic, problem-solving, and decision-making skills. Organizational and time-management skills. Attention to detail. Critical-thinking and active listening skills. Common look proficiency. Effective verbal and written communication skills. Microsoft Office suite and applicable software program(s) proficiency. PREFERRED QUALIFICATIONS: Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ), or other health care certifications. Nursing experience in critical care, emergency medicine, medical/surgical or pediatrics. Billing and coding experience. 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: $29.05 - $67.97 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
RN Utilization Review Full-time
Molina Healthcare

Medical Review Nurse (RN) (Michigan Provider Post Appeals)

apartment Molina Healthcare location_onLong Beach, CA
Job Description Job Summary Provides support for medical claim and internal appeals review activities - ensuring alignment with applicable state and federal regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Contributes to overarching strategy to provide quality and cost-effective member care. Job Duties Facilitates clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases in which an appeal has been made, or is likely to be made, to ensure medical necessity and appropriate/accurate billing and claims processing. Reevaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of relevant and applicable state and federal regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of services provided, length of stay, level of care, and inpatient readmissions. Validates member medical records and claims submitted/correct coding, to ensure appropriate reimbursement to providers. Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) issues. Identifies and reports quality of care issues. Assists with complex claim review including diagnosis-related group (DRG) validation, itemized bill review, appropriate level of care, inpatient readmission, and any opportunities identified by the payment integrity analytical team; makes decisions and recommendations pertinent to clinical experience. Prepares and presents cases representing Molina, along with the chief medical officer (CMO), for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings. Reviews medically appropriate clinical guidelines and other appropriate criteria with medical directors on denial decisions. Supplies criteria supporting all recommendations for denial or modification of payment decisions. Serves as a clinical resource for utilization management, CMOs, physicians and member/provider inquiries/appeals. Provides training and support to clinical peers. Identifies and refers members with special needs to the appropriate Molina program per applicable policies/protocols. Job Qualifications REQUIRED QUALIFICATIONS: At least 2 years clinical nursing experience, including at least 1 year of utilization review, medical claims review, long-term services and supports (LTSS), claims auditing, medical necessity review and/or coding experience, or equivalent combination of relevant education and experience. Registered Nurse (RN). License must be active and unrestricted in state of practice. Experience demonstrating knowledge of ICD-10, Current Procedural Technology (CPT) coding and Healthcare Common Procedure Coding (HCPC). Experience working within applicable state, federal, and third-party regulations. Analytic, problem-solving, and decision-making skills. Organizational and time-management skills. Attention to detail. Critical-thinking and active listening skills. Common look proficiency. Effective verbal and written communication skills. Microsoft Office suite and applicable software program(s) proficiency. PREFERRED QUALIFICATIONS: Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ), or other health care certifications. Nursing experience in critical care, emergency medicine, medical/surgical or pediatrics. Billing and coding experience. 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: $29.05 - $67.97 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
RN Utilization Review Full-time
Catawba Valley Health System

Utilization Review Nurse / Utilization Review / Full Time

apartment Catawba Valley Health System location_onConover, NC
JOB DESCRIPTION Summary of Performance Expectations Manages the utilization review process for assigned patients. Assesses the appropriateness of admission and treatment plans based upon clinical norms and judgment. Participates in a unified program of concurrent and retrospective monitoring of factors contributing to efficient utilization of hospital resources to provide quality patient care in the most cost effective manner possible. Balances fiscal benefits for the patient with fiscal restraints for the organization that may be imposed by regulatory agencies. Advocates for patients and intercedes as necessary to accomplish these goals. Provides education to the patient, patient’s family/significant others, physicians, administration, and hospital staff related to the utilization review. Education And Credentials: Required: Graduate of accredited nursing program. Current NC RN license or licensure from Nursing Compact State. BCLS certification. If the BCLS certification is not from the American Heart Association (AHA), an AHA certification is required within three months of employment date. Bachelor of Science in Nursing Degree Requirements: Effective May 4, 2015 newly employed Registered Nurses and current employees promoted to Registered Nurse positions are required to possess a BSN or higher nursing degree. The BSN or higher nursing degree must be completed within five years from the date of employment or placement into the RN position. Incumbents in CVMC RN positions on the effective date will not be required to satisfy the BSN degree requirement to maintain their current position, be promoted to a charge nurse or Operating Room specialty RN position, or apply for lateral RN positions in another CVMC department. Exception: RNs transferring to the IRT department are subject to the BSN requirement. RNs employed in positions at Catawba Valley Medical Group (CVMG), Fairgrove Primary Health and Catawba Valley Infectious Disease are exempt from this requirement. Preferred: Work Experience: Required: Three years of previous nursing experience. Given training and on-the-job experience, incumbent should be proficient in the basic aspects of the job within three months of employment date. Preferred: Two years discharge planning, utilization review, or case management experience. ABOUT US About Catawba Valley Medical Center COMPREHENSIVE, ACCESSIBLE HEALTHCARE SERVICES IN THE CATAWBA VALLEY As the region’s largest not-for-profit community hospital, we exist to heal and comfort patients, to promote and foster a healthier community, and to ensure access to healthcare to all who need it - regardless of ability to pay. With a wide array of medical specialties, our skilled nurses and providers are trained to treat virtually any type of injury or illness, providing high-quality, easily accessible healthcare close to home. Our mission: Exceptional Healthcare. Every Person. Every Time. At A Glance: North Carolina’s first and only 5-time Magnet recipient for nursing excellence Region’s only level III Neonatal Intensive Care Unit (NICU) Women’s Choice Award winner for America’s Best 100 Hospitals for Patient Experience for six consecutive years American College of Surgeons Accredited Comprehensive Community Cancer Center HIGH LEVEL OF TECHNICAL CARE FROM MEDICAL EXPERTS Catawba Valley Medical Center offers a wide range of services from experienced medical specialists capable of addressing virtually any healthcare concern. Our current hospital holds 258 beds and serves the five-county Hickory area. Through our skilled medical practitioners and our highly trained staff, we strive to provide the highest level of medical expertise using the latest, state-of-the-art technology available. One of our goals at Catawba Valley Medica Center is to provide seamless care between your primary care provider and our hospital. Being a part of a vast healthcare network allows for easier and more efficient communication between local physicians, medical specialists and our hospital. No one should have to travel far for the expert level medical treatment they need. We work with a plethora of medical specialists capable of diagnosing, treating and operating on a wide variety of conditions.
RN Utilization Review Part-time
UF Health

