As a utilization review (UR) nurse, you help ensure that patients are receiving the appropriate level of care while being mindful of expenditures to your employer, whether you work for a hospital, managed care facility, or insurance company.
Wondering where you might work in this role? The federal government requires that organizations participating in Medicare and Medicaid conduct utilization reviews. This means that you’ll find a variety of workplace options for UR nurse jobs.
Education and Certifications for Utilization Review Nursing Jobs
Before you can work in utilization review, you must complete a nursing program from an approved institution. Once you pass the NCLEX and receive your license, you’ll want to gain clinical experience in direct patient care. Registered nurses may also want to pursue experience as an RN case manager.
While likely not required for most jobs, specialty certification can increase both your knowledge and also your leverage when it comes time to look for a new utilization review nurse job. Certifications include:
Health Utilization Management Certification (HUMC)
Put some effort into customizing your utilization review nurse resume to each job posting. For instance, if an employer is seeking a candidate “proficient in insurance prior authorizations and medical necessity criteria for different payers,” include that phrase in your resume. This helps demonstrate that your skills are a good fit for the job.
In your UR nurse cover letter, explain a bit about what drew you to this particular position. Remember, you don’t want just any old job — you want this job. To reinforce this sentiment as you apply to UR nurse jobs, search the employer’s website for their mission statement and see where your values overlap.
Interviewing for a Utilization Review Nurse Job
A job interview has the potential to determine whether or not you’ll get a job offer. Need some pointers? Review our nursing interview tips in advance to help you formulate smart answers to common questions and boost your confidence.
Learn how to answer interview questions about your strengths as a nurse:
Utilization Review Nurse Salary
The average annual salary for a UR nurse is around $91,600 for a registered nurse. Your location, level of education and experience, and employer can impact this number. For a more accurate picture of utilization review nurse jobs’ salary estimates in your area, explore the current UR nursing jobs on IntelyCare.
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Internal Employees: Please ensure that you are logged into Workday and applying through the Jobs Hub before proceeding. RN (Utilization Review) Job Description Utilization Review RN conducts medical certification review for medical necessity for acute care facility and services Uses nationally recognized, evidence-based guidelines approved by medical staff to recommend level of care to the physician and serve as a resource to the medical staff on issues related to admission qualifications, resource utilization, national and local coverage determinations and documentation improvement opportunities. Relays information as requested to the payer sources. Assures the highest quality, most cost effective patient care in the most appropriate setting. Responsibilities Assessment - Collects pertinent data and information relative to the patient's health or the situation. Recognizes normal and abnormal findings when gathering data., Assumes responsibility for remaining current on all regulatory and reimbursement rules and regulations., Concurrently reviews medical necessity, bed status, length of stay and quality of care indicators on all assigned patients. Serves as coordinator for communication with payors and providers to determine the appropriateness of hospital level of care., Confers with attending physician and physician advisor if medically unnecessary inpatient treatment is contemplated., Consults with medical staff, care team, and case managers as necessary to resolve immediate progression-of-care barriers through appropriate administrative and medical channels., Coordinates Medicare appeals with the discharge planner, Director of Utilization Management, Physician Advisor and the QIO., Coordination of Care - Plans and evaluates care in collaboration with appropriate disciplines., Diagnosis - Analyzes assessment data to determine actual or potential diagnosis, problems, and issues., Evaluation - Evaluates progress toward attainment of goals and outcomes. Reports data and outcomes to others as appropriate., Implementation - Implements care or work plan in alignment with the plan and approved safety, infection control, and department/organization standards., Knowledge - In collaboration with leaders, actively pursues required knowledge and skills through orientation activities specific to the position, reading current literature and seeking new learning opportunities., Outcomes Identification - Identifies expected outcomes for a plan individualized to the patient or situations., Planning - Develops a plan that prescribes strategies to attain expected, measurable outcomes., Recognizes and responds appropriately to patient safety/risk