Registered Nurse (RN) Utilization Review Jobs

RN Utilization Review Other
UTHealth Houston

Utilization Review Nurse-(HCPC)

apartment UTHealth Houston location_onHouston, TX
What we do here changes the world. UTHealth Houston is Texas’ resource for healthcare education, innovation, scientific discovery, and excellence in patient care. That’s where you come in. Once you join us you won't want to leave. It’s because we reward our team for the excellent service they provide. Our total rewards package includes the benefits you’d expect from a top healthcare organization (benefits, insurance, etc.), plus: 100% paid medical premiums for our full-time employees Generous time off (holidays, preventative leave day, both vacation and sick time – all of which equates to around 37-38 days per year) The longer you stay, the more vacation you’ll accrue! Longevity Pay (Monthly payments after two years of service) Build your future with our awesome retirement/pension plan! We take care of our employees! As a world-renowned institution, our employees’ wellbeing is important to us. We offer work/life services such as... Free financial and legal counseling Free mental health counseling services Gym membership discounts and access to wellness programs Other employee discounts including entertainment, car rentals, cell phones, etc. Resources for child and elder care Plus many more! Join a growing team! With the opening of Dunn Behavioral Sciences Center/HCPC at UTHealth Houston , we will soon have the largest academic psychiatric hospital in the country, serving the region with an 500+ bed facility. Our dedicated health care employees will have the opportunity to be exposed to a variety of mental health specialties and cutting-edge research. With exposure to a variety of specialties such as Acute, Subacute, and Intensive Outpatient, Continuum of Care, Mood Disorders, ECT, Early Onset Treatment , Adult General Psychiatry, Competency Restoration, Child and Adolescent, Juvenile Justice, Geriatric Psychiatry, Treatment Mall and Unit-Based Programming. This dedicated team will work in an integrated campus to bring world class resources to the community. Apply today to be a part of this committed team serving the mental health needs of the area. Position Summary: Assists in the coordination of the appropriate utilization of services and resources of patient care and continuum at HCPC. Location: Dunn Behavioral Sciences Center/HCPC at UTHealth Houston Dept.: BSC Patient Revenue Cycle Status: Full-Time FLSA: Exempt Position Key Accountabilities: 1. Assists in the coordination of all aspects of concurrent review process for individual cases. 2. Coordinates clinical documentation to third-party payers and state agencies to secure timely payment for patient charges. 3. Participates in the utilization review and/or quality assurance programs. 4. Conducts various types of case reviews for quality and appropriate medical management, cost containment, peer review and rehabilitation. 5. Implements utilization review policies and procedures. 6. Reviews to determine appropriateness and medical necessity of admissions, continued stay and use of ancillary services. 7. Monitors third-party administrator and agency files to oversee contractor handling. 8. Performs data entry, which includes application of criteria sets and Diagnosis Review Groups (DRG) for the utilization review process. 9. Maintains a permanent record of all utilization review records, identifies problems, and follows through with resolutions. 10. Prepares reports and analyzes statistical data. 11. Other duties as assigned. Certification/Skills: Registered Nurse (RN) State Licensure or Nurse Licensure Compact (NLC) by Texas Board of Nursing (BON) required Minimum Education: Bachelor’s degree in Nursing from an accredited school. Minimum Experience: Three years experience in nursing, preferably in Psychiatric nursing. Physical Requirements: Exerts up to 50 pounds of force occasionally and/or up to 20 pounds frequently and/or up to 10 pounds constantly to move objects. Security Sensitive: This position is a security-sensitive position pursuant to Texas Education Code §51.215 and Texas Government Code §411.094. To the extent that a position requires the holder to research, work on, or have access to critical infrastructure as defined in Texas Business and Commerce Code §117.001(2), the ability to maintain the security or integrity of the infrastructure is a minimum qualification to be hired for and to continue to be employed in that position. Personnel in such positions, and similarly situated state contractors, will be routinely reviewed to determine whether things such as criminal history or continuous connections to the government or political apparatus of a foreign adversary might prevent the applicant, employee, or contractor from being able to maintain the security or integrity of the infrastructure. A foreign adversary is a nation listed in 15 C.F.R. §791.4. Residency Requirement: Employees must permanently reside and work in the State of Texas.
RN Oncology Psych Utilization Review Full-time
UNC Health

RN Utilization Manager - Medicine, Oncology, Cardiac, & Psychiatry Services

apartment UNC Health location_onChapel Hill, NC
Description Areas of focus include Medicine, Oncology, Cardiac, and Psychiatry Services Preferences given to candidates with Medical Surgical and/or Psychiatry bedside experience. The Team: Completes clinical reviews for all areas: Inpatient, Observation, Extended Recovery 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 40 hrs/week (Monday-Friday) Weekend rotation 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 Psych Utilization Review Full-time
Centene

Behavioral Health Utilization Review Clinician

apartment Centene location_onLA
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. Position Purpose: Performs a clinical review and assesses care related to mental health and substance abuse. Monitors and determines if level of care and services related to mental health and substance abuse are medically appropriate. Evaluates member’s treatment for mental health and substance abuse before, during, and after services to ensure level of care and services are medically appropriate Performs prior authorization reviews related to mental health and substance abuse to determine medical appropriateness in accordance with regulatory guidelines and criteria Performs concurrent review of behavioral health (BH) inpatient to determine overall health of member, treatment needs, and discharge planning Analyzes BH member data to improve quality and appropriate utilization of services Provides education to providers members and their families regrading BH utilization process Interacts with BH healthcare providers as appropriate to discuss level of care and/or services Engages with medical directors and leadership to improve the quality and efficiency of care Formulates and presents cases in staffing and integrated rounds Performs other duties as assigned. Complies with all policies and standards. Education/Experience: Requires Graduate of an Accredited School Nursing or Bachelor's degree and 2 – 4 years of related experience. License to practice independently, and/or have obtained the state required licensure as outlined by the applicable state required. Master’s degree for behavioral health clinicians required. Clinical knowledge and ability to review and/or assess treatment plans related to mental health and substance abuse preferred. Knowledge of mental health and substance abuse utilization review process preferred. Experience working with providers and healthcare teams to review care services related to mental health and substance abuse preferred. License/Certification: LCSW- License Clinical Social Worker required or LMHC-Licensed Mental Health Counselor required or LPC-Licensed Professional Counselor required or Licensed Marital and Family Therapist (LMFT) required or Licensed Mental Health Professional (LMHP) required or RN - Registered Nurse - State Licensure and/or Compact State Licensure required For Fidelis Care only: LMSW, LCSW, LMHC, LPC, LMFT, LMHP or RN required Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
RN Utilization Review Full-time
Gainwell Technologies LLC

