As a utilization review (UR) nurse, you help ensure that patients are receiving the appropriate level of care while being mindful of expenditures to your employer, whether you work for a hospital, managed care facility, or insurance company.
Wondering where you might work in this role? The federal government requires that organizations participating in Medicare and Medicaid conduct utilization reviews. This means that you’ll find a variety of workplace options for UR nurse jobs.
Education and Certifications for Utilization Review Nursing Jobs
Before you can work in utilization review, you must complete a nursing program from an approved institution. Once you pass the NCLEX and receive your license, you’ll want to gain clinical experience in direct patient care. Registered nurses may also want to pursue experience as an RN case manager.
While likely not required for most jobs, specialty certification can increase both your knowledge and also your leverage when it comes time to look for a new utilization review nurse job. Certifications include:
Health Utilization Management Certification (HUMC)
Put some effort into customizing your utilization review nurse resume to each job posting. For instance, if an employer is seeking a candidate “proficient in insurance prior authorizations and medical necessity criteria for different payers,” include that phrase in your resume. This helps demonstrate that your skills are a good fit for the job.
In your UR nurse cover letter, explain a bit about what drew you to this particular position. Remember, you don’t want just any old job — you want this job. To reinforce this sentiment as you apply to UR nurse jobs, search the employer’s website for their mission statement and see where your values overlap.
Interviewing for a Utilization Review Nurse Job
A job interview has the potential to determine whether or not you’ll get a job offer. Need some pointers? Review our nursing interview tips in advance to help you formulate smart answers to common questions and boost your confidence.
Learn how to answer interview questions about your strengths as a nurse:
Utilization Review Nurse Salary
The average annual salary for a UR nurse is around $91,600 for a registered nurse. Your location, level of education and experience, and employer can impact this number. For a more accurate picture of utilization review nurse jobs’ salary estimates in your area, explore the current UR nursing jobs on IntelyCare.
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Job Details Description Position Summary : 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 Review Experience Required: 3 to 5 years acute care nursing experience Preferred: Experience in case management Education Required: Graduate of accredited diploma, associate degree or baccalaureate degree nursing program Preferred: BSN preferred License and Credentials Required: NJ RN licensure Preferred: Certification in case management Skills Required: Current sound clinical knowledge; knowledge of medical literature, research methodology, financial/ reimbursement issues. Strong collaboration, communication and interpersonal skills. Excellent organizational and time management skills. Knowledge of computers, Electronic Health Records, data base systems and utilization review/case management documentation systems. Desire to work collaboratively and proactively with healthcare teams and other hospital-based interdisciplinary teams. Current knowledge of discharge planning, resource management, and care coordination in an acute care setting. Knowledge of CMS, commercial payer requirements and hospital financial/reimbursement processes. Excellent written/verbal communication skills, critical thinking skills, creative problem solving skills, good organizational and planning skills. Must be self-directed, have the ability to tolerate frequent interruption and work in a fast-paced work environment. Knowledge of funding, resources, services, clinical standards, care coordination processes and outcomes is preferred. Weekend, Holiday and on call may be required. Bi-Weekly Hours: Per-Diem, Day Shift, Weekends The rate for this position is $53.00 When determining a team members base rate, several factors may be considered as applicable (e.g., years of recent relevant experience, education, credentials, and internal equity). At Deborah, healthcare is still about caring...for patients and team members. That is why we offer an outstanding benefits package, which includes healthcare coverage for team members in regularly budgeted positions of at least 30 hours per week. The benefits package also includes generous paid time-off, 401K matching contribution, tuition assistance, short and long term disability benefits, life insurance, meal discount, dependent care subsidy, adoption assistance and free parking. Qualifications Skills Behaviors : Motivations : Education Preferred Bachelor Science Nursing or better in Nursing. Experience Licenses & Certifications Required Registered Prof. Nurse Equal Opportunity Employer This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.
Job Description Job Summary Provides support for medical claim and internal appeals review activities - ensuring alignment with applicable state and federal regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Contributes to overarching strategy to provide quality and cost-effective member care. Job Duties Facilitates clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases in which an appeal has been made, or is likely to be made, to ensure medical necessity and appropriate/accurate billing and claims processing. Reevaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of relevant and applicable state and federal regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of services provided, length of stay, level of care, and inpatient readmissions. Validates member medical records and claims submitted/correct coding, to ensure appropriate reimbursement to providers. Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) issues. Identifies and reports quality of care issues. Assists with complex claim review including diagnosis-related group (DRG) validation, itemized bill review, appropriate level of care, inpatient readmission, and any opportunities identified by the payment integrity analytical team; makes decisions and recommendations pertinent to clinical experience. Prepares and presents cases representing Molina, along with the chief medical officer (CMO), for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings. Reviews medically appropriate clinical guidelines and other appropriate criteria with medical directors on denial decisions. Supplies criteria supporting all recommendations for denial or modification of payment decisions. Serves as a clinical resource for utilization management, CMOs, physicians and member/provider inquiries/appeals. Provides training and support to clinical peers. Identifies and refers members with special needs to the appropriate Molina program per applicable policies/protocols. Job Qualifications REQUIRED QUALIFICATIONS: At least 2 years clinical nursing experience, including at least 1 year of utilization review, medical claims review, long-term services and supports (LTSS), claims auditing, medical necessity review and/or coding experience, or equivalent combination of relevant education and experience. Registered Nurse (RN). License must be active and unrestricted in state of practice. Experience demonstrating knowledge of ICD-10, Current Procedural Technology (CPT) coding and Healthcare Common Procedure Coding (HCPC). Experience working within applicable state, federal, and third-party regulations. Analytic, problem-solving, and decision-making skills. Organizational and time-management skills. Attention to detail. Critical-thinking and active listening skills. Common look proficiency. Effective verbal and written communication skills. Microsoft Office suite and applicable software program(s) proficiency. PREFERRED QUALIFICATIONS: Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ), or other health care certifications. Nursing experience in critical care, emergency medicine, medical/surgical or pediatrics. Billing and coding experience. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $29.05 - $67.97 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
Newport News, Virginia This is not a remote position, this position is located on site at Riverside Regional Medical Center in the Emergency Department working 12 hour shifts. Available Shift: 7am-7pm Responsible for the judicious management of health system resources through advocacy for both the patient and the organization. Provides initial medical necessity reviews for all patients hospitalized within the organization in accordance with national guidelines and standards of excellence, in accordance with the UM Plan established by the organization, facility goals, and strategic plans. What you will do Recognizes and demonstrates shared accountability, both at the patient and the team level. Contributes to decision-making and decision support as a member of the interdisciplinary team. Provides level of care determination to physicians (Emergency and Attending) based upon thorough medical record review and knowledge of federal and evidence-based guidelines, including CMS Conditions of Participation. Aligns practice with organization's mission and vision. Advances the application of research and evidence-based practices through the expert use of MCG national guidelines when assigning levels of care to admitted patients. Communicates effectively and professionally regarding modality. Provides education regarding utilization management to patients, families, and other members of the care team as needed. Maintains current knowledge of health care economics, trends, and reimbursement methodologies, and applies this knowledge to daily practice. Remains current via continuing education, MCG Interrater Reliability, and ACMA Compass modules. Respects and incorporates patients' goals of care and treatment preferences while respecting available resources. Builds and maintains relationships that foster trust and confidence. Engages with physician leaders to provide education and promote optimal patient care. Routinely collaborates with members of the interdisciplinary team, physician advisors, and facility leadership. Advocates on behalf of patients/families/caregivers for service access or creation and for protection of the patient's health, well-being, safety, and rights. Promotes and engages in culturally competent care. Partners with providers and payers to ensure the patient can access their full benefits. Balances resources with patient preferences. Advocates for the organization regarding compliance with the administration of required notices when medical necessity does not exist and ensures the patient/family is in complete understanding. Manages cost of care with the benefits of patient safety, clinical quality, risk, and patient satisfaction to provide recommendations and decisions that ensure optimal outcomes. Informs the interdisciplinary team of the economic impact of treatment options. Facilitates care delivery for the setting and duration that is appropriate to the clinical need. Applies knowledge of contractual arrangements and payment models to daily practice. Embraces and incorporates innovation and technology to improve collaboration and patient outcomes. Ensures compliance with organizational policy and regulatory requirements to securely transmit patient information and protect their health information. Utilizes established processes for secondary review when warranted. Qualifications Education Program Graduate, Professional Nursing (Required) Bachelors Degree, Nursing (Preferred) Experience 3-4 years Clinical nursing experience (Required) Skills and Abilities Excellent verbal and written communication skills Excellent interpersonal skills Excellent organizational skills and attention to detail Ability to act with integrity, professionalism, and confidentiality Proficiency with computer systems required to perform job Licenses and Certifications Registered Nurse (RN) - Virginia Department of Health Professions (VDHP) (Required) Certified Case Manager (CCM) - Commission for Case Manager Certification (Preferred) or Accredited Case Manager (ACM) - American Case Management Association (ACMA) (Preferred) Other Requirements Weekend Shifts Irregular Shifts To learn more about being a team member with Riverside Health System visit us at https://www.riversideonline.com/careers .
