Utilization Review Nurse Jobs

RN Utilization Review Full-time
McLaren Health Care

Utilization Management Registered Nurse, Michigan

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

RN Oasis Reviewer - Home Health Care - Full Time

apartment Virtua Health location_onEvesham, NJ
$43.27 - $58.68 / HOUR
At Virtua Health, we exist for one reason – to better serve you. That means being here for you in all the moments that matter, striving each day to connect you to the care you need. Whether that's wellness and prevention, experienced specialists, life-changing care, or something in-between – we are your partner in health devoted to building a healthier community. If you live or work in South Jersey, exceptional care is all around. Our medical and surgical experts are among the best in the country. We assembled more than 14,000 colleagues, including over 2,850 skilled and compassionate doctors, physician assistants, and nurse practitioners equipped with the latest technologies, treatments, and techniques to provide exceptional care close to home. A Magnet-recognized health system ranked by U.S. News and World Report, we've received multiple awards for quality, safety, and outstanding work environment. In addition to five hospitals, seven emergency departments, seven urgent care centers, and more than 280 other locations , we're committed to the well-being of the community. That means bringing life-changing resources and health services directly into our communities through our Eat Well food access program , telehealth, home health, rehabilitation, mobile screenings, paramedic programs, and convenient online scheduling. We're also affiliated with Penn Medicine for cancer and neurosciences, and the Children's Hospital of Philadelphia for pediatrics. Location: Lippincott - 301 Lippincott Drive Remote Type: On-Site Employment Type: Employee Employment Classification: Regular Time Type: Full time Work Shift: 1st Shift (United States of America) Total Weekly Hours: 40 Additional Locations: Job Information: Hours: FT/40hrs per week. 8:00a - 4:30p. Schedule: M-F Weekends/Holidays: Every 5th weekend, 1 holiday per year. Required Experience: Home Health Care experience. Preferred Experience: Coding experience; Oasis experience. Job Summary : Review of Home Health OASIS documentation tool and other necessary clinical documentation to ensure accuracy and completeness. Works with Case Managers on the revision and corrections required and coordinates with managers to ensure completion. Position Responsibilities: Analyzes and interprets clinical information in the OASIS and medical record to ascertain appropriate documentation, resource utilization, quality of care and cost effectiveness. Provides clinical analysis and oversight of OASIS data entry. Reviews clinical record data with clinician to determine accurate and appropriate diagnoses. Can review/revise Home Health Plan of Care (485) and OASIS for consistency. Responsible for overall timely submission of OASIS data in accordance with federal regulations. Liaison for the Home health Billing Office in matters related to OASIS and PDGM reimbursement issues. Acts as OASIS resource person for clinical and supervisory staff. Assures that all OASIS data entered is correct and accurate in sequence, date and content. Refers records to clinical staff that may require clarification or additional information to accurately assign codes. Collaborates with field nurses working with OASIS and/or coding in the coding conventions specific to Home Care as well as other coding knowledge, as applicable. Demonstrates appropriate and accurate use of the EPIC and SHP software documentation systems, including related OASIS work queues, reports Scheduling Modules, and the basics of ICD-9 coding. Submits required data to contracted vendors for OASIS outcome measurement and benchmarking activities. Accesses state database for all reports related to OASIS submissions and reports. Utilizes PDGM principles and guidelines in OASIS improvement activities. Works with education department to create general OASIS orientation and updates to new OASIS version material. Demonstrates principles of adult learning/education techniques. Demonstrates application of Federal, State and JCAHO standards. Position Qualifications Required : Required Experience: 3 years of RN Coding Experience preferred; Oasis Experience preferred. Required Education: RN; Bachelor’s degree preferred Training / Certification / Licensure: RN License in the State of NJ HCSD or BCHH-C certification preferred OASIS (COS-C/HCS-O) certification preferred Hourly Rate: $43.27 - $58.68 The actual salary/rate will vary based on applicant’s experience as well as internal equity and alignment with market data. Virtua offers a comprehensive package of benefits for full-time and part-time colleagues, including, but not limited to: medical/prescription, dental and vision insurance; health and dependent care flexible spending accounts; 403(b) (401(k) subject to collective bargaining agreement); paid time off, paid sick leave as provided under state and local paid sick leave laws, short-term disability and optional long-term disability, colleague and dependent life insurance and supplemental life and AD&D insurance; tuition assistance, and an employee assistance program that includes free counseling sessions. Eligibility for benefits is governed by the applicable plan documents and policies. For more benefits information click here .
RN Utilization Review Full-time
Centene