RN, Utilization Management

apartment UF Health location_onGainesville, FL
Overview Assists the hospital healthcare team in maintaining quality efficient patient centered care. Serves as a resource to physicians; conducts admission and concurrent reviews; identifies patients who do not meet criteria and takes action to ensure the patient is placed in the most appropriate alternative level of care and determines the correct admission status and level of care for those patients who meet hospital admission criteria (ambulatory surgery, observation, and inpatient). Qualifications Minimum Education and Experience Requirements: Registered nurse (RN) with current Florida license with three (3) years critical care nursing experience, five (5) years medical-surgical nursing experience or three (3) years utilization/case management or 3rd party payer work experience. Ability to adjust priorities quickly. Ability to organize multiple tasks simultaneously. Ability to work independently. Ability to work interdependently with many levels of staff. Attention to detail. Excellent organizational, interpersonal and communication skills. Innovative problem solving skills. Scheduled work hours and days may vary depending upon departmental needs determined by department director/manager. Motor Vehicle Operator Designation: Employees in this position: Will not operate vehicles for an assigned business purpose NOTE: A frequent driver is defined as one who uses his/her personal or Shands automobile a) at least once daily, b) at least five individual trips per week or c) drives, on average, over 150 miles per week in the performance of his/her job. Please indicate the appropriate operator designation on the Request for Personnel (RFP) form at the time a RFP is submitted to post the position. Licensure/Certification/Registration: Registered Nurse (RN) with current Florida License
RN Utilization Review Per Diem
UNC Health

RN Utilization Manager - (Per Diem) Care Management

apartment UNC Health location_onSmithfield, NC
Description Become part of an inclusive organization with over 40,000 teammates, whose mission is to improve the health and well-being of the unique communities we serve. Summary: Works in collaboration with the patient/family, and interdisciplinary team (including physicians, other care providers, and payors), and assesses the patient care progression from acute care episode through post discharge for quality, efficiency, and effectiveness. The Utilization Manager works collaboratively with other Clinical Care Management staff to ensure patient needs are met and care delivery is coordinated across the continuum. The Utilization Manager completes admission, continued stay, and discharge reviews in accordance with federal regulations & the Hospitals? Utilization Management Plan. In addition, the Utilization Manager is responsible for revenue protection by reconciling physician orders, bed billing type, and medical necessity. This may include delivering notifications to patients directly. Interface is completed verbally, via email, data base tasks, or other electronic communication and via telephone. Responsibilities: 1. Clinical Review Process - Uses approved criteria and conducts admission review/status change review within 24 hours of patient admission to the hospital to ensure appropriateness of the setting and timely implementation of the plan of care. Identifies and obtains observation status as appropriate. Partners with physicians, nursing, and other care providers to help ensure timely and accurate documentation of patient data and treatments. Communicates daily with the Case Manager to manage level of care transitions & appropriate utilization of services. Coordinates with the support center to assure third party payor pre-certification and/or re-certifications when required. Utilizes high risk screening criteria to make appropriate referrals to Manager. 2. Discharge Facilitation - Identifies patient/families with the complex psychosocial, on-going medical discharge planning issues, continuing care needs by initiating appropriate case management referrals. Initiates appropriate social work referrals. 3. Utilization Management Process - Performs utilization management assessments and interventions, using collaboration with interdisciplinary team approach, on assigned patients as appropriate to ensure optimal patient outcomes. Using approved criteria, conducts continued stay and quality reviews to monitor the patient's progress along the continuum of care and intervenes as necessary to ensure appropriateness of setting and that the services provided are quality-driven, efficient, and effective. Enters all pertinent review data into the correct computer system in a timely manner. Consults with Physician Advisor as necessary to resolve barriers through appropriate administrative and medical channels. 4. Utilization Outcomes Management - Monitors and guides to trend interdisciplinary documentation and guides medical staff in documentation that will assist in coding accuracy, enhance quality of care, reflect accurate severity of illness and appropriate reimbursement. Facilitates patient movement to appropriate (acuity) level of care including observation status issues through collaboration with patient/family, multidisciplinary team, third party payors and resource center. Provides information regarding denials and approvals to designated entities. Assists in coordination of practice parameter development with the assigned departments/sections/specialties of Medical Staff. Oversees collection and analysis of patient care and financial data relevant to the target case types. Directs delivery of notifications to patients (includes traveling to hospital(s) to deliver notifications. Other Information Other information: Education Requirements: ● Graduation from a state-accredited school of professional nursing ● If hired after October 1, 2015, must be enrolled in an accredited program within four years of employment, and obtain a Bachelor's degree with a major in Nursing or a Master's degree with a major in Nursing within seven years of employment date. Licensure/Certification Requirements: ● Licensed to practice as a Registered Nurse in the state of North Carolina. Professional Experience Requirements: ● Two (2) years of clinical experience in a medical facility and/or comparable Utilization Management experience. Knowledge/Skills/and Abilities Requirements: Job Details Legal Employer: NCHEALTH Entity: Johnston Health Organization Unit: Care Management - Work Type: Per Diem Standard Hours Per Week: 4.00 Salary Range: $35.87 - $51.57 per hour (Hiring Range) Pay offers are determined by experience and internal equity Work Assignment Type: Onsite Work Schedule: Weekend Location of Job: US:NC:Smithfield Exempt From Overtime: Exempt: Yes This position is employed by NC Health (Rex Healthcare, Inc., d/b/a NC Health), a private, fully-owned subsidiary of UNC Heath Care System. This is not a State employed position. Qualified applicants will be considered without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, status as a protected veteran or political affiliation. UNC Health makes reasonable accommodations for applicants' and employees' religious practices and beliefs, as well as applicants and employees with disabilities. All interested applicants are invited to apply for career opportunities. Please email applicant.accommodations@unchealth.unc.edu if you need a reasonable accommodation to search and/or to apply for a career opportunity.
RN Utilization Review Full-time
State of Maryland