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. Position Purpose: Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member. Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines Reviews member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities Collaborates with care management on referral of members as appropriate Performs other duties as assigned Complies with all policies and standards Candidates may reside anywhere within the United States but must hold an active Michigan clinical license . Ideal candidate will have experience in acute care or utilization management . Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience. 2+ years of acute care experience required. Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. License/Certification: LPN - Licensed Practical Nurse - State Licensure required. Pay Range: $27.02 - $48.55 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
Job Description Utilization review nurse is responsible for the day to day coordination of admission criteria as it relates to healthcare needs of the patient and organization. Including knowledge of regulatory and compliance with Medicare, Medicaid and other insurance payors. This team member will communicate with a variety of clinical discipline, commercial payers, patient access, patient financial services, physician advisor and other staff members. Responsibilities Provides, initial, concurrent and retrospective reviews if assigned patients for severity of illness and intensity of service Demonstrates the ability to interpret InterQual and Milliman and Roberts criteria to ensure the patients meet admission and continued stay criteria Provides accurate and complete account authorization and details in plan notes Performs admission review on the following business day of patient's admission Involves the Physician Advisor as needed when physician-to-physician interaction is required to achieve appropriate clinical utilization for the patient Collaboratively works with the Physician Advisor to facilitate all aspects of the utilization management plan Serve as a liaison to patient accounting, patients access as it relates to authorizations and claims Demonstrates ability to communicate effectively with internal and external customers Demonstrates commitment toward customer satisfaction and patient advocacy Maintains confidentiality of patient/physician/and other team members as well as maintaining compliance with all federal/state guidelines and regulations Achieves budget length of stay (LOS) goal May perform other duties as assigned or requested and job specification can be modified or updated at any time Qualifications Required Education: Graduate of an accredited Nursing Program Preferred Education: Bachelors of Science Degree in Nursing (BSN) Required Experience: Three (3) years of experience in acute care nursing. Computers skills a must as well as excellent communication and the ability to work collaboratively with other disciplines Required Certifications and Licensures: Hold a current, active license as a registered nurse in Virginia or hold a current multistate/compact license. Hold a current, active American Heart Association Basic Life Support (AHA BLS) course completion card. Preferred Certifications and Licensures: ACMA Certification
Job Summary: The Clinical Care Reviewer II - Post-Acute is responsible for conducting medical necessity reviews to determine the appropriateness of authorization for post-acute health care services including Skilled Nursing Facilities (SNF), Nursing Facilities (NF), Long Term Acute Care Hospitals (LTACH), and Inpatient Rehabilitation Facilities (IRF). This role assists with discharge planning activities (i.e. DME, home health services) and care coordination for members enrolled with a CareSource Management Group line of business, and monitors the delivery of healthcare services to ensure they are provided in a cost-effective manner. Essential Functions: Conduct prospective, concurrent, and retrospective review of post-acute admissions and related services, including outpatient services provided in the post-acute setting according to established processes. Complete clinical reviews for new and continued stays in post-acute services; assist in facilitating timely and cost-effective member discharges to the appropriate level of care. Refer cases to CareSource Medical Directors when clinical criteria are not met or when a need for a case conference is identified. Maintain knowledge of state and federal regulations governing CareSource, including state contracts, provider agreements, CareSource policies and procedures, benefits, and accreditation standards. Identify and refer quality issues to the Quality Improvement department. Identify and refer members receiving post-acute services to Care Management according to established processes, escalating new or changing member needs as necessary. Document member discharge planning needs to support coordinated care and communicate with providers, care managers/care coordinators, discharge planners, CareSource Provider Relations, and other external stakeholders to support discharge planning activities. Participate in required inter-rater reliability (IRR) audits to ensure consistency and accuracy in reviews. Attend and participate in department huddles, team meetings, and all staff meetings; review meeting minutes and/or other collateral when unable to attend. Provide guidance and support to non-clinical utilization management staff as needed. Attend medical advisement and State Hearing meetings as requested. Assist Team Leader with special projects or research tasks as requested. Performs any other job related duties as requested. Education and Experience: Completion of an accredited registered nursing (RN) degree program required Three (3) years of clinical experience required Med/surgical, emergency, acute clinical care or Post Acute Care experience preferred Utilization Management/Utilization Review experience preferred Medicaid/Medicare/Commercial experience preferred Competencies, Knowledge and Skills: Basic data entry skills and internet utilization skills Working knowledge of Microsoft Outlook, Word, and Excel Effective oral and written communication skills Ability to work independently and within a team environment Attention to detail Familiarity of the healthcare field Proper grammar usage and phone etiquette Time management and prioritization skills Customer service oriented Decision making/problem solving skills Strong organizational skills Change resiliency Licensure and Certification: Current, unrestricted Registered Nurse (RN) licensure in state(s) of practice required MCG Certification is required or must be obtained within six (6) months of hire Working Conditions: General office environment; may be required to sit or stand for extended periods of time Availability to work scheduled weekend and holiday hours to ensure continuous department coverage and support for reviews throughout the year, including all 365 days Travel is not typically required Compensation Range: $62,700.00 - $100,400.00 CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package. Compensation Type (hourly/salary): Hourly Organization Level Competencies Fostering a Collaborative Workplace Culture Cultivate Partnerships Develop Self and Others Drive Execution Influence Others Pursue Personal Excellence Understand the Business This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds. #LI-JM1