Utilization Review Nurse- Remote

apartment Gainwell Technologies LLC location_onArkansas City, AR
$65,000 - $78,000 / year
It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you’ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development. Summary We are seeking a skilled Utilization Review Nurse to conduct prior authorization, prospective, concurrent, and retrospective reviews for medical necessity and appropriateness of services, following clinical criteria, coverage policies, and contract guidelines. This involves reviewing medical documentation, accurately documenting findings, and ensuring policy compliance. Your role in our mission Review admissions, procedures, services, and supplies for medical necessity and appropriateness, meeting quality and production goals. Use clinical criteria for decision-making, referring complex cases to Medical Directors when needed. Engage with providers to gather clinical information, apply guidelines, and make determinations. Document findings and rationale in medical management systems. Assist in training new nurses, provide feedback, and stay updated on clinical guidelines. Maintain RN license and meet continuing education requirements. What we're looking for Active RN license. 3+ years of inpatient clinical experience. 1+ year in prior authorization reviews using InterQual or MCG. Strong written communication skills in a fast-paced setting. Proficient in Microsoft Office and other computer applications. What you should expect in this role Home-based position. High-speed internet and a distraction-free workspace required. Core hours: 8:00 AM - 6:00 PM ET, with potential for extended hours. Occasional travel (up to 10%) based on business needs. This position is for pipeline purposes, and we welcome applications on an ongoing basis. The pay range for this position is $65,000.00 - $78,000.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits , and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities. We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings. Gainwell Technologies is an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics.
RN Utilization Review Full-time
The MetroHealth System

Utilization Review Nurse-Utilization Management

apartment The MetroHealth System location_onCleveland, OH
Location: METROHEALTH MEDICAL CENTER Biweekly Hours: 80.00 Shift: Days; Rotating Weekends and Holidays The MetroHealth System is redefining health care by going beyond medical treatment to improve the foundations of community health and well-being: affordable housing, a cleaner environment, economic opportunity and access to fresh food, convenient transportation, legal help and other services. The system strives to become as good at preventing disease as it is at treating it. Founded in 1837, Cuyahoga County’s safety-net health system operates four hospitals, four emergency departments and more than 20 health centers. Summary Responsible for supporting the physician and interdisciplinary team in the provision of patient care by ensuring the appropriate level of care at the point of entry. The utilization review nurse will work on defined patient populations and is responsible for an initial clinical review at the point of patient entry to the inpatient care setting, this includes observation status. Will collaborate with other interdisciplinary team members to develop and participate in a systematic approach to denial management, and in so doing reduce organizational exposure to revenue loss. Actively participates in the denial management process; improve reimbursement by optimizing revenue recovery due to inappropriate level of care, failure to meet medical necessity, and/or severity of illness. Upholds the mission, vision, values, and customer service standards of The MetroHealth System. Qualifications Required: Bachelor’s degree in Nursing (applies to placements after 1/1/2017). Current Registered Nurse License State of Ohio. Minimum of five years clinical experience. Able to work independently and as a member of an interdisciplinary team. Knowledge and experience with medical necessity criteria for inpatient admission and observation placement. Knowledge and experience of denials based on the absence of documented medical necessity or failure to meet severity of illness and intensity of service criteria. Knowledge of internal criteria set and Milliman Health Management Guidelines. Excellent interpersonal communication and negotiation skills. Strong analytical, data management, and PC skills. Current working knowledge of, utilization management, case-management, performance improvement, and managed care reimbursement. Strong organizational and time management skills. Preferred: Two years of experience with case management, utilization review. Physical Demands: May need to move around intermittently during the day, including sitting, standing, stooping, bending, and ambulating. May need to remain still for extended periods, including sitting and standing. Ability to communicate in face-to-face, phone, email, and other communications. Ability to read job related documents. Ability to use computer.
RN Utilization Review Full-time
Gainwell Technologies LLC

DRG Nurse Reviewer Appeals and Hearings- Remote

apartment Gainwell Technologies LLC location_onTampa, FL
$90,000 - $99,000 / year
It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you’ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development. Summary We are seeking a talented individual for a DRG Nurse Reviewer Appeals and Hearings to coordinate and perform all appeal related duties including analyzing and responding appropriately to appeals from providers; reviewing documentation to ensure all aspects of the appeal have been addressed properly and accurately; prepare case files and case summaries for hearings; and participate in in virtual and on-site hearings. Your role in our mission Reviews provider appeals and redeterminations using approved clinical and coding guidelines and documents appeal determinations clearly and concisely. Analyzes and reviews appeal documentation to ensure all aspects of the appeal have been addressed properly and accurately while maintaining production goals and quality standards. Prepares case files and case summaries for hearings and actively participates in hearings in conjunction with the Medical Director. Assists management with training new reviewers to include daily monitoring, mentoring, feedback and education. Maintains current knowledge of clinical criteria guidelines and/or coding guidelines; successfully completes required CEUs to maintain RN license and/or coding certification. Responsible for attending training and scheduled meetings to enhance skills and working knowledge of clinical policies, procedures, rules, and regulations. Actively cross-trains to perform reviews of multiple claim types to provide a flexible workforce to meet client needs. What we're looking for Active, Unrestricted RN license from the United States and in the primary home residency, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), required Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or Certified Professional Medical Auditor (CPMA) required 5+ years clinical experience or 5+ years medical record coding experience preferred Working knowledge of the appeals and hearings process Excellent written communication skills including ability to write clear, concise, accurate, and fact-based rationales in support of appeal determinations. Excellent oral communication skills with particular emphasis on verbally presenting case summaries and decisions. Ability to multi-task in a fast-paced production environment. What you should expect in this role Remote (Work from Home) Up to 25% Travel for onsite hearing testimony This position is for pipeline purposes, and we welcome applications on an ongoing basis. The pay range for this position is $90,000.00 - $99,000.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits , and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities. We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings. Gainwell Technologies is an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics.
RN Utilization Review Full-time
Baptist Health South Florida