MEDICAL SERVICES REVIEWING NURSE II

apartment State of Maryland location_onBaltimore, MD
GRADE 20 LOCATION OF POSITION MDH - Division of Community Support Services 201 W. Preston Street Baltimore, MD 21201 Main Purpose of Job This position will provide medical and staff support to the Division of Community Support Services (DCSS) within the Office of Long Term Services and Supports (OLTSS). This position will conduct policy and utilization control activities to ensure delivery of appropriate quality medical care to Title XIX recipients of medical supplies, equipment, oxygen, and transportation services. This position supports the mission of the Maryland Department of Health because it controls the utilization of resources expended for medical supplies, equipment, and oxygen, while assuring that Medicaid clients receive these services when medically necessary. This position operates in a hybrid manner, meaning job duties will be performed both remotely and on-site unless otherwise directed by the appointing authority. Minimum Qualifications Education: A Bachelor’s degree in Nursing or a related field from an accredited college or university. Experience: One year of experience reviewing medical services claims to ensure that the nature and quality of services are in accordance with State and federal regulations. Notes Candidates may substitute two years of experience as a Registered Nurse for the required education. Candidates may substitute U.S. Armed Forces military service experience as a commissioned officer in Nursing classifications or Nursing specialty codes in the Nursing field of work on a year-for-year basis for the required education. Desired Or Preferred Qualifications The desired candidate should possess the following: Analytical skills with reviewing claims. Prior Medicaid knowledge and experience. Experience with and understanding of state and federal policies and regulations. Experience with Disposable Medical Supplies and Durable Medical Equipment (DMS/DME), Prosthetics, Orthotics, and Oxygen and Related Respiratory Equipment (Oxygen) criteria. LICENSES, REGISTRATIONS AND CERTIFICATIONS Candidates for positions in this classification must possess a current license as a Registered Nurse from the Maryland State Board of Nursing, 4140 Patterson Avenue, Baltimore, Maryland 21215 or possess a current multi-state license in party states that candidates have declared as primary states of residence. Employees in this classification may be assigned duties which require the operation of a motor vehicle. Employees assigned such duties will be required to possess a motor vehicle operator’s license valid in the State of Maryland. SELECTION PROCESS Applicants who meet the minimum (and selective) qualifications will be included in further evaluation. The evaluation may be a rating of your application based on your education, training and experience as they relate to the requirements of the position. Therefore, it is essential that you provide complete and accurate information on your application. Please report all related education, experience, dates and hours of work. Clearly indicate your college degree and major on your application, if applicable. For education obtained outside the U.S., any job offer will be contingent on the candidate providing an evaluation for equivalency by a foreign credential evaluation service prior to starting employment (and may be requested prior to interview). Complete applications must be submitted by the closing date. Information submitted after this date will not be added. Incorrect application forms will not be accepted. Resumes will not be accepted in lieu of a completed application. Candidates may remain on the certified eligible list for a period of at least one year. The resulting certified eligible list for this recruitment may be used for similar positions in this or other State agencies. Benefits STATE OF MARYLAND BENEFITS FURTHER INSTRUCTIONS Online applications are highly recommended. However, if you are unable to apply online, the paper application (and supplemental questionnaire) may be submitted to MDH, Recruitment and Selection Division, 201 W. Preston St., Room 114-B, Baltimore, MD 21201. Paper application materials must be received by 5 pm, close of business, on the closing date for the recruitment, no postmarks will be accepted. If additional information is required, the preferred method is to upload. If you are unable to upload, please fax the requested information to 410-333-5689. Only additional materials that are required will be accepted for this recruitment. All additional information must be received by the closing date and time. For questions regarding this recruitment, please contact the MDH Recruitment and Selection Division at 410-767-1251. If you are having difficulty with your user account or have general questions about the online application system, please contact the MD Department of Budget and Management, Recruitment and Examination Division at 410-767-4850 or Application.Help@maryland.gov . Appropriate accommodations for individuals with disabilities are available upon request by calling: 410-767-1251 or MD TTY Relay Service 1-800-735-2258. We thank our Veterans for their service to our country. People with disabilities and bilingual candidates are encouraged to apply. As an equal opportunity employer, Maryland is committed to recruitment, retaining and promoting employees who are reflective of the State's diversity. MDHMedCare
RN Utilization Review Full-time
St. Bernards Healthcare

UTILIZATION EXPERT - RN

apartment St. Bernards Healthcare location_onJonesboro, AR
JOB REQUIREMENTS Education Must be licensed as a Registered Nurse in the state of Arkansas or a Compact State. BSN preferred. Experience Minimum of one year recent experience in hospital practice preferred. Physical This is a safety sensitive position. Please see the St. Bernards Substance Abuse Policy for further information. Normal hospital environment. Occasional exposure to fumes, odors, biological and electrical hazards. Normal/corrected eyesight with close eye work. Hearing of normal and soft tones. Uses computer, telephone, copier, fax, and scanner. Long periods of sitting. Occasional walking, bending, and climbing. May lift, carry, push and pull up to 5 pounds. JOB SUMMARY The Utilization Review Expert Nurse is responsible for the providing the physicians with direction on the admission status, recording the admission interview, medication reconciliation initiating the Plan of Care and delivering patient education process. The person in this position must possess excellent communication skills and function at a high level as a member of the collaborative interdisciplinary team. The role of this position is pivotal in coordinating the care of the patient to facilitate an efficient and effective stay in the hospital. This position is required to utilize independent judgment.
RN Utilization Review Full-time
UT Southwestern Medical Center

PRN Utilization Review RN - M-F Days

apartment UT Southwestern Medical Center location_onDallas, TX
Must be available to work daytime hours (between 8am-6:30pm) Monday - Friday WHY UT SOUTHWESTERN? With over 75 years of excellence in Dallas-Fort Worth, Texas, UT Southwestern is committed to excellence, innovation, teamwork, and compassion. As a world-renowned medical and research center, we strive to provide the best possible care, resources, and benefits for our valued employees. Ranked as the number 1 hospital in Dallas-Fort Worth according to U.S. News & World Report, we invest in you with opportunities for career growth and development to align with your future goals. Our highly competitive benefits package offers healthcare, PTO and paid holidays, on-site childcare, wage, merit increases and so much more. We invite you to be a part of the UT Southwestern team where you'll discover a culture of teamwork, professionalism, and a rewarding career! Job Summary Conduct medical certification review for medical necessity for acute care facility and services. Use nationally recognized, evidence-based guidelines approved by medical staff to recommend level of care to the physician and serve as a resource to the medical staff on issues related to admission qualifications, resource utilization, national and local coverage determinations and documentation requirements. Benefits UT Southwestern is proud to offer a competitive and comprehensive benefits package to eligible employees. Our benefits are designed to support your overall wellbeing, and include: PPO medical plan, available day one at no cost for full-time employee-only coverage 100% coverage for preventive healthcare-no copay Paid Time Off, available day one Retirement Programs through the Teacher Retirement System of Texas (TRS) Paid Parental Leave Benefit Wellness programs Tuition Reimbursement Public Service Loan Forgiveness (PSLF) Qualified Employer Learn more about these and other UTSW employee benefits! Required EXPERIENCE AND EDUCATION Education Graduate of accredited nursing program and holds an active unrestricted RN license in the State of Texas Experience 5 years experience to include 2 years of clinical experience and minimum of 3 years of recent utilization review experience. and Prior experience with Epic CCM. Licenses and Certifications (RN) REGISTERED NURSE Holds an active unrestricted license in the State of Texas. and Preferred Experience Job Duties Acute care experience preferred Collaborates with the Central Scheduling Department (CSD) team to provide accurate and complete clinical information in order to obtain authorization. Conducts admission reviews for Medicare and Medicaid beneficiaries as well as private insurance members and self-pay patients utilizing evidence-based guidelines. New admission reviews are done concurrently at the point of entry when the admission order is placed and necessary clinical information is available in the medical record. Communicate with admitting physicians and physician advisors when documentation does not appear to support hospital level of care. Use hospital approved medical necessity tool to determine level of care for inpatient or observation/outpatient services based on physician documentation, H&P, treatment plan, potential risks, and basis for expectation of a two-midnight stay. Keeps current on all Federal, State and local regulatory changes that affect delivery or reimbursement of acute care services within the scope of Utilization Management. Uses knowledge of national and local coverage determinations to appropriately advise physicians. Proactively collaborates with admitting physician to provide accurate level of care determination at the time of review. Escalates identified progression-of-care/patient flow barriers to appropriate departments. Actively participates in daily huddles, departmental meetingsand education offerings. Identifies and records episodes of preventable delays or avoidable days due to failure of progression-of-care processes. Educates members of the patient's care team on the appropriate access to and use of various levels of care. Promotes use of evidence-based protocols and/or order sets to influence high-quality and cost-effective care. Serves as a resource person to physicians, care coordinators, physician offices and billing office for coverage and compliance issues. Completes all reviews within department established policies and best practice standards. Meets department quality standards as established for the department, ie: Inter-rater Reliability audits, completing all initial reviews within established time frames, completes concurrent and discharge reviews to meet department and industry standards. Performs other duties as assigned. SECURITY AND EEO STATEMENT Security This position is security-sensitive and subject to Texas Education Code 51.215, which authorizes UT Southwestern to obtain criminal history record information. EEO UT Southwestern Medical Center is committed to an educational and working environment that provides equal opportunity to all members of the University community. As an equal opportunity employer, UT Southwestern prohibits unlawful discrimination, including discrimination on the basis of race, color, religion, national origin, sex, sexual orientation, gender identity, gender expression, age, disability, genetic information, citizenship status, or veteran status. Primary Location Texas-Dallas-5323 Harry Hines Blvd Work Locations 5323 Harry Hines Blvd Job Nursing Organization 844107 - Utilization Management Schedule Per Diem - PRN Shift Day Job Employee Status Regular Job Type Standard Job Posting Jan 21, 2026, 12:49:13 AM
RN Utilization Review Full-time
Molina Healthcare