RN Quality Review Manager- Registered Nurse Brooklyn, NY This a full time , in-person position based out of Brooklyn, NY . RN new grads are welcome . Pay: $90, 000- $105, 000/ annually About Us : With over 50 years of dedicated service to our communities, Personal Touch has been a trusted provider of home care. Our priority lies in ensuring exemplary patient care while fostering a supportive and empowering workplace culture for all team members. We are currently seeking compassionate and skilled nurses to join our team and continue our legacy of providing personalized and attentive care to patients in the comfort of their own home. Why Choose Us: At Personal-Touch Home Care, we are committed to creating a rewarding and fulfilling experience for our team members. Our established history and reputation provide a stable and trusted foundation for your career. Join us in positively impacting the lives of our patients and their families. As a member of our team, you will enjoy a wide range of benefits that enhance your overall well-being and support your career growth. They include: Employee Recognition Programs: We acknowledge and celebrate your contributions. Comprehensive Health Benefits: We offer an inclusive package with Medical, Dental, Vision, Accident, and Long-Term Disability Coverage to ensure access to quality medical care while promoting overall wellness. Generous Paid Time Off: We provide generous paid time off to ensure you can recharge and return to work refreshed, leading to greater productivity and job satisfaction. We support a healthy work-life balance. Retirement Benefits: We offer a 401k plan to secure your financial future and help you save for retirement. Life Insurance: We offer company paid life insurance providing peace of mind and financial protection for you and your loved ones. Mileage Reimbursement: We make sure you're compensated for your business travel. Opportunities for Professional Growth and Development: Empowering you to thrive and grow. Employee Assistance Program: Supporting the well-being of you and your family. Perks Program: Exclusive deals and offers on products, services, and experiences you need and love Job Details Overview: As a RN Clinical Manager/ Quality Review Manager , you will play a pivotal role in coordinating and managing patient care to ensure the highest standards are met. This position involves supervising clinical personnel and ensuring the delivery of quality home care services. Responsibilities: Receive case referrals and assess patient needs to assign appropriate clinicians. Review and evaluate each case, providing guidance to clinicians for effective performance. Instruct and guide clinicians to promote quality care delivery, being available to assist as needed. Review patient clinical information, including diagnosis, medications, and procedures. Assist in establishing therapeutic goals and developing care plans. Attend case conference meetings to facilitate care coordination. Conduct concurrent chart and record reviews and communicate findings to appropriate personnel. Assist in screening, interviewing, and orienting new personnel. Assist in planning and implementing in-service and continuing education programs. Contribute to the formulation, revision, and implementation of policies and procedures. Perform direct patient care duties as needed. Maintain compliance with professional standards and principles. Performs all other duties as assigned. Qualifications: Registered Nurse (RN) with current licensure to practice professional nursing in the State. Graduate of an accredited nursing school; BSN degree preferred. Two (2) years of prior home health care experience. At least one (1) year of management or supervisory experience in a health care setting, preferably home care. Demonstrates excellent observation, verbal and written communication skills. Verbal and written communication skills in English. Job type: Full-time Pay: $90, 000- $105, 000/ annually We are excited to welcome passionate and dedicated individuals to join our team at Personal Touch Home Care . We’re more than just a company, we’re a close-knit family dedicated to supporting each other’s success and well-being. Apply now and join us in making a positive impact on the communities we serve.
Overview Job Summary Manages the care for a specific population; facilitates the safe transition of patients throughout the continuum of care for appropriate utilization of resources, service delivery and compliance with federal and other payer requirements. Provides early assessment of transitional needs identified during their hospitalization, illness, and/or life situation. Performs other duties as assigned. Responsibilities Utilization Review Discharge planning Readmission Reduction Participation Payer Communication and denial reduction Completes assigned goals. Specifications Experience Minimum Required RN with at least one (1) year of clinical experience Preferred/Desired RN with 3 years of clinical experience with Case Management experience in a hospital or payer setting Education Minimum Required Diploma or Associate Degree in Nursing Preferred/Desired BSN or MSN Training Minimum Required Preferred/Desired Certified Case Manager Special Skills . Minimum Required Critical thinking skills, communication, organization, interpersonal and computer skills. Problem solving; and governmental regulations. Preferred/Desired Critical thinking skills, communication, organization, interpersonal and computer skills. Knowledge of payer requirements; problem solving; and governmental regulations. Licensure RN Minimum Required RN Preferred/Desired RN;CCM;ACM
Overview Job Summary Manages the care for a specific population; facilitates the safe transition of patients throughout the continuum of care for appropriate utilization of resources, service delivery and compliance with federal and other payer requirements. Provides early assessment of transitional needs identified during their hospitalization, illness, and/or life situation. Performs other duties as assigned. Responsibilities Utilization Review Discharge planning Readmission Reduction Participation Payer Communication and denial reduction Completes assigned goals. Specifications Experience Minimum Required RN with at least one (1) year of clinical experience Preferred/Desired RN with 3 years of clinical experience with Case Management experience in a hospital or payer setting Education Minimum Required Diploma or Associate Degree in Nursing Preferred/Desired BSN or MSN Training Minimum Required Preferred/Desired Certified Case Manager Special Skills . Minimum Required Critical thinking skills, communication, organization, interpersonal and computer skills. Problem solving; and governmental regulations. Preferred/Desired Critical thinking skills, communication, organization, interpersonal and computer skills. Knowledge of payer requirements; problem solving; and governmental regulations. Licensure RN Minimum Required RN Preferred/Desired RN;CCM;ACM
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)
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 8710 Medical Staff Services A team-oriented and quality focused professional who is responsible for overseeing the Medical Staff Peer Review process. QUALIFICATIONS License /Certification Required: Current California Registered Nurse License BLS Education Preferred: Bachelor's degree Experience Required: Three years clinical experience in an acute care setting. Experience with Cerner EMR. Preferred: Quality management experience. Knowledge/Skills/Abilities Strong computer skills to include Microsoft Office, Word, and Excel. Exceptionally strong interdisciplinary collaboration skills. Knowledge of peer review concepts and process and risk management principles preferred. Knowledge of guidelines, healthcare standards, and regulations, (i.e.: evidence-based, CMS, TJC, AHRQ Patient Safety Indicators, Hospital Acquired Conditions) preferred. Knowledge of quality improvement methodologies and analytic tools and methods preferred. Strong communication skills, both written and verbal preferred. JOB RESPONSIBILITIES Essential Supports and coordinates the Medical Staff Peer Review committees and activities as outlined in the Peer Review and Code of Conduct policy including but not limited to: Maintains the confidentiality of patients, practitioners, and the organization. Identifies cases which meet the criteria for preliminary clinical or behavioral case review. Assists peer reviewers in obtaining or provide a complete medical record, imaging studies and other documentation reasonably required to perform Peer Review. Coordinates and communicates with physicians and/or their offices in regard to screening, scoring and assist with their presentation of select cases for peer review or unprofessional behavior review. Attends the medical staff peer review behavior meetings and other related ad hoc meetings. Provides full administrative support which includes preparation of agendas, material gathering, speaker scheduling, chair preparation, recording minutes, and coordinating follow up processes and activities. Provides data identifying the relevant practice patterns and trends of the Practitioner related to defined departmental outcomes. Maintains positive working relationships with medical staff, nursing, and ancillary services as it relates to peer review processes. Performs preliminary (RN level) case review and highlight the potentially relevant issues. Provides relevant benchmark comparisons of the Practitioner under review. Identifies instances of clinical performance and/or unprofessional conduct regarding non-Practitioner staff. Facilitates timely and accurate triage of Medical Staff related Risk Events. Demonstrates the knowledge and skills necessary to provide care and services appropriate to the population served on the assigned unit or work area. 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.