Pool Utilization Review Registered Nurse, Case Management, Per Diem, Shift Varies (Rotating Weekends)

apartment Baptist Health South Florida location_onBoca Raton, FL
Baptist Health is the region’s largest not-for-profit healthcare organization, with 12 hospitals, over 28,000 employees, 4,500 physicians and 200 outpatient centers, urgent care facilities and physician practices across Miami-Dade, Monroe, Broward and Palm Beach counties. With internationally renowned centers of excellence in cancer, cardiovascular care, orthopedics and sports medicine, and neurosciences, Baptist Health is supported by philanthropy and driven by its faith-based mission of medical excellence. For 25 years, we’ve been named one of Fortune’s 100 Best Companies to Work For, and in the 2024-2025 U.S. News & World Report Best Hospital Rankings, Baptist Health was the most awarded healthcare system in South Florida, earning 45 high-performing honors. What truly sets us apart is our people. At Baptist Health, we create personal connections with our colleagues that go beyond the workplace, and we form meaningful relationships with patients and their families that extend beyond delivering care. Many of us have walked in our patients’ shoes ourselves and that shared experience fuels out commitment to compassion and quality. Our culture is rooted in purpose, and every team member plays a part in making a positive impact – because when it comes to caring for people, we’re all in. Description: The purpose of this position is to conduct initial, concurrent, retrospective chart review for clinical, financial and resource utilization. Coordinates with healthcare Team for optimal efficient patient outcomes, while decreasing length of stay and avoid delays and denied days. They are accountable for a designated patient caseload and provides intervention and coordination to decrease avoidable delays denial of reimbursement. Specific functions within this role include: Screens pre-admission, admission process using established criteria for all points of entry, Facilitates communication between payers, review agencies and healthcare team, Identify delays in treatment or inappropriate utilization and serves as a resource, Coordinates communication with physicians, Identify opportunities for expedited appeals and collaborates resolve payer issues and ensures, maintains effective communication with Revenue Cycle Departments. Estimated pay range for this position is $45.00 / hour depending on shift as applicable. Qualifications: Degrees: Associates. Licenses & Certifications: Registered Nurse. Additional Qualifications: RNs hired prior to 2/2012 (10/1/2017 at Bethesda or 7/1/2019 at BRRH) with an Associates Degree in Nursing are not required to have a BSN to continue their non-leadership role as an RN; however, required to complete the BSN within 5 years of hire. 3 years of hospital clinical experience preferred. Excellent written, interpersonal communication and negotiation skills. Strong critical thinking skills and the ability to perform clinical chart review abstract information efficiently. Strong analytical, data management and computer skills. Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components. Current working knowledge of payer and managed care reimbursement preferred. Ability to work independently and exercise sound judgment in interactions with the health care team and patients/families. Knowledgeable in local, state, and federal legislation and regulations, and ability to tolerate high volume production standards. Minimum Required Experience: 3 Years of Utilization Review experience in an acute care setting required EOE, including disability/vets
RN Utilization Review Full-time
SUNY Upstate Medical University

Clinical Professional RN Clinical Quality Reviewer

apartment SUNY Upstate Medical University location_onSyracuse, NY
Job Summary: High level clinical review of patients admitted to University Hospital for the purpose of risk identification and referral to clinical departments for ongoing review of quality improvement. Report adverse events to the majority of regulatory agencies and conducts internal quality reviews through the institution defined quality review process. Supports the Attorney General's office in the review and defense of medical malpractice actions brought against the state. Minimum Qualifications: Registered Nurse, NYS License and Bachelors Degree in Nursing or healthcare related field and three years acute care clinical experience or Associates Degree in Nursing and 5 years acute care clinical required. Excellent communication and customer service skills required for interface with health care payers, regulatory agencies and other health care related entities. Preferred Qualifications: CPHRM certified. Candidates with quality review experience & familiarity with DOH Regulatory reporting requirements preferred. Work Days: Monday-Friday, Days Message to Applicants: Recruitment Office: Human Resources
RN Utilization Review Full-time
Capital Health