Care Review Clinician (RN)

apartment Molina Healthcare location_onLong Beach, CA
JOB DESCRIPTION Job SummaryProvides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines. • Analyzes clinical service requests from members or providers against evidence based clinical guidelines. • Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. • Conducts reviews to determine prior authorization/financial responsibility for Molina and its members. • Processes requests within required timelines. • Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner. • Requests additional information from members or providers as needed. • Makes appropriate referrals to other clinical programs. • Collaborates with multidisciplinary teams to promote the Molina care model. • Adheres to utilization management (UM) policies and procedures. Required Qualifications • At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience. • Registered Nurse (RN). License must be active and unrestricted in state of practice. • Ability to prioritize and manage multiple deadlines. • Excellent organizational, problem-solving and critical-thinking skills. • Strong written and verbal communication skills. • Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications • Certified Professional in Healthcare Management (CPHM). • Recent hospital experience in an intensive care unit (ICU) or emergency room. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $26.41 - $61.79 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
RN ER Utilization Review Full-time
Integris Health

RN Quality Reviewer - Baptist Emergency Dept - Days

apartment Integris Health location_onOklahoma City, OK
Job Description INTEGRIS Health Baptist Medical Center, Oklahoma's largest not-for-profit health system has a great opportunity for an RN Quality Reviewer in Oklahoma City, OK. In this position, you'll work work Days M-F 8a to 5p with our Baptist Emergency Dept providing exceptional care to those who have entrusted INTEGRIS Health with their healthcare needs. If our mission of partnering with people to live healthier lives speaks to you, apply today and learn more about our recently enhanced benefits package for all eligible caregivers such as, front loaded PTO, 100% INTEGRIS Health paid short term disability, increased retirement match, and paid family leave. We invite you to join us as we strive to be The Most Trusted Partner for Health. The RN Coordinator Quality & Performance Improvement, coordinates, plans, and implements the Quality Program, Performance Improvement Program, and Patient Safety Program for the assigned department. This position requires population specific competencies. Adheres to National Patient Safety Goals as appropriate based on the level of patient contact this position requires. INTEGRIS is an Equal Opportunity/Affirmative Action Employer. All applicants will receive consideration regardless of membership in any protected status as defined by applicable state or federal law, including protected veteran or disability status. Responsibilities The RN Coordinator Quality & PI, responsibilities include, but are not limited to, the following: Supports the medical staff and hospital departments to effectively measure, assess, and improve the quality and safety of patient care and services. Assists staff in identifying achievable performance goals and implementing strategies to achieve these goals. Assists in the identification and development of policies and procedures that improve the safety of patients and staff. Coordinate Quality & Performance Excellence departmental meetings. Maintains knowledge of current accreditation standards and the coordination of the hospital survey process. Maintains accurate and complete records of quality and performance improvement policies, activities and outcomes Reports to department director. This position may have additional or varied physical demand and/or respiratory fit test requirements. Please consult the Physical Demands Project SharePoint site or contact Risk Management/Employee Health for additional information. Normal working conditions with small exposure to infectious diseases. NZTI only: Reviews charts of patients for compliance and reports concerns to the medical & administrative staff. Provides monthly chart review roll-up reports. Reviews performance Improvement Plans post surveys and checks for adherence. Provides monthly TIEDI Compliance Reports. Assists Data Analyst with Data Collection. Reviews Policies and works in conjunction with division managers to update. INTEGRIS Edmond only: Develops, through collaboration with the medical staff and leadership team, organization-wide Performance Improvement projects based on analysis of trended data and patient care outcomes. Improves patient care outcomes based on strategic plan priorities by achieving targets set by the organization and incorporating evidence-based practice. Coordinates hospital response to grievances and oversees compliance with other CMS guidelines. Administrates the Joint Commission Accreditation Program on behalf of the hospital and manages, coordinates, and leads hospital preparedness for regulatory and accreditation standards by analyzing and overseeing correction of compliance gaps. Acts as facility clinical representative for EHR initiatives. Coordinates facility response to patient safety hazards related to recalls of products and devices. Provides administrative functions that promote key clinical operational processes. Plans, coordinates, and implements Employee Health services INTEGRIS Southwest Medical Center only: Responsible for Trauma Registry coverage. Qualifications REQUIRED QUALIFICATIONS EXPERIENCE: 1 year experience in performance improvement, management and education Previous experience with relevant accreditation guidelines Previous experience with MS Office EDUCATION: INTEGRIS Edmond only: Bachelor's degree required, masters preferred LICENSE/CERTIFICATIONS: RN (Registered Nurse) Current licensure as a Registered Nurse (RN) in the State of Oklahoma or current multistate license from a Nurse Licensure Compact (eNLC) member state Other certifications and competencies required based on service line skill Preferred Qualifications EDUCATION: Bachelor's Degree About Us INTEGRIS Health mission: Partnering with people to live healthier lives. To our patients, that means we will partner to provide unprecedented access to quality and compassionate health care. To you, it means some of the state's best career and development opportunities. With INTEGRIS Health, you will have a genuine chance to make a difference in your life and your career. INTEGRIS Health is the state's largest Oklahoma-owned health system with hospitals, rehabilitation centers, physician clinics, mental health facilities and home health agencies throughout much of the state.
RN Utilization Review Full-time
Atrium Health