JOB DESCRIPTION Job SummaryProvides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines. • Analyzes clinical service requests from members or providers against evidence based clinical guidelines. • Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. • Conducts reviews to determine prior authorization/financial responsibility for Molina and its members. • Processes requests within required timelines. • Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner. • Requests additional information from members or providers as needed. • Makes appropriate referrals to other clinical programs. • Collaborates with multidisciplinary teams to promote the Molina care model. • Adheres to utilization management (UM) policies and procedures. Required Qualifications • At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience. • Registered Nurse (RN). License must be active and unrestricted in state of practice. • Ability to prioritize and manage multiple deadlines. • Excellent organizational, problem-solving and critical-thinking skills. • Strong written and verbal communication skills. • Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications • Certified Professional in Healthcare Management (CPHM). • Recent hospital experience in an intensive care unit (ICU) or emergency room. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $26.41 - $51.49 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. **Applicants for this role must have a compact nursing license and will have the flexibility to work remotely from their home anywhere in the United States. The work schedule will be Monday – Friday, 8am – 5pm, Eastern or Central with a rotating weekend / holiday schedule as needed. An RN with previous Post Acute experience is strongly preferred.** Position Purpose: Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member. Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines Reviews member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities Collaborates with care management on referral of members as appropriate Performs other duties as assigned Complies with all policies and standards Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience. 2+ years of acute care experience required. Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. License/Certification: LPN - Licensed Practical Nurse - State Licensure required Pay Range: $27.02 - $48.55 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities, and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable, and equitable. Ready to make a difference? Join us to start Caring. Connecting. Growing together. As a Secondary Review Nurse , you will be conducting a review of long-term support services (LTSS) for the United Healthcare Community Plan of Kansas population. This nurse will work with the service coordination teams to ensure that the LTSS services align with the state guidelines along with the policies and procedures of the health plan. Additionally, this nurse will track various reporting elements for analysis and trending along with serving as a resource to others. The Secondary Review team consists of nurses and technicians within the plan. Hours are Monday - Friday 8am - 5pm. If you are located within the state of Kansas , you will have the flexibility to work remotely* as you take on some tough challenges. Primary Responsibilities Review technical metrics/specifications/ measures Evaluate documentation of Functional Assessment, compare to adherence to form instructions. Review and compare to prior assessment for changes. Provide recommendations to SC completing assessment if areas of opportunity exist Follow relevant regulatory guidelines, policies and procedures in reviewing clinical documentation (e.g., HEDIS, Clinical Practice Guidelines, HCC) Review relevant HEDIS specifications to guide chart review Review/ interpret/ summarize medical records/data to address quality of care questions Review provider responses to reports/findings and correlate with medical records Verify necessary documentation is included in medical records Maintain HIPAA requirements for sharing minimum necessary information Based on review of clinical data/documentation, identify potential quality of care issues (e.g., variations from standard practice potentially resulting in adverse outcomes) and potential fraud/waste/abuse Solve moderately complex problems and/or conduct moderately complex analyses Work with minimal guidance; seeks guidance on only the most complex tasks. Translate concepts into practice Provide explanations and information to others on difficult issues Coach, provides feedback, and guide others while acting as a resource for others with less experience What Are The Reasons To Consider Working For UnitedHealth Group? Put It All Together - Competitive Base Pay, a Full And Comprehensive Benefit Program, Performance Rewards, And a Management Team Who Demonstrates Their Commitment To Your Success. Some Of Our Offerings Include Paid Time Off which you start to accrue with your first pay period plus 8 Paid Holidays Medical Plan options along with participation in a Health Spending Account or a Health Saving account Dental, Vision, Life& AD&D Insurance along with Short-term disability and Long-Term Disability coverage 401(k) Savings Plan, Employee Stock Purchase Plan Education Reimbursement Employee Discounts Employee Assistance Program Employee Referral Bonus Program Voluntary Benefits (pet insurance, legal insurance, LTC Insurance, etc.) More information can be downloaded at: http://uhg.hr/uhgbenefits You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear directions on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications Current, unrestricted RN license in the state of Kansas 2+ years of experience working with the needs of vulnerable populations who have chronic or complex bio-psychosocial needs 1+ years of experience working with people receiving services on one of the homes and community-based waivers in KS 1+ years of Medicaid, Medicare, or Managed Care experience in long-term care, Long Term Services and Supports, home health, hospice, behavioral health, public health or assisted living 1+ years of computer experience, including experience with email, internet research, enter/retrieve data in electronic clinical records, use of online calendars and other software applications Preferred Qualifications Knowledge of community resources Strong written and verbal communication skills Problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action All Telecommuters will be required to adhere to UnitedHealth Group's Telecommuter Policy. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $28.94 to $51.83 per hour based on full-time employment. We comply with all minimum wage laws as applicable. At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location, and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups, and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission. UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations. UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment. #RPO #GREEN
We've made a lot of progress since opening the doors in 1942, but one thing has never changed - our commitment to serve, heal, lead, educate, and innovate. We believe that every award earned, every record broken and every patient helped is because of the dedicated employees who fill our hallways. At Ochsner, whether you work with patients every day or support those who do, you are making a difference and that matters. Come make a difference at Ochsner Health and discover your future today! This job functions as the liaison and communicator with the patient, caregivers, healthcare providers, and multi-disciplinary team members as well as post-acute care and third party payers. Discusses alternative care options with patient / caregivers as well as the multi-disciplinary team and assists with discharge planning needs. Facilitates movement along the health care continuum to ensure quality, cost–effective outcomes are achieved in collaboration with the multi-disciplinary team. Full Time Ochsner Medical Center-Baton Rouge To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential duties. This job description is a summary of the primary duties and responsibilities of the job and position. It is not intended to be a comprehensive or all-inclusive listing of duties and responsibilities. Contents are subject to change at the company's discretion. Education Required - Graduate of an accredited school of nursing. Preferred - Bachelor’s degree in nursing. Work Experience Required - 2 years of related experience. Certifications Required - Current registered nurse (RN) license in state of practice. Basic Life Support (BLS.) through the American Heart Association. Preferred - Certification in Case Management (CCM). Health Care Management (CPHM). Knowledge Skills and Abilities (KSAs) Proficiency in using computers, software, and web-based applications. Effective verbal and written communication skills and ability to present information clearly and professionally to varying levels of individuals throughout the patient care process. Good organizational and time management skills. Conflict resolution skills and ability to demonstrate good judgement and decision making in performing tasks. Job Duties Manages various aspects of the planning process in anticipation of the patient’s movement through the healthcare system. Uses care managements policies and procedures including application of evidenced based criteria and level of care and continued appropriateness. Manages the care of assigned patients through the healthcare system based on the patient’s individual needs. Prepares, executes, and reinforces post-discharge care plan. Adapts behavior to the specific patient population, including but not limited to respect for privacy, method of introduction to the patient, adapting explanation of services or procedures to be performed, requesting permissions and communication style. Performs other related duties as required. The above statements describe the general nature and level of work only. They are not an exhaustive list of all required responsibilities, duties, and skills. Other duties may be added, or this description amended at any time. Remains knowledgeable on current federal, state and local laws, accreditation standards or regulatory agency requirements that apply to the assigned area of responsibility and ensures compliance with all such laws, regulations and standards. This employer maintains and complies with its Compliance & Privacy Program and Standards of Conduct, including the immediate reporting of any known or suspected unethical or questionable behaviors or conduct; patient/employee safety, patient privacy, and/or other compliance-related concerns. The employer is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status, or disability status. Physical and Environmental Demands The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Medium Work - Exerting 20 to 50 pounds of force occasionally, and/or 10 to 25 pounds of force frequently, and/or greater than negligible up to 10 pounds of force constantly to move objects. (Constantly: activity or condition exists 2/3 or more of the time) to move objects. Physical demand requirements are in excess of those for Sedentary Work. Even though the weight lifted may be only a negligible amount, a job should be rated Light Work: (1) when it requires walking or standing to a significant degree; or (2) when it requires sitting most of the time but entails pushing and/or pulling of arm or leg controls; and/or (3) when the job requires working at a production rate pace entailing the constant pushing and/or pulling of materials even though the weight of those materials is negligible. NOTE: The constant stress and strain of maintaining a production rate pace, especially in an industrial setting, can be and is physically demanding of a worker even though the amount of force exerted is negligible. Normal routine involves no exposure to blood, body fluid or tissue, but exposure or potential for exposure may occur. The incumbent works with patients who have known or suspected communicable diseases and may enter isolation rooms. The incumbent has an occupational risk for exposure to all communicable diseases. Because the incumbent works within a healthcare setting, there may be occupational risk for exposure to hazardous medications or hazardous waste within the environment through receipt, transport, storage, preparation, dispensing, administration, cleaning and/or disposal of contaminated waste. The risk level of exposure may increase depending on the essential job duties of the role. Are you ready to make a difference? Apply Today! Ochsner Health does not consider an individual an applicant until they have formally applied to the open position on this careers website. Please refer to the job description to determine whether the position you are interested in is remote or on-site. Individuals who reside in and will work from the following areas are not eligible for remote work position: Colorado, California, Hawaii, Illinois, Maryland, Massachusetts, Minnesota, New Jersey, New York, Vermont, Washington, and Washington D.C. Ochsner Health endeavors to make our site accessible to all users. If you would like to contact us regarding the accessibility of our website, or if you need an accommodation to complete the application process, please contact our HR Employee Solution Center at 504-842-4748 (select option 1) or careers@ochsner.org . This contact information is for accommodation requests only and cannot be used to inquire about the status of applications. Ochsner is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to any legally protected class, including protected veterans and individuals with disabilities.