Utilization Review RN

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

Utilization Review Nurse

apartment University of Utah Health location_onSalt Lake City, UT
Overview As a patient-focused organization, University of Utah Health exists to enhance the health and well-being of people through patient care, research and education. Success in this mission requires a culture of collaboration, excellence, leadership, and respect. University of Utah Health seeks staff that are committed to the values of compassion, collaboration, innovation, responsibility, integrity, quality and trust that are integral to our mission. EO/AA This position is responsible for maintaining the financial integrity of both the patient and the organization through the provision of quality based patient care focusing on the medical necessity and efficiency of the delivery of such care; achieved via managing the cost of care while providing timely and accurate information to third party payers and medical care team. This position may be required to access and administer medications within their scope of practice and according to state law. Corporate Overview: The University of Utah is a Level 1 Trauma Center and is nationally ranked and recognized for our academic research, quality standards and overall patient experience. Our five hospitals and eleven clinics provide excellence in our comprehensive services, medical advancement, and overall patient outcomes. Responsibilities Applies approved utilization criteria to monitor appropriateness of admissions with associated levels of care and continued stay review. Communication to third-party payers for initial and concurrent clinical review. Reviews patient chart to ensure patient continues to meet medical necessity. Documentation of all actions and information shared with care team members or third-party payer. Alerts and discusses with physician/provider and case manager/discharge planner when patient no longer meets medical necessity criteria for the inpatient stay. Discusses with physicians the appropriateness of resource utilization. Tracks length of stay (LOS) and resource utilization to identify at risk patients. Refers to UR committee any case that surpasses expected LOS, expected cost, or over/under-utilization of resources. Performs verbal/fax clinical review with payer as determined by nursing judgment and/or collaboration with the payer per university contractual obligation. Participant in UR Committee as needed. Collects data on variances in LOS, avoidable days, costs/barriers to discharge/transition and denied days. Prepares appeals on denied cases when appropriate. At the discretion of department operational and patient care needs, this position is required to work rotating schedules, which may include variable hours, weekends, nights, and holidays to meet the staffing and patient care demands of a 24/7 complex health system. Regular, reliable, and punctual attendance during assigned shifts is considered an essential function of the role. Knowledge / Skills / Abilities Demonstrated availability to work variable and rotating shifts, including nights, weekends, and holidays, in a 24/7 patient care environment. Ability to perform the essential functions of the job as outlined above. Demonstrated team leadership, relationship building, critical analysis, and written and verbal communication skills. Demonstrated knowledge of payers, payer systems, cost effective utilization management and InterQual criteria. The ability to demonstrate knowledge of the principles of life span growth and development and the ability to assess data regarding the patient's status and provide care as described in the department's policies and procedures manual. Ability to work autonomously and as a team member. Qualifications Qualifications Required One year Utilization Review or Case Management experience. Licenses Required Current license to practice as a Registered Nurse in the State of Utah, or obtain one within 90 days of hire under the interstate compact if switching residency to State of Utah. Must maintain current Interstate Compact (multi-state) license if residency is not being changed to Utah. * Additional license requirements as determined by the hiring department. Qualifications (Preferred) Preferred Basic Life Support Health Care Provider card. Proficiency in application of InterQual Criteria, knowledge of ICD-9, DRG's and CPT Codes. Utilization Review Certification designation. Knowledge of CMS Regulations. Working Conditions and Physical Demands Employee must be able to meet the following requirements with or without an accommodation. This is a sedentary position in an office setting that may exert up to 10 pounds and may lift, carry, push, pull or otherwise move objects. This position involves sitting most of the time and is not exposed to adverse environmental conditions. This position does not provide care to patients. Physical Requirements Color Determination, Far Vision, Listening, Near Vision, Sitting, Speaking
RN Utilization Review Full-time
Kaweah Health

RN Case Manager (Utilization Review Experience Preferred)

apartment Kaweah Health location_onVisalia, CA
Kaweah Health is a publicly owned, community healthcare organization that provides comprehensive health services to the greater Visalia area in central California. With more than 5,000 employees, Kaweah Health provides state-of-the-art medicine and high-quality preventive services in our acute care hospital, specialized health centers and clinics. Our eight-campus healthcare district has 613 beds and offers comprehensive health services across a broad continuum of care. It takes a special person to work for Kaweah Health. We serve a region where the needs are great, which makes the rewards even greater. Every day, we care for people facing unique challenges and in need of healing. Throughout it all, our focus is to make a difference, and we do — in the health of our patients, our loved ones, and our community. Benefits Eligible Full-Time Benefit Eligible Work Shift Day - 8 Hour or less Shift (United States of America) Department 8790 Case Management The RN Case Manager assesses plans, coordinates care, evaluates and advocates for services to meet patients health needs as they move through the continuum of care to promote quality and cost effective outcomes. QUALIFICATIONS License /Certification Required: California RN license BLS Education Preferred: BSN, MSN, or currently enrolled in RN-BSN program Experience Required: Two years of acute care clinical nursing experience (LVN/RN) with at least one year as a RN Department Specific Requirements For Emergency Department: must have three years of RN experience in an Emergency Department or Critical Care setting. JOB RESPONSIBILITIES Essential Identifies needs and facilitates provision of services with physicians, nurse managers and multidisciplinary team members as the patient moves through the continuum of care. Assessment Acts as a resource person for clinical care issues, identifies action plans, and facilitates communication with appropriate physician(s) for direction. Assists and communicates with physician offices and all appropriate departments to discuss new admissions, demographic information, and other data pertinent to the patient/family which may affect their care. Evaluates the assessment process of new patients within 30 days of admission to determine needs and develop a Care Management Plan to address Social Determinants of Health (SDOH) barriers. Planning Establishes a specific plan with action steps for each patient within assigned population. Collaborates with the patient/family, care team, and physician(s) to determine goals and objectives to achieve patient/family outcomes, which include physical and psychological factors. Takes the lead in assessing care plan progression and revising care plan as necessary. Rounds with physicians and multidisciplinary team. Coordinates with the multidisciplinary team to ensure graduation planning goals and objectives are developed and modified as needed. Implementation Takes the lead in moving patients through the continuum of care in a timely, cost effective, and safe manner. Assists in the organization and integration of resources needed to meet stated goals and plans. Works with patient, family, multidisciplinary team, and outside services to accomplish set outcomes. Supervises implementation of treatment plan, including appropriate use of pre-printed orders. Documents in patient Progress Notes information including significant patient data, problems identified, assessment needs, and treatment goals. Documents findings in the electronic health record. Makes timely referrals for services. Evaluation Evaluates care plan for appropriateness and monitors progress towards outcomes. Suggests appropriate level of care when changes in level of function, medical, and psychological issues arise. Reviews medical records of patients for proper and timely documentation of services provided, evidence of functional progress. In collaboration with patient, family, and multidisciplinary team, changes the plan of care as appropriate. The nurse's practice is guided by the Code for Nurses. Decisions and actions on behalf of patients/residents are determined in an ethical manner. Maintains patient confidentiality within legal and regulatory parameters. Acts as a patient/resident advocate and assists patients/residents in developing skills so they can advocate for themselves. Delivers care in a nonjudgmental and nondiscriminatory manner that preserves patient autonomy, dignity and rights. Addendum (essential for specific dept) POST ACUTE CARE CASE MANAGER: Reviews and screens 100% of patients same day referred to TCS using InterQual Criteria. Interviews, researches and gathers data to identify patient's needs and formulate a post-acute plan of care in collaboration with the patient, family, physician, acute case manager and other disciplines which enhances appropriate utilization of post-acute levels of care. Facilitates transition of patient more efficiently to TCS by ensuring proper documentation, orders, and arrangements are complete for timely transfer. PROGRAM LIAISON FOR INPATIENT REHABILITATION: Assumes responsibility for the implementation of each individual patient program. Assists the patient/family to become adequately oriented to their program. Enables the patient's program to proceed in an orderly, purposeful, and goal directed manner. Promotes the participation of the person served on an ongoing basis. Participates consistently in team conferences concerning the person served. Facilitates the exit/discharge process and arranged for follow-up and appropriate supportive services. Monitors the patient/family response to treatment and determines need for intervention and/or referral. CARDIAC SURGERY CARE COORDINATOR: Serves as the Cardiac surgery program liaison to patients, their families, and the cardiac care team. Provides periodic updates during surgery, concentrating on emotional support and education to the family. Facilitates and coordinates care with referral physicians, outside hospitals, admission staff, and surgical department to arrange transfer of potential patients referred to open heart surgery. Collaborates with nurse managers. Acts as a resource person for clinical care issues. Available for educational needs of nursing staff. Facilitates movement through the continuum of care insuring all services, consults and treatments needed by patient are being provided. Collaborates with multidisciplinary team and case manager for individual patient discharge needs and plan. Rounds daily rounds with physician to identify patient needs related to diagnosis, treatment, prognosis, and projected discharge. Assists with current and accurate data collection pertaining to the cardiac surgery program. POPULATION HEALTH RN CASE MANAGER: Serves as a clinical resource for patients and families enrolled in Population Health Management programs such as Enhanced Care Management (ECM), Chronic Care Management, Transitional Care Management with goal of improving health outcomes, reducing unnecessary healthcare utilization and addressing Social Determinants of Health (SDOH) in partnership with a multidisciplinary team to include Primary Care Provider, Community Care Coordinator, Pharmacist, Medical Assistant, etc. Additional Demonstrates the knowledge and skills necessary to provide care and services appropriate to the population served on the assigned unit or work area. Knowledgeable of growth and development for all patient/family cultural, linguistic, spiritual, gender, and age specific needs. Able to effectively communicate and care for patient and family as reflected in the Plan for Provision of Care. Performs other duties as assigned. Pay Range $46.44 -$69.66 If you want to use your talents alongside people who face each day with courage and purpose, in an environment that empowers you to do your absolute best, this is where you belong.
RN Utilization Review Full-time
Bryan Health