RN - Atrium Health Utilization Management Nurse GCM

apartment Atrium Health location_onConcord, NC
Department: 11200 Atrium Health Cabarrus - Case Management Status: Full time Benefits Eligible: Yes Hou rs Per Week: 40 Schedule Details/Additional Information: Regular, FT Pay Range $35.50 - $53.25 Essential Functions Coordination with members of the healthcare team and payors to facilitate placement of patients in the appropriate level of care related to medical necessity. Promotes an open communication between utilization management and the health care team concerning level of care. Responsible for timely provision/flow of specific clinical information to third-party payors to ensure authorization of stay. Maintaining compliance with professional standards, national and local coverage determinations, the Centers for Medicare, and Medicaid Services (CMS) as well as state and federal regulatory requirements, as applicable. Performs admission and continued stay utilization reviews to assure the medical necessity of hospital admissions, appropriate level of care, continued stay and supportive services, and to examine delays in the provision of services, in accordance with the utilization management plan. Demonstrates proficiency in applying nationally accepted evidence-based criteria to assure appropriate hospital level of service. Maintains timely and appropriate documentation of all utilization management activities. Utilizes critical thinking skills based upon extensive knowledge of disease processes and clinical outcomes to identify the need for further clarification of physician documentation within the medical record. Prioritize work to facilitate timely accurate utilization management activities for each evidence-based product type. Collaborates to improve quality throughput coordination of care impacting length of stay with minimizing cost and ensuring optimum outcomes. Identification and documentation of potentially avoidable delays. Demonstrates the ability to utilize the licensed software tool to perform and record daily medical reviews. Communicates information effectively, including comprehensive clinical information, to third-party payors, to secure timely authorization forthe appropriate level of service. Provides payor feedback to case managers, social workers, and providers. Escalates and resolves denials to secure payment for the necessary care and services provided to the patient. Collaborates with payor, physician advisor, attending provider and multi-disciplinary team to reconcile payor-issued denials. Demonstrates proficiency and knowledge of various reimbursement criteria, including documentation necessary for reimbursement from regulatory bodies. Assist in process improvement of various committees, interdepartmental and departmental as assigned by the VP, AVP, Director, Medical Director, Manager or Team Supervisor. Supports and contributes to the Patient Centered Care Philosophy by understanding that every staff member is a Caregiver whose role is to meet the needs of the patient. Performs other duties and responsibilities as assigned and within the time frame specified. Physical Requirements Works in an office type setting, extensive walking throughout the facility. Prolonged periods of sitting reviewing medical records and documentation. Repetitive wrist motion and occasional lifting of 10-20 pounds. Intact sight and hearing with or without assistive devices are required. Must speak English fluently and write English in understandable terms Education, Experience and Certifications Bachelor's in Nursing from an accredited school of nursing, required. Master's degree in business or healthcare related field, preferred. Previous utilization review experience preferred. Current RN license or temporary license as a Registered Nurse Petitioner in the state in which you work and reside or if declaring a National License Compact (NLC) state as your primary state of residency, meet the licensure requirements in your home state; or for Non-National License Compact states, current RN license or temporary license as a Registered Nurse Petitioner required in the state where the RN works. 5 years of related nursing experience preferred. Clinical experience within the assigned population. Extensive knowledge of disease processes and clinical outcomes. Case Management experience or background preferred. Strong financial and analytical skills preferred. Appropriate Professional certification required within 3 years of hire and per Clinical Care Management Certification Guidelines. Additional education, training, certifications, or experience may be required within the department by the department leader. Our Commitment to You: Advocate Health offers a comprehensive suite of Total Rewards: benefits and well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more – so you can live fully at and away from work, including: Compensation Base compensation listed within the listed pay range based on factors such as qualifications, skills, relevant experience, and/or training Premium pay such as shift, on call, and more based on a teammate's job Incentive pay for select positions Opportunity for annual increases based on performance Benefits and more Paid Time Off programs Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability Flexible Spending Accounts for eligible health care and dependent care expenses Family benefits such as adoption assistance and paid parental leave Defined contribution retirement plans with employer match and other financial wellness programs Educational Assistance Program About Advocate Health Advocate Health is the third-largest nonprofit, integrated health system in the United States, created from the combination of Advocate Aurora Health and Atrium Health. Providing care under the names Advocate Health Care in Illinois; Atrium Health in the Carolinas, Georgia and Alabama; and Aurora Health Care in Wisconsin, Advocate Health is a national leader in clinical innovation, health outcomes, consumer experience and value-based care. Headquartered in Charlotte, North Carolina, Advocate Health services nearly 6 million patients and is engaged in hundreds of clinical trials and research studies, with Wake Forest University School of Medicine serving as the academic core of the enterprise. It is nationally recognized for its expertise in cardiology, neurosciences, oncology, pediatrics and rehabilitation, as well as organ transplants, burn treatments and specialized musculoskeletal programs. Advocate Health employs 155,000 teammates across 69 hospitals and over 1,000 care locations, and offers one of the nation’s largest graduate medical education programs with over 2,000 residents and fellows across more than 200 programs. Committed to providing equitable care for all, Advocate Health provides more than $6 billion in annual community benefits. Utilization Management RN supports medical necessity, revenue integrity and denial prevention while coordinating with members of the healthcare team and payors for authorization of appropriate level of care and length of stay for medically necessary services. Accurately conducts medical necessity reviews, utilizing the electronic medical record, in accordance with all state and federal regulations and the Utilization Management Plan. Advocates for the patient while balancing the responsibility of stewardship for their organization, and in general, the judicious management of resources.
RN Utilization Review Full-time
DeKalb Regional Medical Center

Utilization Review Nurse & Discharge Planning - DeKalb Case Management - FT - 1st Shift

apartment DeKalb Regional Medical Center location_onFort Payne, AL
The RN Case Manager is to support the physician and interdisciplinary team in facilitating patient care, with the underlying objective of enhancing the quality of clinical outcomes and patient satisfaction while managing the cost of care and providing timely and accurate information to payers. This role integrates and coordinates Utilization management, care coordination and discharge planning functions. The Case Manager is accountable for a designated patient caseload and plans effectively in order to meet patient needs, manage the length of stay, and promote efficient use of resources. Education: Minimum of A.S.N. from an accredited college or university (BSN Preferred) and current Alabama licensure. Experience: Three years acute care experience required. Additional Skills/Abilities: Excellent interpersonal communication and negotiation skills; strong organizational and time management skills as evidenced by capacity to prioritize multiple tasks and role components; ability to work independently and exercise sound judgment in interactions with physicians, patients and their families, and payers. DeKalb Regional Medical Center celebrated its 35th anniversary in October 2021. Throughout its history, the team of healthcare providers here have been proud to serve the people of Fort Payne, Alabama. Today, DeKalb Regional is 134-beds and offers comprehensive services including cardiac catheterization, geriatric psychiatric services, women’s and children’s services, bariatric services, orthopedics services, and many more. DeKalb Regional and its physicians serve patients from throughout Northeast Alabama and Western Georgia. DeKalb Regional is committed to providing quality care close to home. The hospital is accredited by The Joint Commission and the American College of Cardiology as a Primary Stroke Center and Chest Pain Center. It was also awarded the 2023 Get with the Guidelines Rural Stroke Bronze Quality Award from the American Heart Association. In fall of 2023, DeKalb Regional was one of seven hospitals in Alabama to receive an “A” grade from The Leapfrog Group. DeKalb Regional Medical Center has 500 employees and more than 100 members of the medical staff.
RN Utilization Review Full-time
Lexington Medical Center