Job Summary: Clinical Care Reviewer II is responsible for processing medical necessity reviews for appropriateness of authorization for health care services, assisting with discharge planning activities (i.e. DME, home health services) and care coordination for members, as well as monitoring the delivery of healthcare services. Essential Functions: Complete prospective, concurrent and retrospective review such as acute inpatient admissions, post-acute admissions, elective inpatient admissions, outpatient procedures, homecare services and durable medical equipment Identify, document, communicate, and coordinate care, engaging collaborative care partners to facilitate transitions to an appropriate level of care Engage with medical director when additional clinical expertise if needed Maintain knowledge of state and federal regulations governing CareSource, State Contracts and Provider Agreements, benefits, and accreditation standards Identify and refer quality issues to Quality Improvement Identify and refer appropriate members for Care Management Provide guidance to non-clinical staff Provide guidance and support to LPN clinical staff as appropriate Attend medical advisement and State Hearing meetings, as requested Assist Team Leader with special projects or research, as requested Perform any other job related duties as requested. Education and Experience: Associates of Science (A.S) Completion of an accredited registered nursing (RN) degree program required Three (3) years clinical experience required Med/surgical, emergency acute clinical care or home health experience preferred Utilization Management/Utilization Review experience preferred Medicaid/Medicare/Commercial experience preferred Competencies, Knowledge and Skills: Proficient data entry skills and ability to navigate clinical platforms successfully Working knowledge of Microsoft Outlook, Word, and Excel Effective oral and written communication skills Ability to work independently and within a team environment Attention to detail Proper grammar usage and phone etiquette Time management and prioritization skills Customer service oriented Decision making/problem solving skills Strong organizational skills Change resiliency Licensure and Certification: Current, unrestricted Registered Nurse (RN) Licensure in state(s) of practice required MCG Certification or must be obtained within six (6) months of hire required Working Conditions: General office environment; may be required to sit or stand for extended periods of time Travel is not typically required Compensation Range: $62,700.00 - $100,400.00 CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package. Compensation Type (hourly/salary): Hourly Organization Level Competencies Fostering a Collaborative Workplace Culture Cultivate Partnerships Develop Self and Others Drive Execution Influence Others Pursue Personal Excellence Understand the Business This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. Applies critical thinking and is knowledgeable in clinically appropriate treatment, evidence based care and clinical practice guidelines for Behavioral Health and/or medical conditions based upon program focus. Concurrent Medical Reviews for Commercial Plans. Collaborating with facilities and providers to document and review for extended stay request. Required Qualifications Licensed Registered Nurse (Compact RN a Plus) with 3 or more years of Behavioral Health Clinical Experience. Independently licensed behavioral health clinician in state of residence. 3+ years post degree experience in a psychiatric or substance abuse setting required 3 years of direct clinical practice experience post masters degree, e.g., hospital setting or alternative care setting such as ambulatory care or outpatient clinic/facility. Preferred Qualifications 3 years Managed care/utilization review experience preferred. Crisis intervention skills and experience preferred Proficiency with computer and technology skills which includes navigating multiple systems and keyboarding. California license or ability to obtain California license preferred Education : Master's degree in Behavioral/Mental health or Human Service/Health Services Associates degree with a Registered Nurse Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $60,522.00 - $129,615.00 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan . No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 02/28/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
Interested in working for the Golden Isles’ healthcare provider and employer of choice? Throughout the many locations that make up the Southeast Georgia Health System network, there is a common thread that pulls everything together: A team of committed professionals like you. These individuals appreciate the value of every person who walks through our doors and are the key to our culture of Service Excellence. Summary: Manages the Medical Staff Peer Review Process for the Health System by identifying records, review, and analysis of information obtained, summarizing findings, and coordination of provider review. Maintains the integrity, confidentiality, and privilege of the safety event reporting system and Peer Review Professional Practice Evaluation Process. Conducts thorough research, interviews, and retrospective chart reviews on reported safety events and patient/family complaints with provider involvement contributing to the event and/or complaint as appropriate. Coordinates Peer Review meetings to include documentation and follow-up recommendations. Drafts and submits educational and informative decision letters to providers as required and oversees management of Peer Review files. Attends medical staff meetings to integrate medical staff into Performance Improvement Program and advise medical staff on policies and procedures as needed. Adheres to credentialing and peer review deadlines. Processes Peer Review issues in a timely manner. Assists in identifying and coordinating resolution of system process issues that may adversely affect the quality and safety of care being provided to patients. Collaborates with the Risk Analyst on event management through use of the event reporting software, assigning event investigations to appropriate leadership for review and follow-up, ensuring follow-up is timely and complete. Closes the event submission upon completion. Follow up with team members and/or complainants when appropriate. Prepares Risk Reviews as directed. Other job duties pertaining to the functions of the Medical Staff Services Department and Risk Management Department. Minimum Qualifications: Graduate of a Diploma, Associate’s Degree or Bachelor’s Degree Nursing Program Current RN license to practice in the State of Georgia Knowledge of basic nursing theory and practice, medical terminology, and familiarity with Health System policies and procedures. Familiarity with hospital regulatory requirements. Possesses knowledge of Microsoft and Cerner applications. Possess excellent written, oral, and interpersonal communication skills; Strong analytical, problem solving, decision making, and organizational skills Able to establish and maintain effective rapport with members of the medical staff. Able to work in a high volume, complex environment while maintaining confidentiality Able to work independently and able to be a part of a collaborative team. Able to multi-task, create and present data as needed. Why Choose Southeast Georgia Health System? We are mission-focused to provide safe, quality, accessible, and cost-effective care to meet the health needs of the people and communities it serves. Our workplace is as pleasant and rewarding as the setting we enjoy outside of work -- imagine stepping out of your workspace and into a world of scenic beauty, outdoor recreational activities, mild winters, natural beaches, fine dining, and a full array of cultural and colonial historic attractions. The chance to work within a culture that is collegial yet professional, has exceptional career-advancement potential, and work/life balance that is practically unparalleled. Our facility will allow you to use, sharpen, and add to your skills without having to commute to a large city environment. We offer competitive salaries and a comprehensive benefits package which includes generous Paid Time Off, tuition reimbursement, and wellness programs. The ability to be a part of the prestigious Coastal Community Health, a regional affiliation between Baptist Health and Southeast Georgia Health System. This collaboration forms a highly integrated hospital network focused on significant initiatives designed to enhance the quality and value of care provided to our contiguous communities.