Utilization Management RN- Weekender

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

RN Manager, Utilization Review - Full time - Days

apartment UChicago Medicine location_onChicago, IL
Job Description Be a part of a world-class academic healthcare system, Company, as a RN Manager in the Rev Cycle Department. This position will be primarily a work from home opportunity with the requirement to come onsite as needed. You may be based outside of the greater Chicagoland area. The Manager of Utilization Review (UR) provides leadership and oversight of utilization review activities across the health system, including the academic medical center and affiliated community hospitals. This position ensures consistent application of medical necessity criteria, compliance with payer and regulatory requirements, and alignment of utilization management (UM) practices across all entities. The Manager serves as the primary liaison between the health system, external utilization review vendors, and internal stakeholders including physicians, case management, and revenue cycle teams. The role focuses on optimizing patient status determinations, reducing avoidable denials, and supporting appropriate reimbursement through collaboration, education, and data-driven oversight. Essential Job Functions Oversee daily utilization review operations across multiple hospital sites to ensure timely, compliant reviews and consistent application of UM standards. Develop, implement, and monitor system-wide UR policies, workflows, and performance metrics. Identify opportunities and maintain responsibility for technology optimization, including EMR workflows and other UR platforms. Supervise and mentor UR staff and coordinate work between onsite and centralized review teams as applicable. Serve as a subject matter expert on medical necessity, payer requirements, and regulatory standards (CMS, Joint Commission, state). Maintain oversight of interdisciplinary education to ensure consistent understanding of UM criteria across departments (case management, physician advisors, financial counselors, etc.) Act as the primary point of contact for the system’s external Utilization Review vendor, ensuring high-quality, timely reviews and compliance with contractual performance metrics. Monitor vendor performance dashboards, review audit findings, and lead performance improvement initiatives. Provide input to contract negotiations. Collaborate with external partners to streamline communication, resolve escalations, and enhance consistency across hospital sites. Track and analyze utilization metrics, denial trends, and audit outcomes across the system. Prepare regular reports for leadership highlighting performance, compliance, and financial impact. Benchmark against national standards and peer institutions, and create action plans to meet those standards. Identify opportunities for improvement in review processes, technology use, and documentation practices. Provide root cause analysis of denials, and missed reviews as applicable. Participate in and/or coordinate daily multidisciplinary rounds with clinical and case management teams to support real-time status determinations and discharge planning. Serve as a liaison between hospitalists, attending physicians, physician advisors, CDI, and UR staff to ensure appropriate documentation of medical necessity and level of care. Build strong working relationships with Revenue Cycle, Case Management, CDI, and Physician Leadership teams to ensure alignment of clinical and financial objectives. Partner with Denials, CDI, Payer compliance, and Revenue Integrity teams to address payer trends and support denial prevention strategies. Provide education and support to clinical staff and physicians on UM criteria (InterQual, MCG), medical necessity documentation, and payer requirements. Stay current with regulatory updates, payer policies, and value-based care trends impacting utilization management. Participate in policy and training development for payer trends applicable to the UR function. Ensure all UR activities comply with CMS Conditions of Participation and other regulatory standards, and monitor competency assessments of UR staff. Required Qualifications Minimum 5 years of clinical experience in an acute care setting. Minimum 3–5 years of experience in Utilization Review, Case Management, or Denials Management, preferably in a health system or multi-site environment. Demonstrated experience in vendor management and cross-functional collaboration. Prior supervisory or leadership experience required.Required: Current Registered Nurse (RN) license, in good standing. Required: Bachelor’s degree in Nursing (BSN). Preferred: Master’s degree in Nursing, Healthcare Administration, or related field. Position Details Job Type: Full Time (1.0FTE) Shift: Days Work Location: Full Time (Hybrid) Hyde park, Crown Point and Ingalls rotation. Unit/Department: Revenue Cycle CBA Code: Non-Union Why Join Us We’ve been at the forefront of medicine since 1899. We provide superior healthcare with compassion, always mindful that each patient is a person, an individual. To accomplish this, we need employees with passion, talent and commitment… with patients and with each other. We’re in this together: working to advance medical innovation, serve the health needs of the community, and move our collective knowledge forward. If you’d like to add enriching human life to your profile, UChicago Medicine is for you. Here at the forefront, we’re doing work that really matters. Join us. Bring your passion. UChicago Medicine is growing; discover how you can be a part of this pursuit of excellence at: UChicago Medicine Career Opportunities UChicago Medicine is an equal opportunity employer. We evaluate qualified applicants without regard to race, color, ethnicity, ancestry, sex, sexual orientation, gender identity, marital status, civil union status, parental status, religion, national origin, age, disability, veteran status and other legally protected characteristics. As a condition of employment, all employees are required to complete a pre-employment physical, background check, drug screening, and comply with the flu vaccination requirements prior to hire. Medical and religious exemptions will be considered for flu vaccination consistent with applicable law. Compensation & Benefits Overview UChicago Medicine is committed to transparency in compensation and benefits. The pay range provided reflects the anticipated wage or salary reasonably expected to be offered for the position. The pay range is based on a full-time equivalent (1.0 FTE) and is reflective of current market data, reviewed on an annual basis. Compensation offered at the time of hire will vary based on candidate qualifications and experience and organizational considerations, such as internal equity. Pay ranges for employees subject to Collective Bargaining Agreements are negotiated by the medical center and their respective union. Review the full complement of benefit options for eligible roles at Benefits - UChicago Medicine.
RN Utilization Review Per Diem
Cedars-Sinai