Quality Review Specialist-RN

apartment Lexington Medical Center location_onWest Columbia, SC
Quality Management - Acute Full Time Day Shift 8-430 Lexington Health is a comprehensive network of care that includes six community medical and urgent care centers, nearly 80 physician practices, more than 9,000 health care professionals and Lexington Medical Center, a 607-bed teaching hospital in West Columbia, South Carolina. It was selected by Modern Healthcare as one of the Best Places to Work in Healthcare and was first in the state to achieve Magnet with Distinction status for excellence in nursing care. Consistently ranked as best in the Columbia Metro area by U.S. News & World Report, Lexington Health delivers more than 4,000 babies each year, performs more than 34,000 surgeries annually and is the region's third largest employer. Lexington Health also includes an accredited Cancer Center of Excellence, the state’s first HeartCARE Center, the largest skilled nursing facility in the Carolinas, and an Alzheimer’s care center. Its postgraduate medical education programs include family medicine and transitional year residencies, as well as an informatics fellowship. Job Summary The Quality Review Specialist-RN provides consultative services regarding quality assessment and trends to medical staff and to hospital ancillary department personnel. In this role, the employee will perform comprehensive retrospective reviews in a timely manner utilizing criteria developed and approved by the medical staff, hospital, and regulatory agents. Minimum Qualifications Minimum Education: High School Diploma or Equivalent Minimum Years of Experience: 4 Years of clinical or hospital experience; 2 Years of experience in quality or utilization review. Substitutable Education & Experience (Optional): None. Required Certifications/Licensure: Registered Nurse (RN) Required Training: None. Essential Functions Utilizes in-depth knowledge of clinical workflows, policies and procedures, patient care / clinical business processes, regulatory requirements, and best practices to: Risk Management- Perform daily review of new occurrence reports. Identify occurrences that require additional follow-up and reports these to the Director or designee in a timely manner. Ensure that occurrences are categorized correctly and all fields completed and correct. Verifies data accuracy with medical record if necessary. Ensure that occurrence reports are forwarded to all appropriate persons. Access other sources of data as needed for investigation and follow up. Serves as System Administrator for the occurrence reporting system. Primary liaison between Risk Management, Information Services, and system users. Manages access to the occurrence reporting system. Adds new locations and new users and provides new-user training. Assigns passwords. Removes users as needed. Provides new user training and ongoing user support, paying keen attention to user needs and opportunities to offer solutions and modify processes to improve efficiencies. Coordinates with vendor and Information Services to troubleshoot system as needed. Center for Best Practice & PN Quality- Assists with development, implementation, and evaluation of the hospital’s overall quality improvement program. Assist with coordination, preparation, and maintenance of performance improvement assessment and improvement activities. Responsible for data integrity and follows well defined processes for maintaining data integrity as well as manage assigned database. Assists in evaluation, analysis, maintenance and development of system functionality of the EHR to meet clinical objectives including participating in project plan development/tracking and workflow analysis. Duties & Responsibilities Provides accurate and timely routine statistical analyses and reports to designated parties. Identifies need for new reports and develops and creates reports. Generates user-friendly reports from other databases. Evaluates and analyzes data for trends, identifies areas of concern, and uses data display techniques to provide reports for various meetings and hospital committees. Prepares materials for meetings and assists with maintenance of performance improvement project records. Represents department on committees / teams as assigned. Participates and supports department goals, objectives and timelines, working with a sense of urgency and accuracy to ensure effective implementation. Successfully engages in multiple initiatives simultaneously and demonstrates flexibility in role and a willingness to help others. Attains an annual minimum of 12 hours of continuing education in topics related to role. May prepare materials for meetings and assists with maintenance of performance improvement project records. May represent department on committees / teams as assigned. Risk Management: Resolves problems and recommends solutions through research, inquiry, and data analysis, maintaining support call logs and tracking of issues. Compiles and maintains accurate statistics pertaining to occurrence data. Participates in and contributes to patient safety / risk reduction activities, including: Participates in and contributes to investigations of serious unanticipated events and "close-calls". Participates in and contributes to development, implementation and evaluation of corrective action plans. Supports a culture of safety by encouraging staff to speak up and report safety and quality issues. Center for Best Practice & PN Quality: Identifies opportunities for improvement and coordinates/participates in the development and implementation of action plans to make improvements- recommends changes to systems/processes that do not contribute to desired outcomes. Works collaboratively and communicates effectively with administration, IS, and clinical care teams through participation in the planning, development, and evaluation and maintenance of the Clinical Information system. Audits database contents for accuracy and validity. Acts as a resource person in quality assessment activities with hospital departments and committees. Works directly with hospital personnel to provide assistance and guidance in establishing criteria, reviewing medical records, etc. Requires efficient use of numerous software products (Word, Excel, PowerPoint, Outlook, etc.) Performs all other duties as assigned. We are committed to offering quality, cost-effective benefits choices for our employees and their families: Day ONE medical, dental and life insurance benefits Health care and dependent care flexible spending accounts (FSAs) Employees are eligible for enrollment into the 403(b) match plan day one. LHI matches dollar for dollar up to 6%. Employer paid life insurance – equal to 1x salary Employee may elect supplemental life insurance with low cost premiums up to 3x salary Adoption assistance LHI provides its full-time employees employer paid short-term disability and long-term disability coverage after 90 days of eligible employment Tuition reimbursement Student loan forgiveness Equal Opportunity Employer It is the policy of Lexington Health to provide equal opportunity of employment for all individuals, and to remain compliant with applicable state and federal laws and regulations. Lexington Health strives to provide a discrimination-free environment, and to recruit, select, on-board, and employ all employees without regard to race, color, religion, sex, age, disability, national origin, veteran status, or pregnancy, childbirth, or related medical conditions, including but not limited to, lactation. Lexington Health endeavors to upgrade and promote employees from within the hospital where possible and consistent with the employee’s desires and abilities and the hospital’s needs.
RN Utilization Review Full-time
Summit Healthcare