Job Description UW Medical Center has an outstanding opportunity for an experienced Utilization Review Nurse to join our team. WORK SCHEDULE Fully remote / work from home Must be available to work day shifts during Pacific Standard Time Sat, Sun and one day during the week (8 hour shifts) POSITION HIGHLIGHTS Ensures the delivery of optimal care for our patients while promoting fiscal responsibility Maintains efficient, cost effective care management processes by determining the medical necessity and financial liability for all hospitalized patients Plays a key role ensuring compliance with regulatory requirements, policies, and procedures Primary Job Responsibilities Identify clinical indications for admission Track hospital events and course in order to justify patient admission and continued stay for payer reimbursement Communicate with third party payers regarding patient clinical progress Assess and communicate potential reasons for payer denials and attempts to resolve the denial with the team at the time of identification Participate in activities of identifying high risk vulnerabilities to the organization Use critical thought processes and decision making in monitoring the continuum of care Support work at both UW Medical Center – Northwest and UW Medical Center - Montlake Requirements 3 years of work experience in utilization management 5 years of nursing work experience in an acute care med-surg setting Bachelor's Degree in Nursing, or equivalent education and training Active licensure to practice as a Registered Nurse in Washington State by start date Knowledge of medical screening criteria Computer skills to appropriately navigate electronic charting and referral systems Case Management certification and previous experience with Xsolis software and MCG criteria preferred, but not required About Uw Medicine – Where Your Impact Goes Further UW Medicine is Washington’s only health system that includes a top-rated medical school and an internationally recognized research center. UW Medicine’s mission is to improve the health of the public by advancing medical knowledge, providing outstanding primary and specialty care to the people of the region, and preparing tomorrow’s physicians, scientists and other health professionals. All across UW Medicine, our employees collaborate to perform the highest quality work with integrity and compassion and to create a respectful, welcoming environment where every patient, family, student and colleague is valued and honored. Nearly 29,000 healthcare professionals, researchers, and educators work in the UW Medicine family of organizations that includes: Harborview Medical Center, UW Medical Center - Montlake, UW Medical Center - Northwest, Valley Medical Center, UW Medicine Primary Care, UW Physicians, UW School of Medicine, and Airlift Northwest. Become part of our team. Join our mission to make life healthier for everyone in our community. Compensation, Benefits And Position Details Pay Range Minimum: $108,000.00 annual Pay Range Maximum $150,000.00 annual Benefits Other Compensation: For information about benefits for this position, visit https://www.washington.edu/jobs/benefits-for-uw-staff/ Shift First Shift (United States of America) Temporary or Regular? This is a regular position FTE (Full-Time Equivalent) 60.00% Union/Bargaining Unit Not Applicable About The UW Working at the University of Washington provides a unique opportunity to change lives – on our campuses, in our state and around the world. UW employees bring their boundless energy, creative problem-solving skills and dedication to building stronger minds and a healthier world. In return, they enjoy outstanding benefits, opportunities for professional growth and the chance to work in an environment known for its diversity, intellectual excitement, artistic pursuits and natural beauty. Our Commitment The University of Washington is committed to fostering an inclusive, respectful and welcoming community for all. As an equal opportunity employer, the University considers applicants for employment without regard to race, color, creed, religion, national origin, citizenship, sex, pregnancy, age, marital status, sexual orientation, gender identity or expression, genetic information, disability, or veteran status consistent with UW Executive Order No. 81. To request disability accommodation in the application process, contact the Disability Services Office at 206-543-6450 or dso@uw.edu. Applicants considered for this position will be required to disclose if they are the subject of any substantiated findings or current investigations related to sexual misconduct at their current employment and past employment. Disclosure is required under Washington state law.
Position: Clinical Review Nurse, Appeals Location: Any Job Id: 684 # of Openings: 1 Position Summary: Enhances continuity of patient care by providing liaison between assigned populations, providers, hospitals, and physicians through the processing of medical determinations. To review, coordinate and facilitate all necessary information required from the payer or provider in order to render an informed determination on medically reasonable, necessary and appropriate clinical care. Roles and Responsibilities: • Primary role as an appeal or claim reviewer. Perform pre-service appeals, post service appeals, and post service claim reviews, and provide documented recommendations based on the use of appropriate clinical guidelines. • Review initial evaluation and all additional clinical documentation against clinical standards, applicable state regulations and relevant treatment guidelines. • Review and comply with treatment guidelines and clinical review criteria to assist in determining the appropriateness of services. • Clinical nurse reviewers cannot render a recommendation or a determination for an appeal, however, may assist with providing appeals and claims recommendations to the payer, and in the notification process for delegated appeals. • Assist manager and clinical staff in quality improvement projects to provide instructive feedback to clients and providers within scope of practice. • Resolves patient care issues by working one-to-one with clients, community providers and staff to resolve issues in determination process. • Support non-clinical staff with clinically related questions or issues that arise within scope of practice. • Meets medical operational standards by contributing information to strategic plans and reviews, implementing production, productivity, quality, and customer-service standards; resolving problems; identifying system improvements. • Educates clients and community provider’s team by attending nursing team meetings; providing input relating to clinical concerns for individual patient requests. • Provides information by responding to queries of payers, physicians, and their practice staffs; sorting and distributing messages and documents; answering questions and requests; preparing information for recommendations and determinations; maintaining databases. • Improves quality results by studying, evaluating procedures and processes, recommending changes to services if needed. JOB DESCRIPTION • Serves and protects the company by adhering to URAC and NCQA standards, professional standards, policies and procedures, federal, state, and local requirements, and professional and licensing standards. • Contributes to company effectiveness by identifying short-term and long-range issues that must be addressed; providing information and commentary pertinent to deliberations; recommending options and courses of action; implementing directives. • Attend meetings and training. • Updates job knowledge by participating in educational opportunities; reading professional publications; maintaining personal networks; participating in professional organizations. • Enhances company reputation by accepting ownership for accomplishing new and different requests; exploring opportunities to add value to job accomplishments. • Follows company policies and procedures and conducts annual performance reviews in a timely manner. • Acts as a liaison for interdepartmental communication. • Respects and maintains HIPAA confidentiality guidelines. • Other duties as directed. Education, Experience and Licensure: Internal candidates must have at least 6 months in current role or prior claims and/or appeals experience No corrective action or attendance issues on file • Active and unrestricted Registered Nurse or License Practical Nurse licensure in any State in the United States. Some states may require an active and unrestricted nursing license. • Diploma of nursing from an accredited school required. • Bachelor’s Degree in a health related field preferred. • Minimum of 5 years’ experience in healthcare operations preferred. • Excellent verbal and written communication skills. Ability to foster a cohesive working environment. Preferred Professional Competency: • RN: National Certification in specialty area (i.e. Orthopedics, Cardiology, etc.) • LPN: Experienced in area of UM focus and working within a managed care environment. Preferred Skills: Creating a Safe, Effective Environment, Health Promotion and Maintenance, Nursing Skills, Verbal Communication, Listening, Confidentiality, Dependability, Emotional Control, Medical Teamwork. Strong organizational skills; commitment to customer service; ability to problem solve; strong presentation skills throughout all levels of the organization. Must be able to foster a positive and productive work environment with ability to lead, build teams and motivate staff. Proficient in Microsoft Word, Excel and Outlook. Apply for this Position