factors., Refers all denials, as appropriate, to the Director of Utilization Management and/or Physician Advisor., Relationships - Establishes effective working relationships with peers, physicians, and other members of the health care / work team. Identifies and confers with appropriate resources regarding patient / work decisions., Reviews operating room (OR) schedule 48 hours in advance of scheduled procedures to confirm that all eligible Medicare and Medicaid admissions were identified and the coded procedure is or is not on the Medicare inpatient-only list. Confirms that physician’s admission orders accurately reflect status., Serves as a resource person to physicians, case managers, physician offices, and billing office for coverage and compliance issues., Serves as coordinator for third party payer reviews, certifications and authorizations., Teaching - Employs teaching strategies to promote health and a safe environment., Works closely with physician advisor to review resource utilization data and trends to identify outliers who may benefit from real-time coaching to improve outcomes. Requirements ADN (Required)RN-Registered Nurse - Illinois Department of Financial and Professional Regulation Compensation Estimated Compensation Range $66,768.00 - $103,500.80 Pay based on experience
Overview Performs utilization review of inpatient admissions, outpatient surgeries, and ancillary services. Performs precertification, concurrent and retrospective reviews, and coordination of discharge planning. Determines medical necessity and appropriateness of services using clinical review criteria. Collaborates with physicians and other providers to facilitate provision of services throughout the health care continuum. Acts as a member advocate by expediting the care process through the continuum, working in concert with the health care team to maintain high quality and cost effective care delivery. Requires an Associates of Nursing (ASN). Bachelors of Nursing (BSN) preferred. Requires an active Registered Nurse (RN) license in the state of Indiana or an active Nurse Licensure Compact (NLC) RN license. Requires that the RN has graduated from a nationally accredited nursing program. Requires 3-5 years of relevant experience. Basic Life Support certification through the AHA or other advanced life support certifications may be required per unit/department specialty according to patient care policies. Requires proficiency in Microsoft Office and applications. Requires understanding of medical record requirements, regulations and policies.
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Regular business hours are 8:00 am-8:00 pm EST. Must be available to work any 8 hour shift within this timeframe with start times ranging from 8:00 am-11:30am EST. About Us American Health Holding, Inc. (AHH), a division of Aetna/CVS Health, is a URAC-accredited medical management organization founded in 1993. We provide flexible, cost-effective care management solutions that promote high-quality healthcare for members. Position Summary Join our Utilization Management team as a Nurse Consultant, where you'll apply clinical judgment and evidence-based criteria to review inpatient and outpatient services. You'll collaborate with providers, authorize care, and escalate cases when needed, all while navigating multiple systems and maintaining accurate documentation. This role suits nurses who thrive in fast-paced environments, are highly organized, and comfortable with computer-based work. Key Responsibilities Apply critical thinking and evidence-based clinical criteria to evaluate outpatient and inpatient services requiring precertification and concurrent review. Conduct clinical reviews via phone and electronic documentation, collaborating with healthcare providers to gather necessary information. Use established guidelines to authorize services or escalate to Medical Directors as needed. Navigate multiple computer systems efficiently while maintaining accurate documentation. Thrive in a fast-paced, high-volume environment with strong organizational, multitasking, and prioritization skills. Perform sedentary work that primarily involves extended periods of sitting, as well as frequent talking, listening, and use of a computer. Flexibility to provide coverage for other Utilization Management (UM) Nurses across various UM specialty teams as needed, ensuring continuity of care and operational support. Participate in occasional on-call rotations, including some weekends and holidays, per URAC and client requirements. Remote Work Expectations This is a 100% remote role; candidates must have a dedicated workspace free of interruptions. Dependents must have separate care arrangements during work hours, as continuous care responsibilities during shift times are not permitted. Required Qualifications Active unrestricted state Registered Nurse licensure in state of residence required. Minimum 5 years of relevant experience in Nursing. At least 1 year of Utilization Management experience in concurrent review or prior authorization. Strong decision-making skills and clinical judgment in independent scenarios. Proficient with phone systems, clinical documentation tools, and navigating multiple digital platforms. Commitment to attend a mandatory 3-week training (Monday–Friday, 8:30am–5:00pm EST) with 100% participation. Preferred Qualifications 1+ year of experience in a managed care organization (MCO). Experience in a high-volume clinical call center or prior remote work environment. Education Associate's degree in nursing (RN) required, BSN preferred. Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $29.10 - $62.32 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan . No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits This job does not have an application deadline, as CVS Health accepts applications on an ongoing basis. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