Utilization Review Clinician - ABA

apartment Centene location_onTX
$26.50 - $47.59 / HOUR
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. 2 POSITIONS AVAILABLE. THESE POSITIONS ARE REMOTE/WORK FROM HOME SUPPORTING CHILDREN AND ADOLECENTS ABA BEHAVIORAL HEALTH. ABA EXPERIENCE REQUIRED. BCBA STRONGLY PREFERRED. ACTIVE CURRENT STATE LICENSURE IS REQUIRED. WORK SCHEDULE IS MONDAY - FRIDAY 8AM - 5PM EITHER CENTRAL TIME ZONE OR EASTERN TIME ZONE AND VOLUNTARY HOLIDAYS WILL BE PART OF THE WORK SCHEDULE. Position Purpose: Performs reviews of member's care and health status of Applied Behavioral Analysis (ABA) services provided to determine medical appropriateness. Monitors clinical effectiveness and efficiency of member's care in accordance with ABA guidelines. Evaluates member’s care and health status before, during, and after provision of Applied Behavioral Analysis (ABA) services to ensure level of care and services are medically appropriate related to behavioral health (BH) and/or autism spectrum disorder needs and clinical standards Performs prior authorization reviews related to BH to determine medical appropriateness in accordance with ABA regulatory guidelines and criteria Analyzes BH member data to improve quality and appropriate utilization of services Interacts with BH healthcare providers as appropriate to discuss level of care and/or services provided to members receiving Applied Behavior Analysis Services Provides education to members and their families regrading ABA and BH utilization process Provides feedback to leadership on opportunities to improve care services through process improvement and the development of new processes and/or policies Performs other duties as assigned. Complies with all policies and standards. Education/Experience: Requires Graduate of an Accredited School of Nursing or Bachelor's degree and 2-4 years of related experience. For Enterprise Population Health 2+ years providing ABA services as a BCBA License to practice independently, and/or have obtained the state required licensure as outlined by the applicable state (BCBA) required. Master’s degree for behavioral health clinicians required. Behavioral health clinical knowledge and ability to review and/or assess ABA Treatment Plans required. Knowledge of ABA services and BH utilization review process required. Experience working with providers and healthcare teams to review care services related to Applied Behavior Analysis Services preferred. License/Certification: LCSW- License Clinical Social Worker required or LMHC-Licensed Mental Health Counselor required or LPC-Licensed Professional Counselor required or Licensed Marital and Family Therapist (LMFT) required or Licensed Mental Health Professional (LMHP) required or Board Certified Behavior Analyst (BCBA) required RN - Registered Nurse - State Licensure and/or Compact State Licensure RN - Registered Nurse- State Licensure and/or Compact State Licensure with BCBA required or Independent licensure with ABA experience and BCBA preferred. preferred Licensed Behavior Analyst (LBA) where required by state required Pay Range: $26.50 - $47.59 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
RN Utilization Review Full-time
Centene

Clinical Review Nurse - Concurrent Review

apartment Centene location_onIL
$26.50 - $47.59 / HOUR
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. ****NOTE: This is a fully remote role. Preference will be given to applicants (1) with an active Illinois or a compact LPN or RN licensure, (2) as well as some experience in each of the following areas: acute care, utilization management (UM), InterQual knowledge, and discharge planning knowledge.**** Additional Details: • Department: Concurrent Review MCD • Business Unit: Corporate • Schedule: Mon-Fri 8am - 5pm CST with rotating weekends and holidays (required). Subject to change per business. **** Position Purpose: Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member. Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines Reviews member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities Collaborates with care management on referral of members as appropriate Performs other duties as assigned Complies with all policies and standards Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience. 2+ years of acute care experience required. Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. License/Certification: LPN - Licensed Practical Nurse - State Licensure required For Health Net of California: RN license required Pay Range: $26.50 - $47.59 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
LPN Utilization Review Full-time
South Texas Health System McAllen