Are you looking to take your career to new heights with a leader in healthcare? SUNY Downstate Health Sciences University is one of the nation's leading metropolitan medical centers. As the only academic medical center in Brooklyn, we serve a large population that is among the most diverse in the world. We are also highly-ranked by Castle Connolly Medical, a healthcare rating company for consumers, among the top 5 leading U.S. medical schools for training doctors. Bargaining Unit UUP Job Summary The Department of Case Management at SUNY Downstate Health Sciences University is seeking a full-time TH Utilization Review & Quality Assurance Senior Coordinator / Utilization Review Nurse. The successful candidate will: Report directly to the RN Case Management Manager. Review patient records for chief complaints, signs and symptoms of disease to justify medical necessity for admission to acute inpatient rehabilitation facility (IRF) per Milliman Care Guidelines (MCGs). Provide critical feedback per established MCGs. Collaborate with social workers, referring case managers, and physicians for alternative care sites when appropriate. Validate admission and continuing stay criteria with third party payers as well as primary care and attending physicians. Complete clinical reviews and forward to MCOs. Use clinical knowledge and knowledge of anticipated response to treatment to assess patient progression toward anticipated outcomes. Assess patients and care support for continuing care needs to develop, implement and evaluate an effective discharge plan in collaboration with the multidisciplinary team. Use knowledge of usual length of stay to initiate a plan for discharge. Determine medical necessity, appropriateness of admission, continuing stay and level of care using a combination of clinical information, clinical criteria, and third-party information. Intervene when determinations are not in alignment with clinical information, clinical criteria, IT systems or third-party information to resolve the situation. Communicate and coordinate with patients/care teams to intervene when progression is stalled or diverted. Collaborate and communicate with patients/care teams related to reimbursement issues and to create a discharge plan. Support the process of patient choice in establishing a discharge plan. Actively contribute to and participate in all IRF AM huddles, Rehab Unite team meetings, rehab unit related length of stay meetings, discharge planning rounds, unit daily reports, clinical practice team and department meetings. PRN participate in med-surg unit interdisciplinary team rounds. Complete IRF discharge calls, perform utilization reviews, and facilitate peer-to-peer reviews in care management module. Complete PRls and forward to SAR/SNF after patient/care team selection. Assist in Joint Reconstruction surgery QAPI and optimization. Work in dynamic work environment across multiple settings, while frequently communicating with team members as necessary and appropriate. Be a team player and a role model for other staff members and students. Model the organization's WE CARE values. Demonstrate flexibility and perform other job related duties as business need demands, as the position is not limited to the above description. Required Qualifications New York State Registered Nurse Licensure. Current Patient Review Instrument (PRI) Certification. 2+ years of recent acute care clinical nursing experience (Critical Care preferred). Working knowledge of Utilization Review processes. Use of CareGuidelines (MCG/Interqual). Computer proficiency in Microsoft Word, Excel, PowerPoint. Strong interpersonal, communication, administrative, and organizational skills. Or, a satisfactory equivalent combination of experience, education and training to the above. Preferred Qualifications Bachelor of Science Degree preferred. Competency/experience with Careport, Allscripts EHR. Work Schedule Monday to Friday; 9:00am to 5:00pm (Full-Time) Salary Grade/Rank SL-4 Salary Range Commensurate with experience and qualifications Executive Order Pursuant to Executive Order 161, no State entity, as defined by the Executive Order, is permitted to ask, or mandate, in any form, that an applicant for employment provide his or her current compensation, or any prior compensation history, until such time as the applicant is extended a conditional offer of employment with compensation. If such information has been requested from you before such time, please contact the Governor’s Office of Employee Relations at (518) 474-6988 or via email at info@goer.ny.gov. Equal Employment Opportunity Statement SUNY Downstate Health Sciences University is an affirmative action, equal opportunity employer and does not discriminate on the basis of race, color, national origin, religion, creed, age, disability, sex, gender identity or expression, sexual orientation, familial status, pregnancy, predisposing genetic characteristics, military status, domestic violence victim status, criminal conviction, and all other protected classes under federal or state laws. Women, minorities, veterans, individuals with disabilities and members of underrepresented groups are encouraged to apply. If you are an individual with a disability and need a reasonable accommodation for any part of the application process, or in order to perform the essential functions of a position, please contact Human Resources at ada@downstate.edu
Description The Emergency Department (ED) Utilization Review (UR) Case Manager RN reflects the mission, vision, and values of NM, adheres to the organization’s Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards RESPONSIBILITIES: Utilizes advanced clinical skills to perform utilization review on patients admitted through the Emergency Department. Maintains current knowledge of clinical criteria sets and evidence-based research around utilization review. Promotes and evaluates the effective utilization of resources using current clinical knowledge to achieve optimal clinical and resource outcomes. Performs Medical Necessity Outreach (MNO) with providers to clarify severity of illness and intensity of services offered. Build rapport with ED provider staff. Document the medical necessity for the observation status in the electronic medical record. Monitors electronic medical record track board for eligible patients. Places hospital status orders in collaboration with ED providers. Documents unusual occurrences and patient relations issues; makes appropriate referrals to risk management, infection control and quality departments. Collaborates with the ED Case Manager/Social Worker on patient specific discharge planning, safety, or clinical concerns of a patient that is being reviewed. Partners with manager/director in evaluating and analyzing quality/utilization cases, admission/discharge criteria, ED observation cases, and ED to Observation data. Consults with physicians in assigning admission level of care status and uses physician advisory group as needed. Stays up-to-date on Medicare rules and regulations for hospital. Performs medical record review to assess for appropriateness of admissions. Monitors and documents avoidable days and recommends change in services or processes. Develops and educates staff on clinical practice guidelines/Protocols/pathways that complement industry standards to reduce unnecessary admissions, ED length of stay and resource consumption while maintaining quality of care. Monitors documentation of an appropriate diagnosis for outpatient/observation testing to pass medical necessity. Educates ED physicians on documentation best practice. Qualifications Required: Registered Nursing license issued by the State of Illinois. Bachelor of Science in Nursing. 3 or more years of related clinical or utilization review experience. Preferred: Master of Science in Nursing. Membership in Professional Nursing Organization. Certification in Case Management (ACM or CCM). 5 or more years of clinical or utilization review experience Equal Opportunity Northwestern Medicine is an equal opportunity employer (disability, VETS) and does not discriminate in hiring or employment on the basis of age, sex, race, color, religion, national origin, gender identity, veteran status, disability, sexual orientation or any other protected status. Background Check Northwestern Medicine conducts a background check that includes criminal history on newly hired team members and, at times, internal transfers. If you are offered a position with us, you will be required to complete an authorization and disclosure form that gives Northwestern Medicine permission to run the background check. Results are evaluated on a case-by-case basis, and we follow all local, state, and federal laws, including the Illinois Health Care Worker Background Check Act. Artificial Intelligence Disclosure Artificial Intelligence (AI) tools may be used in some portions of the candidate review process for this position, however, all employment decisions will be made by a person. Benefits We offer a wide range of benefits that provide employees with tools and resources to improve their physical, emotional, and financial well-being while providing protection for unexpected life events. Please visit our Benefits section to learn more. Sign-on Bonus Eligibility: Internal employees and rehires who left Northwestern Medicine within 1 year are not eligible for the sign on bonus. Exception: New graduate internal employees seeking their first licensed clinical position at NM may be eligible depending upon the job family.