Registered Nurse - Utilization Review Case Manager - PER DIEM - 8 Hour Days

apartment Cedars-Sinai location_onLos Angeles, CA
Job Description When the work you do every single day has a crucial impact on the lives of others, every effort, every detail, and every second matters. This shared culture of happiness, passion, and dedication pulses through Cedars-Sinai, and it’s just one of the many reasons why we rank as one of the top hospitals in the nation by U.S. News & World Report. Cedars-Sinai Medical Center is an organization known nationally for excellence in cancer treatment, research, and education. We are seeking a highly motivated Administrative Assistant to provide administrative support and contribute to our mission of providing word-class health care and the best quality service to our patients and communities. We invite you to consider this exciting opportunity and provide us with an opportunity to learn more about you and your skills! What will you be doing in this role? The Utilization Review Case Manager validates the patient's placement to be at the most appropriate level of care based on nationally accepted admission criteria. The UR Case Manager uses medical necessity screening tools, such as InterQual or MCG criteria, to complete initial and continued stay reviews in determining appropriate level of patient care, appropriateness of tests/procedures and an estimation of the patient's expected length of stay. The UR Case Manager secures authorization for the patient's clinical services through timely collaboration and communication with payers as required. The UR Case Manager follows the UR process as defined in the Utilization Review Plan in accordance with the CMS Conditions of Participation for Utilization Qualifications Qualifications: Education: Bachelor of Science, Nursing (BSN) required Master's Degree, Nursing (MSN) preferred License/Certification: Current, unrestricted California RN License required BLS from the American Heart Association or American Red Cross required Certified Case Management RN preferred Experience: A minimum of 5 years of acute care nursing experience required A minimum of 2 years of case management experience required At least 3 of years of ED nursing experience preferred Emergency Department Case Manager experience preferred Experience using Interqual or Milliman required High level of competency performing medical necessity reviews with accepted criteria required Req ID : 14141 Working Title : Registered Nurse - Utilization Review Case Manager - PER DIEM - 8 Hour Days Department : Utilization Management Business Entity : Cedars-Sinai Medical Center Job Category : Patient Services Job Specialty : RN Overtime Status : NONEXEMPT Primary Shift : Day Shift Duration : 8 hour Base Pay : $67.50 - $68.49
RN Manager/Supervisor Utilization Review Full-time
Molina Healthcare

Supervisor, Healthcare Services (RN, Utilization Management)