Case Manager (LPN/LVN) Utilization Review-FT

apartment South Texas Health System McAllen location_onMcAllen, TX
Responsibilities POSITION SUMMARY: Under the guidance and supervision of the Director, the clinical associate will perform retrospective reviews for payors, utilizing the current documentation system and enter the appropriate ICD/CPT and DRG when indicated. May be occasions when it will be necessary to work weekends, holidays, evenings, nights, and/or on-call/call-back status. Demonstrates Service Excellence standards at all times. Qualifications QUALIFICATIONS: 1. 5 years of varied clinical experience. 2. Basic Computer skills are required, additional college hours preferred 3. Must demonstrate commitment and adherence to STHS’s Compliance Program and Code of Conduct through compliance with all policies and procedures, the Code of Conduct, attendance at required training and immediately reporting suspected compliance issue(s) to the Compliance Officer. EDUCATION / LICENSURE: 1. LVN licensed in the State of TX 2. Coding experience preferred, Inpatient or outpatient EEO Statement All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws. We believe that diversity and inclusion among our teammates is critical to our success. Notice At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skillset and experience with the best possible career path at UHS and our subsidiaries. We take pride in creating a highly efficient and best in class candidate experience. During the recruitment process, no recruiter or employee will request financial or personal information (Social Security Number, credit card or bank information, etc.) from you via email. The recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc. If you are suspicious of a job posting or job-related email mentioning UHS or its subsidiaries, let us know by contacting us at: https://uhs.alertline.com or 1-800-852-3449. Pay Transparency: To encourage pay transparency, promote pay equity, and proactively address regulations, UHS and all our subsidiaries will comply with all applicable state or local laws or regulations which require employers to provide wage or salary range information to job applicants and employees. Salary offers may be based on key factors such as education and related experience.
RN Utilization Review Full-time
State of Ohio

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

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

Registered Nurse Utilization Review KMH

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

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

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

Utilization Review Team Lead (RN)

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

Clinical Review Nurse - Concurrent Review

apartment Centene location_onLos Angeles, CA
$26.50 - $47.59 / HOUR
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. This position is a M-F 8am to 5pm serving our LA Medicaid inpatient adult and pediatric members. Position Purpose: Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member. Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines Reviews member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities Collaborates with care management on referral of members as appropriate Performs other duties as assigned Complies with all policies and standards Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience. 2+ years of acute care experience required. Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. License/Certification: LPN - Licensed Practical Nurse - State Licensure required For Health Net of California: RN license required Pay Range: $26.50 - $47.59 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
RN Utilization Review Full-time
ECU Health

Quality Nurse Specialist II - Peer Review

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

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

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

Utilization Review Nurse | Corporate Utilization Management | PRN | Variable

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

Permanent Staff Utilization Review RN job in Saint Louis, MO - Make $33 to $50 per hour

apartment Aya Healthcare location_onSt. Louis, MO
$33 - $50 / HOUR
Access This Permanent Staff Utilization Review Registered Nurse Job in Saint Louis, MO. Job Details Pay: $33.00 to $50.00 per hour. (This info is approximate. To view complete pay and facility information, please log in to your Aya account or register with us now.) Shift: , 0-Hour 00:00 - 00:00 Join Aya for the most career options. Aya Healthcare gives you access to the most jobs — and the most exclusive opportunities — in the industry. We have strong relationships with leading facilities nationwide, and job options to support your personal and professional goals. Whether you want to put down roots with a permanent role, explore the country with a travel job or pick up per diem shifts close to home, Aya’s got you covered. Log In Today And Search jobs View pay & facility details Get real-time job notifications Register now to get started.
RN Utilization Review Full-time
Elevance Health