Current Emanate Health Employees - Please log into your Workday account to apply Everyone at Emanate Health plays a vital role in the care we deliver. No matter what department you belong to, the work you do at Emanate Health affects lives. When you join Emanate Health, you become part of a team that works together to strengthen our communities and grow as individuals. On Glassdoor's list of "Best Places to Work" in 2021, Emanate Health was named the #1 ranked health care system in the United States, and the #19 ranked company in the country. Job Summary Provides expertise to the organization in the form of quality management review and performance improvement knowledge. Supports the hospital and medical staff in Performance Improvement activities and works within the organization's Performance Improvement plan. Job Requirements a. Minimum Education Requirement : BSN preferred. b. Minimum Experience Requirement : All (1) newly graduated nurses, (2) re-entry nurses, and (3) nurses new to the U.S. healthcare system must satisfactorily complete the Emanate Health R.N. Residency Program within the first 6 months of employment. Minimum of three years of acute care experience. Experience in quality- related job preferred. Computer proficiency is required. Excellent customer service skills required. c. Minimum License Requirement : Current California RN license. CPHQ preferred. Delivering world-class health care one patient at a time. Pay Range: $54.63 - $84.67
Job Summary: The Behavioral Health Utilization Review Registered Nurse (RN) manages and coordinates the nursing care activities during the client's hospitalization in accordance with organization policies and procedures. This includes assessment, diagnosis, planning and establishing outcomes, implementation, and evaluation. Based on this process, the RN directs and is responsible for other personnel involved in client care. The RN maintains professional accountability for all nursing care provided to clients in the organization. Demonstrates competency in nursing judgment. Maintains awareness of economic barriers of health care and acts accordingly. Demonstrates knowledge of nursing care needs and treatments for clients of various clinical specialties in compliance with established standards of nursing practice. Functions and Duties: Provides appropriate nursing care by planning, organizing, and directing the nursing functions of clients on the unit. Makes nursing assignments appropriate to the skill level of employees. Accurately and promptly implements physicians’ orders. Prepares, administers, and records medications in accordance with the policy regarding the administration of medications. Records information concisely, accurately and completely. Coordinates and provides emergency care as needed. Evaluates the performance of personnel with recommendations for appropriate action. Adjust interventions based on age appropriate guidelines as indicated. Demonstrates abilities to set priorities in directing and/or providing safe client care by functioning in an organized and time conscious manner. Contributes to the care of the environment by maintaining work areas and assisting with light housekeeping tasks as needed. Maintains customers’ rights (confidentiality, privacy, safety, security). Accepts working assignments according to client care needs in accordance with job skill level. Assists with the development and implementation of unit goals. Conducts group therapies as assigned. Participates in multidisciplinary treatment planning and revises plan of care based on assessment. Participate and promote activities regarding Process Improvement. Provides care based upon client's age specific needs. Adheres to nursing staffing and scheduling policy (to include use of overtime). Follows chain of command resolving any issues or problems identified. Monitors clients and documents appropriately according to risk precaution level. Maintains a safe environment monitoring continuously for any harmful contraband. Attends and participates in departmental meetings. Precepts and trains other employees as assigned. Performs all other duties as assigned Minimum Qualifications: Graduate of an accredited school of nursing required. Bachelors’ degree preferred. Prior behavioral health experience preferred. Current Illinois nursing license. (BLS) certification required. Obtains and renews annually or as recommended by departmental leadership crisis de-escalation certification. Ability to operate standard office equipment. Physical Demands: Must be able to wear personal protective equipment (PPE) (mask, gown, gloves) when required. Requires grasping and reaching with hands/arms. Ability to lift up to, but not limited to 25 pounds when assisting clients, turning clients or assisting client with activities. Requires bending, stooping, and walking. Requires good body mechanics to prevent injury. Day shift
Registered Nurse Looking for Utilization Management AND Education experience. Medical Management Educator within Utilization Management This is a hybrid position. The role includes being an Epic Credentialed Trainer from March - October 2026, returning to the Utilization Management team upon Epic implementation. Scope of work: In conjunction with Medical Management leadership, coordinates the educational plan for the Behavioral Health, Care Management, and Utilization Management departments. Stakeholders include staff, physicians, department leadership, and third-party vendors. Uses specific age and culture-related physical, intellectual, psychological, and development attributes in the educational plans for staff. Reports to either a Director of Behavioral Health, Care Management, or Utilization Management with matrix reporting to other areas in Medical Management. Develops/implements the educational plan for Behavioral Health, Care Management, and Utilization Management. ·Develops/implements orientation of new staff which is comprehensive and individualized with one-on-one training for three or more weeks. ·Rounding and telephonic support of staff education needs and problem solving. ·Ongoing education based on analysis of outcomes from external audits. ·Education and support for implementation and ongoing use of new electronic medical record system and supplemental ancillary computer systems. ·Collaborate with educators to Provide education and support as needed. Conducts department-specific assessment for educational needs related to Compliance Monitoring and Education. ·Monthly auditing of Compliance Risk areas and identification of staff education and documentation needs to ensure compliance ·Annual education on InterQual ® criteria changes with annual Interrater Reliability Assessment. ·Analyze and evaluate the effectiveness of all educational activities. Conducts educational workshops to medical management and related audiences as requested. ·Education of changes and payor requirements to targeted Physician groups. Develops informational materials and/or other media to be distributed to internal/external customers. · Internal/external orientation material. · Maintains and updates repositories of educational content needed for staff orientation, day-to-day operations, and continuing education on Sharepoint sites. · Develops annual education plan to ensure Care and Utilization management staff have access to current best practice and relevant updates. · Monthly auditing for specific areas of focus as directed by leadership, to ensure adherence to clinical best practice. Department Liaison for external audits. ·Coordinates and facilitates with other departments to ensure readiness for audits ·Analyze audit recommendations ·Reporting outcomes and development/implementation of staff education as needed. ·Assists with project and program improvement efforts Qualifications Required Bachelor's Degree Preferred Master's Degree Utilization Management experience highly preferred. Education and/or training experience highly preferred 3 years of relevant experience Must have 3 to 5 years' experience in Care Management, or Utilization Management. Required Registered Nurse (RN) - State of Michigan Upon Hire required How Corewell Health cares for you Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here . On-demand pay program powered by Payactiv Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more! Optional identity theft protection, home and auto insurance, pet insurance Traditional and Roth retirement options with service contribution and match savings Eligibility for benefits is determined by employment type and status Primary Location SITE - Priority Health - 1231 E Beltline Ave NE - Grand Rapids Department Name Utilization Management Operations - PH Managed Benefits Employment Type Full time Shift Day (United States of America) Weekly Scheduled Hours 40 Hours of Work 8 a.m. to 5 p.m. Days Worked Monday to Friday Weekend Frequency N/A CURRENT COREWELL HEALTH TEAM MEMBERS – Please apply through Find Jobs from your Workday team member account. This career site is for Non-Corewell Health team members only. Corewell Health is committed to providing a safe environment for our team members, patients, visitors, and community. We require a drug-free workplace and require team members to comply with the MMR, Varicella, Tdap, and Influenza vaccine requirement if in an on-site or hybrid workplace category. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process, to perform the essential functions of a job, or to enjoy equal benefits and privileges of employment due to a disability, pregnancy, or sincerely held religious belief. Corewell Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category. An interconnected, collaborative culture where all are encouraged to bring their whole selves to work, is vital to the health of our organization. As a health system, we advocate for equity as we care for our patients, our communities, and each other. From workshops that develop cultural intelligence, to our inclusion resource groups for people to find community and empowerment at work, we are dedicated to ongoing resources that advance our values of diversity, equity, and inclusion in all that we do. We invite those that share in our commitment to join our team. You may request assistance in completing the application process by calling 616.486.7447.