RN Quality Reviewer- Full Time, Day Shift

apartment Summit Healthcare location_onShow Low, AZ
Provides comprehensive review of patient care issues. Assists with the implementation of the hospital and medical staff performance improvement program. Collects and organizes data to support hospital quality initiatives. Serves as member of appropriate committees/teams. Essential Functions - Performs accurate and thorough chart audits for care issues, complaints, and abstractions (HSAG, IHI, Qnet). - Conducts investigations related to patient complaints and incident reports in Quantros. - Participates in implementation of evidence-based practices for the facility. - Performs data collection for trending physician activity and quarterly reports. - Monitors feedback reports (i.e. Patient Satisfaction vendor to create scorecards/dashboards demonstrating the perceived quality of care and satisfaction). - Coordinates Peer Review process. - Communicates information and follow-up work; assists managers within the service lines. - Facilitates and participates in designated meetings; types agenda and minutes. - Performs all functions according to established policies, regulatory and accreditation requirements, and professional service standards. Other Duties - Posts the PI bulletin board. - Implements new processes and educates staff hospital wide. - Conducts various surveys, CMS and HSAG chart reviews, monthly physician department meetings. - Participates in departmental and association wide informational meetings and in services, including staff meetings, association wide forums, and seminars. - Reviews department and association wide policies and procedures annually. Develops and maintains new policies and procedures as needed. Duties, responsibilities and activities may change or new ones may be assigned at any time with or without notice. Abilities - Must be able to read, write, understand, and speak English. - This position requires operational knowledge of all equipment in the Performance Improvement department, including: fax, printers, copy machine, phone systems, and commonly used computer programs in the hospital. - Service orientated - Excellent customer service - Organizational skills - Multitasking skills - Professional interpersonal skills - Time management skills - Telephone etiquette. Supervisory Responsibilities None. Work Environment At Summit Healthcare, our mission statement is that we are trusted to provide exceptional, compassionate care close to home. Our vision is to be the healthcare system of choice. To uphold our mission and vision statements, we expect all employees to practice SHINE Behavioral standards: - Always SHINE – show respect and be kind. - Always work together – we are on the same team. - Always serve others – no job is beneath you. - Always maintain high standards of quality and safety – best practice every time. - Always communicate clearly – be compassionate. - Always practice integrity – maintain confidentiality. - Always be accountable – take responsibility. - Always empower – create an environment of success. - Always excel – don’t settle for mediocrity. - Always promote wellness – make choices for a healthy lifestyle. Physical Demands Exerts up to 20 lbs. of force occasionally, and/or up to 10 lbs. of force frequently, and/or a negligible amount of force constantly to move objects. Physical demands are in excess of those of Sedentary work. Light work usually requires walking or standing to a significant degree. Worker is exposed to extensive computer work. Required Education and Experience - BLS CPR AED within 30 days of hire - Current AZ RN license - 5 years of experience as an RN - Certification in Certified Professional in Healthcare Quality (CPHQ), Lean Six Sigma, or another accredited healthcare quality improvement certification (within 18 months of hire). Preferred Education and Experience - Master’s Degree - Advanced Practice Nurse Certificate OSHA Exposure Category: Involves no regular exposure to blood, body fluids, or tissues, and tasks that involve exposure to blood, body fluids, or tissues and are not a condition of employment.
RN Utilization Review Full-time
PeaceHealth

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

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

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

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

Home Health Quality Review Nurse, Registered Nurse

apartment Trilogy Home Healthcare Tampa Office location_onTampa, FL
Quality Review Nurse - RN (Onsite) Full Time | Tampa, FL Trilogy Home Healthcare , a Humana company, is hiring a dedicated and organized Quality Review Registered Nurse (QRN) to join our award-winning team. We've been named Best of Best of Florida for Home Care services, and we pride ourselves on being a fun, supportive, and team-driven organization where your voice matters. What You'll Do: Review OASIS documentation and QAPI for accuracy and compliance Evaluate clinical practices and documentation to improve efficiency and outcomes Collaborate with clinicians to support quality patient care Analyze data for performance improvement Assist with clinical education and ongoing training Why Choose Trilogy? Supportive leadership Opportunities for advancement and growth A fun, team-spirited environment Full Time Employee Benefits Include: Medical ($0 deductible and $0 copay!), Dental, Vision, and Life Insurance 401k with company match Paid Time Off and Holiday Pay Employee Referral Bonus Program Qualifications: Active Registered Nurse (RN) license in Florida 1-2 years of experience in Medicare home health and OASIS documentation required OASIS Certification preferred Strong collaboration, judgement, and communication skills Ability to work independently and drive team goals To learn more please visit our website at www.trilogyhomehealthcare.com and follow us on Facebook and Instagram ! For more Information regarding the HB531 Florida Agency for Health Care Administration, please visit: https://info.flclearinghouse.com/
RN Utilization Review Full-time
State of Arizona