Nurse Reviewer I

apartment Elevance Health location_onChicago, IL
$33.12 - $56.77 / HOUR
Anticipated End Date: 2025-12-19 Position Title: Nurse Reviewer I Job Description: Nurse Reviewer I Virtual: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Alternate locations may be considered if candidates reside within a commuting distance from an office. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. Schedule: 9:30am-6:00pm local time, with rotating weekends. New Grads are encouraged to apply! The Nurse Reviewer I will be responsible for conducting preauthorization, out of network and appropriateness of treatment reviews for diagnostic imaging services by utilizing appropriate policies, clinical and department guidelines. Collaborates with healthcare providers, and members to promote the most appropriate, highest quality and effective use of diagnostic imaging to ensure quality member outcomes, and to optimize member benefits. Works on reviews that are routine having limited or no previous medical review experience requiring guidance by more senior colleagues and/or management. Partners with more senior colleagues to complete non-routine reviews. Through work experience and mentoring learns to conduct medical necessity clinical screenings of preauthorization request to assess assessing the medical necessity of diagnostic imaging procedures, out of network services, and appropriateness of treatment. How you will make an impact: Conducts initial medical necessity clinical screening and determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review. Conducts initial medical necessity review of exception preauthorization requests for services requested outside of the client health plan network. Notifies ordering physician or rendering service provider office of the preauthorization determination decision. Follows-up to obtain additional clinical information. Ensures proper documentation, provider communication, and telephone service per department standards and performance metrics. Minimum ​Requirements: AS in nursing and minimum of 3 years of clinical nursing experience in an ambulatory or hospital setting or minimum of 1 year of prior utilization management, medical management and/or quality management, and/or call center experience; or any combination of education and experience, which would provide an equivalent background. Current unrestricted RN license in applicable state(s) required. Preferred Skills, Capabilities, and Experiences​: Familiarity with Utilization Management Guidelines, ICD-9 and CPT-4 coding, and managed health care including HMO, PO and POS plans strongly preferred. BA/BS degree preferred. Previous utilization and/or quality management and/or call center experience preferred. Knowledge in Microsoft office. For candidates working in person or virtually in the below location(s), the salary* range for this specific position is $33.12/hr - $56.77/hr Locations: New York, New Jersey, Washington, Nevada, Maryland, Massachusetts, Illinois, District of Columbia In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws . * The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law. Job Level: Non-Management Non-Exempt Workshift: Job Family: MED > Licensed Nurse Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health. Who We Are Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. How We Work At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business. We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few. Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws. Elevance Health is an Equal Employment Opportunity employer, and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.
RN Utilization Review Per Diem
John Muir Health

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

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

Utilization Management Nurse (RN) (H)

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

Inpatient Auth Review Services RN or LPN -NICU

apartment TriStar Health location_onNashville, TN
Description Introduction This Work from Home position requires that you live and will perform the duties of the position; within 60 miles of an HCA Healthcare Hospital (Our hospitals are located in the following states: FL, GA, ID, KS, KY, MO, NV, NH, NC, SC, TN, TX, UT, VA). Do you want to join an organization that invests in you as an Inpatient Authorization Review Services Registered Nurse or Licensed Practical Nurse -NICU (Code Pink)? At Parallon, you come first. HCA Healthcare has committed up to 300 million in programs to support our incredible team members over the course of three years. Benefits Parallon offers a total rewards package that supports the health, life, career and retirement of our colleagues. The available plans and programs include: Comprehensive medical coverage that covers many common services at no cost or for a low copay. Plans include prescription drug and behavioral health coverage as well as free telemedicine services and free AirMed medical transportation. Additional options for dental and vision benefits, life and disability coverage, flexible spending accounts, supplemental health protection plans (accident, critical illness, hospital indemnity), auto and home insurance, identity theft protection, legal counseling, long-term care coverage, moving assistance, pet insurance and more. Free counseling services and resources for emotional, physical and financial wellbeing 401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service) Employee Stock Purchase Plan with 10% off HCA Healthcare stock Family support through fertility and family building benefits with Progyny and adoption assistance. Referral services for child, elder and pet care, home and auto repair, event planning and more Consumer discounts through Abenity and Consumer Discounts Retirement readiness, rollover assistance services and preferred banking partnerships Education assistance (tuition, student loan, certification support, dependent scholarships) Colleague recognition program Time Away From Work Program (paid time off, paid family leave, long- and short-term disability coverage and leaves of absence) Employee Health Assistance Fund that offers free employee-only coverage to full-time and part-time colleagues based on income. Learn more about Employee Benefits Note: Eligibility for benefits may vary by location. You contribute to our success. Every role has an impact on our patients’ lives and you have the opportunity to make a difference. We are looking for a dedicated Inpatient Authorization Review Services Registered Nurse or Licensed Practical Nurse -NICU (Code Pink) like you to be a part of our team. Job Summary and Qualifications The Inpatient Authorization Review Services Registered Nurse or Licensed Practical Nurse NICU (Code Pink) will review post discharge, prebill accounts that do not have authorization on file, ALOS versus days authorized variances, and/or other account discrepancies identified that will result in the account being denied by the payor that require clinical expertise. Communicates with third party payors to resolve discrepancies prior to billing. Accurately and concisely documents all communications and action taken on the account in accordance with policies and procedures. Escalate medical review request and /or denial activities to management as needed. What you will do in this role: Work post discharge, prebill accounts efficiently and effectively daily to resolve accounts with “no auth numbers, ALOS vs. authorized days or other discrepancies. Evaluates clinical documentation on multiple patient accounts and escalates issues through the established channels. Perform accurate and timely documentation of all review activities based on policy and procedure. Demonstrates a working knowledge of managed care agreements based on available resources which may include and not be limited to payer UM Manual, policy and procedure, facility contract information. Escalates variations timely. Work assigned accounts in eRequest to resolve outstanding issues. Report insurance denial trends identified during daily operational assignments. Contact facilities, physicians’ offices and/or insurance companies to resolve denials/appeals if needed. Demonstrates knowledge of regulatory requirements, Ethics and Compliance policies, and quality initiatives; monitors self-compliance and implements process changes to ensure compliance to such regulations and quality initiatives. Assess CPT code(s) for outpatient accounts that require authorization when accounts have not been coded. Qualifications that you will need: Registered Nursing degree and current licensure or Vocational nursing degree required. Healthcare experience in an acute care hospital. Utilization Review, appeals, denials, managed care contracting, experienced preferred. Currently licensed as a registered nurse (RN) in the state(s) of practice and/or has an active compact license, in accordance with law and regulation or Licensed Practical Nurse -Currently licensed as a licensed practical nurse in the state in which he or she resides and practices, in accordance with law and regulation. Multi-state nursing licensure for compact states Parallon provides full-service revenue cycle management, or total patient account resolution, for HCA Healthcare. Our services include scheduling, registration, insurance verification, hospital billing, revenue integrity, collections, payment compliance, credentialing, health information management, customer service, payroll and physician billing. We also provide full-service revenue cycle management as well as targeted solutions, such as Medicaid Eligibility, for external clients across the country. Parallon has over 17,000 colleagues, and serves close to 1,000 hospitals and 3,000 physician practices, all making an impact on patients, providers and their communities. HCA Healthcare has been recognized as one of the World’s Most Ethical Companies® by the Ethisphere Institute more than ten times. In recent years, HCA Healthcare spent an estimated 3.7 billion in cost for the delivery of charitable care, uninsured discounts, and other uncompensated expenses. "Good people beget good people." - Dr. Thomas Frist, Sr. HCA Healthcare Co-Founder We are a family 270,000 dedicated professionals! Our Talent Acquisition team is reviewing applications for our Inpatient Auth Review Services RN or LPN -NICU opening. Qualified candidates will be contacted for interviews. Submit your resume today to join our community of caring! We are an equal opportunity employer. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.
RN Utilization Review Full-time
Gainwell Technologies LLC