apartment Molina Healthcare location_onLong Beach, CA
** Pacific daytime business hours required. West Coast or Nevada residents preferred JOB DESCRIPTION Job Summary Leads and supervises multidisciplinary team of healthcare services professionals in some or all of the following functions: care management, utilization management, behavioral health, care transitions, long-term services and supports (LTSS), and/or other special programs. Ensures members reach desired outcomes through integrated delivery and coordination of care across the continuum, and contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Assists in implementing health management, care management, utilization management, behavioral health and other program activities in accordance with regulatory, contract standards and accreditation compliance. • Functions as a “hands-on” supervisor, assisting with assessing and evaluation of systems, day-to-day operations and efficiency of operations/services. • Assists in the coordination of orienting and training staff to ensure maximum efficiency and productivity, program implementation, and service excellence. • Trains and supports team members to ensure high-risk, complex members are adequately supported. • Assists with staff performance appraisals, ongoing monitoring of performance, and application of protocols and guidelines. • Collaborates with and keeps healthcare services leadership apprised of operational issues, staffing, resources, system and program needs. • Assists with coordination and reporting of department statistics and ongoing client reports, as assigned. • Local travel may be required (based upon state/contractual requirements). Required Qualifications • At least 5 years health care experience, and at least 2 years of managed care experience with utilization management. management or equivalent combination of relevant education and experience. • Registered Nurse (RN) Clinical licensure and/or certification required ONLY if required by state contract, regulation or state board licensing mandates. If licensed, license must be active and unrestricted in state of practice. • Ability to manage conflict and lead through change. • Operational and process improvement experience. • Strong written and verbal communication skills. • Working knowledge of Microsoft Office suite. • Ability to prioritize and manage multiple deadlines. • Excellent organizational, problem-solving and critical-thinking skills. Preferred Qualifications • Registered Nurse (RN). License must be active and unrestricted in state of practice. • Certified Case Manager (CCM), Certified Professional in Health Care Management certification (CPHM), Certified Professional in Health Care Quality (CPHQ) or other health care or management certification. • Medicaid/Medicare population experience. • Clinical experience. • Supervisory/leadership 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: $69,779 - $136,069 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
RN Utilization Review Full-time
Bryan Health

Utilization Management RN

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

Utilization Management Specialist - Admissions RN (Full Time/Days)

apartment Penn Medicine location_onLancaster, PA
Description Penn Medicine is dedicated to our tripartite mission of providing the highest level of care to patients, conducting innovative research, and educating future leaders in the field of medicine. Working for this leading academic medical center means collaboration with top clinical, technical and business professionals across all disciplines. Today at Penn Medicine, someone will make a breakthrough. Someone will heal a heart, deliver hopeful news, and give comfort and reassurance. Our employees shape our future each day. Are you living your life's work? LOCATION: Fully remote position after 12-week onsite orientation HOURS: Full Time (40 hours per week). Monday-Friday, one weekend every 11 weeks. Flexible start time from 6:30am-9am. No holidays Penn Medicine Lancaster General Health is looking for an experienced RN to join our Utilization Management Specialist team! In this critical role, you’ll advocate for patients by conducting thorough chart reviews, communicating with payors to secure timely authorizations, and ensuring accurate patient status throughout their stay. You’ll collaborate closely with physicians, clinical staff, and financial teams to support optimal outcomes and minimize denials—all while meeting tight deadlines in a fast-paced acute care environment. If you have deep clinical knowledge, strong decision-making skills, and thrive under pressure, we’d love to hear from you! Summary : The Utilization Management Specialist - Admissions is responsible for evaluating medical records to determine severity of patient's illness and the appropriate patient class in accordance with industry guidelines. Serves as a liaison for patients and hospital with insurance companies. Qualified individuals must have the ability with or without reasonable accommodation to perform the following duties: Complete chart review and communicate patient status medical needs with insurance companies in order to advocate for patients and facilitate appropriate reimbursement while meeting tight payor deadlines, often less than 24 hours. Amend patient status and complete order requests to Attending Physician/Advance Practice Provider urgently. Deep and thorough knowledge of clinical process in the Acute Care setting with the ability to make bold, independent decisions in regard to patient status and authorization requests. Ensure that patients are assigned the appropriate patient class throughout patient stay by using Industry standard review tools, department policies, and critical thinking. Frequently coordinate with clinical staff to facilitate appropriate documentation to support patient class, optimal patient outcomes, and minimize denied days. Work closely with physician advisers to provide timely, accurate and thorough clinical reviews to assist in patient class decision-making process. Ability to handle an unpredictable workload shaped by census and payor demands. Must be able to complete assignment by end of day to comply with department standards and payor requests. Complete all documentation, including authorizations and denials according to departmental standard operating procedures. Communicate with Patient Financial Services staff regarding changes to patient class to ensure proper billing. Work with Financial Clearance and Registration staff to ensure proper billing. Facilitate Peer to Peer appeal processes post-denial in a timely fashion. Follow up with payers to account for all bed days for authorization prior to discharge. Maintain knowledge of specific payer requirements to ensure efficient review process. Serve as a point of contact subject matter expert in the process of outside facilities transferring patients to Lancaster General Hospital. The following duties are considered secondary to the primary duties listed above: Participates in Continuous Improvement for the department and the organization. Identifies professional needs to maintain expertise and keep current with health care trends, both clinical and financial. Participates in orientation and education of individuals to the functions of this position. Participate in weekend coverage based on department rotation Other duties as assigned. Minimum Required Qualifications: Current licensure as a Registered Nurse, issued by the Pennsylvania Board of Nursing Bachelor’s of Science in Nursing Minimum of five years of nursing experience which includes a minimum of three years in an acute care hospital setting Excellent written, interpersonal communication and negotiation skills. Strong critical thinking skills and the ability to perform clinical chart review efficiently. Strong analytical, data management and computer skills. Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components. Ability to advocate for the patient, as well as the hospital’s best interests. Ability to adjust adapt to varying needs of the department and the ever-changing industry requirements Ability to work independently and exercise sound judgment in interactions with the health care team Ability to tolerate high volume production standards. Preferred Qualifications: Knowledge of health care and managed care delivery systems. This includes standards of medical practice; insurance benefit structures and related legal medical issues. Knowledge of utilization management and quality improvement processes. Experience working within the managed care environment. #LI-LJ1 We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region. Penn Medicine employees are actively engaged and committed to our mission. Together we will continue to make medical advances that help people live longer, healthier lives. Live Your Life's Work We are an Equal Opportunity employer. Candidates are considered for employment without regard to race, ethnicity, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, age, disability, marital status, familial status, genetic information, domestic or sexual violence victim status, citizenship status, military status, status as a protected veteran or any other status protected by applicable law.
RN Utilization Review Full-time
UNC Health