Clinical Review Nurse

apartment State of Arizona location_onPhoenix, AZ
AHCCCS Arizona Health Care Cost Containment System Accountability, Community, Innovation, Leadership, Passion, Quality, Respect, Courage, Teamwork The Arizona Health Care Cost Containment System (AHCCCS), Arizona’s Medicaid agency, is driven by its mission to deliver comprehensive, cost-effective health care to Arizonans in need. AHCCCS is a nationally acclaimed model among Medicaid programs and a recipient of multiple awards for excellence in workplace effectiveness and flexibility. AHCCCS employees are passionate about their work, committed to high performance, and dedicated to serving the citizens of Arizona. Among government agencies, AHCCCS is recognized for high employee engagement and satisfaction, supportive leadership, and flexible work environments, including remote work opportunities. With career paths for seasoned professionals in a variety of fields, entry-level positions, and internship opportunities, AHCCCS offers meaningful career opportunities in a competitive industry. Come join our dynamic and dedicated team. Clinical Review Nurse Division of Fee for Service Management (DFSM) Job Location: Address: 150 North 18th Avenue Phoenix, Arizona 85007 All AHCCCS Employees must reside within the state of Arizona. This position may offer the ability to work remotely, within Arizona, based upon the department's business needs and continual meeting of expected performance measures. Posting Details: Salary: $71,032 FLSA Status: Exempt Grade: 22 Closing Date: Open until filled Job Summary: This position is responsible for timely and accurate claims review and adjudication to avoid penalties, establishing and maintaining records and reports, interacting with claims personnel for review and assessing adjudication of work process, recommending edits and revision of claim charges, review of system parameters, and medical necessity based on standard of care and in accordance with AHCCCS Rules, Regulations and Federal Guidelines. This position may be asked to provide cross-division support including support of clinical administration in evaluating and approving or denying payment for medical and/or behavioral health care services through prospective, concurrent, and retrospective review; in additional to support of the monitoring of quality management and quality assurance of FFS providers, including on-site provider visits and monitoring of corrective action plans; in addition to support of prepayment review of clinical documentation for appropriateness of billing; in addition to care management support of FFS members. The State of Arizona strives for a work culture that affords employees flexibility, autonomy, and trust. Across our many agencies, boards, and commissions, many State employees participate in the State’s Remote Work Program and are able to work remotely in their homes, in offices, and in hoteling spaces. All work, including remote work, should be performed within Arizona unless an exception is properly authorized in advance. Major duties and responsibilities include but are not limited to: • Monitor, evaluate, and approve or deny payment of medical and/or behavioral healthcare services through prospective, concurrent, and retrospective review. Determine medical necessity based on standards of care, rules, regulations, policies and procedures governing the provision of covered services. Ensure timely and accurate claims or authorization reviews, including timely determination for emergency criteria and/or medical necessity criteria, appropriate level of care and/or length of stay, determination of correct revenue/CPT/HCPC coding, timely claims adjudication or timely issuance of authorization determinations. Interact with claims personnel for review and assessment of the adjudication work process, recommend system edits or need to revise claim charges, and review of system parameters. • Interact with other internal and external stakeholders, including other department providers, and tribal stakeholders, as needed. Collaborate to improve compliance related to utilization management process standards, AHCCCS policies and procedures, and Federal and State rules and regulations. • Evaluate, recommend action, and provide ongoing monitoring for program policy compliance and reporting of data related to FESP or specialty services such as Specialty DME, Exception NF Rates, negotiated rates, and Over Institutional Cost services. • Confer with Utilization Review Coordinators from the Peer Review Organizations regarding admission, concurrent length of stay, appropriateness of services, and retrospective reviews. • Maintain documentation files, prepares and submits system generated reports, extracts, analyses savings and trends for unit, division, and management. • May be asked to provide cross division support in clinical administration, Quality Management/Quality Assurance, Care Management, and Prepayment Review, in which case primary percent of time would be transitioned to that task. Knowledge, Skills & Abilities (KSAs): Knowledge of: • Principles of utilization review • Utilization review protocols related to all member populations including Maternal and Child Health services, preventive health, family planning, sterilization, and pregnancy termination, EPSDT, acute, LTC, chronic long-term elderly and physically disabled, developmentally disabled, behavioral/mental health, tribal, and FESP • Understanding of tribal and non-tribal health care delivery systems and mechanisms necessary for coordination and delivery of services • Principles and current standards of practice for the delivery emergent and non-emergent medical and/or behavioral health care • Alternative levels of care • ICD10 Diagnosis Coding; DSM-IV/V; CPT procedure coding • Medical technology computer data retrieval and input • InterQual or Milliman review criteria • CCI • Interrelations of governmental agencies • Medicaid and Medicare member populations • Federal Regulations. State Statute, Rule, and policies applicable to AHCCCS programs • AHCCCS and ALTCS program design and implementation, including case management functions and responsibilities, and funding source • Familiarity with American Indian Tribes/programs and policy relative to IGA's and other related policies Skill in: • Organizational skills that result in prioritization of multiple tasks • Interpretation of rules, laws and agency policy pertaining to the AHCCCS program • Good written and communication skills • Computer skills • Utilization Review skills • Medical Claims Review skills • Producing work products with limited supervision • Effectively collaborating with people in positions of all levels • Research and analysis • Team player and can work independently • Public relations skills, interacting with statewide providers of healthcare services, public organizations, and social agencies • Organizational skills for setting priorities; workload, and record keeping • Intermediate computer skills to access and input member information • Analytical ability to identify and correlate specific patterns, initiate investigations, submit findings and recommendations • Strong Interpersonal skills in working with people of diverse cultures and socioeconomic backgrounds Ability to: • Proficiency in oral and written communication • Teach and train • Interpret clinical information and assess implications for treatment • Negotiate competitive rates to maximize available funding for members' care • Read, Interpret, and apply complex rules and regulations • Interpret and apply medical and claims policies • Read and interpret medical documentation • Evaluate medical documentation for emergency criteria, medical necessity, correct CPT coding • Determine appropriate hospital levels of care and lengths of stay • Respond to inquiries for UR/CPT coding decisions • Maintain data for monthly reports • Work independently with minimal supervision Selective Preference(s): Minimum: Possession of a current license to practice as a registered nurse in the State of Arizona and 3 year's experience in health care delivery systems. Preferred: Experience in concurrent and retrospective review; CCI, lnterQual, HCPCS and CPT Coding; managed care medical review experience. Certification in CPT Coding is a plus. Pre-Employment Requirements: • Successfully pass fingerprint background check, prior employment verifications and reference checks; employment is contingent upon completion of the above-mentioned process and the agency’s ability to reasonably accommodate any restrictions. • Travel may be required for State business. Employees who drive on state business must complete any required driver training (see Arizona Administrative Code R2-10-207.12.) If this position requires driving or the use of a vehicle as an essential function of the job to conduct State business, then the following requirements apply: Driver’s License Requirements. All newly hired State employees are subject to and must successfully complete the Electronic Employment Eligibility Verification Program (E-Verify). Benefits: Among the many benefits of a career with the State of Arizona, there are: • 10 paid holidays per year • Paid Vacation and Sick time off (13 and 12 days per year respectively) - start earning it your 1st day (prorated for part-time employees) • Paid Parental Leave-Up to 12 weeks per year paid leave for newborn or newly-placed foster/adopted child. Learn more about the Paid Parental Leave pilot program here. • Other Leaves - Bereavement, civic duty, and military. • A top-ranked retirement program with lifetime pension benefits • A robust and affordable insurance plan, including medical, dental, life, and disability insurance • Participation eligibility in the Public Service Loan Forgiveness Program (must meet qualifications) • RideShare and Public Transit Subsidy • A variety of learning and career development opportunities By providing the option of a full-time or part-time remote work schedule, employees enjoy improved work/life balance, report higher job satisfaction, and are more productive. Remote work is a management option and not an employee entitlement or right. An agency may terminate a remote work agreement at its discretion. Learn more about the Paid Parental Leave pilot program here . For a complete list of benefits provided by The State of Arizona, please visit our benefits page Retirement: Lifetime Pension Benefit Program • Administered through the Arizona State Retirement System (ASRS) • Defined benefit plan that provides for life-long income upon retirement. • Required participation for Long-Term Disability (LTD) and ASRS Retirement plan. • Pre-taxed payroll contributions begin after a 27-week waiting period (prior contributions may waive the waiting period). Deferred Retirement Compensation Program • Voluntary participation. • Program administered through Nationwide. • Tax-deferred retirement investments through payroll deductions. Contact Us: Persons with a disability may request a reasonable accommodation such as a sign language interpreter or an alternative format by emailing careers@azahcccs.gov. Requests should be made as early as possible to allow time to arrange the accommodation. The State of Arizona is an Equal Opportunity/Reasonable Accommodation Employer.