Clinical Quality Nurse Reviewer, Sr. Specialist

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

Permanent Staff Utilization Review RN job in Mission Hills, CA - Make $56 to $88 per hour

apartment Aya Healthcare location_onFremont, CA
$56 - $88 / HOUR
Access This Permanent Staff Utilization Review Registered Nurse Job in Mission Hills, CA. Job Details Pay: $56.00 to $88.00 per hour. (This info is approximate. To view complete pay and facility information, please log in to your Aya account or register with us now.) Shift: 3, 12-Hour 07:00 - 19:00 Join Aya for the most career options. Aya Healthcare gives you access to the most jobs — and the most exclusive opportunities — in the industry. We have strong relationships with leading facilities nationwide, and job options to support your personal and professional goals. Whether you want to put down roots with a permanent role, explore the country with a travel job or pick up per diem shifts close to home, Aya’s got you covered. Log In Today And Search jobs View pay & facility details Get real-time job notifications Register now to get started.
RN Utilization Review Full-time
Molina Healthcare

Care Review Clinician (RN)

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

RN - Case Manager - Case Management - Utilization Review

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

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

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

Clinical Review Nurse - Concurrent Review

apartment Centene location_onNV
$26.50 - $47.59 / HOUR
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. This is a Remote position - Nevada RN License preferred ****Post Acute Care experience preferred ***** Position Purpose: Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member. Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines Reviews member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities Collaborates with care management on referral of members as appropriate Performs other duties as assigned Complies with all policies and standards Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience. 2+ years of acute care experience required. Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. License/Certification: RN - State Licensure Preferred Pay Range: $26.50 - $47.59 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
RN Utilization Review Full-time
Centene

Clinical Review Nurse - Concurrent Review

apartment Centene location_onNew York, NY
$26.50 - $47.59 / HOUR
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. Must have a NY state nursing license. Hours: 8:30am-5pm EST, Monday-Friday. 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 RN - Registered Nurse - State Licensure preferred Pay Range: $26.50 - $47.59 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act