Utilization Manager (RN)

apartment UNC Health location_onHendersonville, 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: The Utilization Manager (UM) assesses new admissions, continued stay and discharge review cases for medical necessity, appropriate class and level of care (LOC). This position works collaboratively with an interdisciplinary team (including physicians, other care providers, payers, etc.) to ensure the patient’s needs are met and care delivery is coordinated. The UM completes utilization reviews in accordance with federal regulations and the health system’s Utilization Review Plan. Responsibilities: Uses approved criteria and conducts admission review/class change review as trigger by patient admission to the hospital to ensure appropriateness of the setting and timely implementation of the plan of care. Identifies and obtains observation services 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 Care Manager to manage level of care transitions & appropriate utilization of services. Coordinates with the appropriate staff/payers to assure third party payer pre-certification and/or re-certifications when required . Discharge Facilitation: Utilizes high risk screening criteria to make appropriate referrals . Identifies patient/families with the complex psychosocial, on-going medical transition planning issues , continuing care needs by initiating appropriate care management referrals. Initiates appropriate social work referrals. 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 initial and continued stay 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. 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 services issues through collaboration with patient/patient representative, multidisciplinary team, third party payers and care managers/social workers. Provides information regarding denials and approvals to appropriate staff and/or designated entities. Documents and delivers notifications to patients, patient representative and/or appropriate staff . Reviews Pre-Scheduled surgery admissions for proper status order for inpatient-only procedures. Collaborates to problem-solve issues with complex patients and identify trends. Formulates potential solutions with Care Manager and Social Worker and continuously monitors cases/follows up on all action items. Proactively identify high risk cases that need to be escalated to the list that are not scheduled for discussion that week. PARDEE Other information: Required Must be licensed to practice as a Registered Nurse in the state of North Carolina or one of compact states. Two (2) years of experience working as a Registered Nurse. Strong verbal and written communication. Basic Life Support (BLS) certification. Preferred Bachelor's of Science in Nursing (BSN) Certification in Case Management 01.6015.1542 Job Details Legal Employer: Pardee - HCHC Entity: Pardee UNC Health Care Organization Unit: Acute Care Case Management Work Type: Full Time Standard Hours Per Week: 40.00 Work Assignment Type: Onsite Work Schedule: Day Job Location of Job: PARDEEHOSP Exempt From Overtime: Exempt: No 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.
RN Utilization Review Per Diem
UNC Health

RN Utilization Manager - Care Management

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

Utilization Review RN

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

RN - Care Coordinator - In-patient HOT JOB

apartment SouthEast Alaska Regional Health Consortium location_onSitka, AK
Pay Range: Pay Range:$41.66 - $58.69 As part of a consortium-wide team, support and manage patient progression of care in the hospital setting, promote evidence-based protocols, ensure the appropriateness of interventions, assess patient psycho-social needs, and expedite care delivery for patients. SEARHC is a non-profit health consortium which serves the health interests of the residents of Southeast Alaska. We see our employees as our strongest assets. It is our priority to further their development and our organization by aiding in their professional advancement. Working at SEARHC is more than a job, it’s a fulfilling career. We offer generous benefits, including retirement, paid time off, paid parental leave, health insurance, dental, and vision benefits, life insurance and long and short-term disability, and more. ********************************************************* $25K Sign On and $10K Relocation for qualified hire! ************************************************************ Key Essential Functions and Accountabilities of the Job Works collaboratively with consortium wide team supporting inpatient Care Coordination and Utilization Management Coordinate local CAH Swing Bed/Transitional Care program. Lead local CAH Inpatient interdisciplinary team meeting. Reviews all admissions to develop personalized treatment plans that are clinically appropriate, match the patients care needs and are consistent with patient choice and available resources while ensuring a timely and appropriate discharge. Collaborate with providers, leadership, and clinical support team to ensure treatment plan is based upon patient need and meets criteria approved by consortium and regulatory agencies/payors. Ensure ongoing documentation supports Utilization Management functions and communicate with payors appropriately. Provide appropriate information to educate patients/families regarding healthcare benefits and treatment plan. Assess patient to obtain relevant psycho-social information, make interventions and professional support referrals as needed. Develop and communicate discharge plan with the care team and patient/family, ensuring safe and well-coordinated transition of care. Support Peer Review process as part of consortium plan. Education, Certifications, and Licenses Required Current full, unrestricted Registered Nursing license in Alaska or other U.S. state required. Bachelor’s preferred. Direct Hire must have applied for an Alaska nursing license before start date. Agency staff must have an active Alaska license. Case Management certification by recognized certifying organization within 24 months of hire. BLS. ACLS. PALS preferred. High school diploma or equivalent required. Clinical Competency required within 3 months of hire and every three years High Risk Competency required within 3 months of hire and every year Experience Required 5 years clinical nursing experience 1 year experience with chart review, risk management, or related quality service preferred. Knowledge of Medical record review, medical necessity/insurance guidelines, and regulatory compliance. Skills in Communication, both verbal and written Strong organizational skills Ability to Work collaboratively as part of an interdisciplinary team. Build relationships with colleagues, community partners, and consumers. Physical Demands: While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to stand; walk; sit; use hands to finger, handle or feel and reach with hands and arms. The employee is occasionally required to climb or balance; stoop, kneel, crouch or crawl. The employee must lift and/or move 50 lbs. Required Certifications : Advanced Cardiovascular Life Support (ACLS) - American Heart Association, Basic Life Support (BLS) - American Heart Association, Case Manager Certification - Commission for Case Manager Certification, Clinical Competency Assessment - SEARHC, High Risk Competency - SEARHC, Registered Nurse License - State of Alaska - Alaska State Board of Nursing If you like wild growth and working with happy, enthusiastic over-achievers, you'll enjoy your career with us!
RN Utilization Review Full-time
L.A. Care Health Plan

Utilization Management Nurse Specialist RN II

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

RN, Hospital Case Manager/Utilization Management

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

Registered Nurse Utilization Review KMH

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

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

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