ABOUT MARINHEALTH Are you looking for a place where you are empowered to bring innovation to reality? Join MarinHealth, an integrated, independent healthcare system with deep roots throughout the North Bay. With a world-class physician and clinical team, an affiliation with UCSF Health, an ever-expanding network of clinics, and a new state-of-the-art hospital, MarinHealth is growing quickly. MarinHealth comprises MarinHealth Medical Center, a 327-bed hospital in Greenbrae, and 55 primary care and specialty clinics in Marin, Sonoma, and Napa Counties. We attract healthcare’s most talented trailblazers who appreciate having the best of both worlds: the pioneering medicine of an academic medical center combined with an independent hospital's personalized, caring touch. MarinHealth is already realizing the benefits of impressive growth and has consistently earned high praise and accolades, including being Named One of the Top 250 Hospitals Nationwide by Healthgrades, receiving a 5-star Ranking for Overall Hospital Quality from the Centers for Medicare and Medicaid Services, and being named the Best Hospital in San Francisco/Marin by Bay Area Parent, among others. Company: Marin General Hospital dba MarinHealth Medical Center Compensation Range: $66.03 - $99.04 Work Shift: 10 Hour (days) (United States of America) Scheduled Weekly Hours: 40 Job Description Summary: The Utilization Review Nurse is responsible for completion of admission, concurrent and retrospective reviews for designated health plans. This function includes appropriate application of standardized criteria and concurrent documentation. As appropriate, the UR nurse will assess for clinical stability and coordinate transfer back to Marin General for continued care when patients are admitted to non-contracted hospitals. The UR nurse is also responsible for initial RAC review prior to submission to Physician Advisor and will appeal medical necessity denials. Denials submitted to the case management department from Patient Financial Services will be reviewed to determine if the medical record has sufficient medical necessity documentation prior to a written appeal. The UR nurse will escalate cases to the Medical Director (as necessary) to ensure the provision of appropriate and effective patient care. Job Requirements, Prerequisites and Essential Functions: EDUCATION Bachelor of Science degree in Nursing preferred EXPERIENCE 1. Three (3) or more years of experience in an acute patient care setting preferably in medical/surgical or critical care. 2. Substantial recent experience in utilization review and/or discharge planning in an acute care setting is strongly preferred. 3. Experience in applying evidence based criteria related to utilization management. 4. Experience using case management software LICENSURE AND CERTIFICATIONS Registered Nurse Required at hire Basic Life Support Required at hire PREREQUISITE SKILLS 1. Must have the ability to read, write, and follow English verbal and written instructions, and have excellent oral and written communication, interpersonal, problem-solving, conflict resolution, presentation, time management, and positive personal influence and negotiation skills. 2. Able to carry out review function and access medical records. 3. Must have the ability to work independently with a minimum of direction, anticipate and organize work flow, prioritize and follow through on responsibilities. 4. Utilization review/discharge planning services appropriate to patients with complex 5. Strong attention to detail and accuracy is required. 6. Must have the ability to work in a high volume case load environment and deal effectively with rapidly changing priorities. 7. Demonstrated ability to work constructively with a broad spectrum of health care professionals is required. 8. Must be assertive and creative in problem solving, system planning and management. 9. Proficient computer skills are required including use of Electronic Health Record. Microsoft Office Suite Products. Accommodation: Qualified applicants with disabilities may request reasonable accommodation during the application process by contacting Human Resources at 415-925-7040 or TalentAcquisition@mymarinhealth.org . C.A.R.E.S. Standards: MarinHealth seeks candidates ready to model our C.A.R.E.S. standards—Communication, Accountability, Respect, Excellence, Safety—which foster a healing, trust-based environment for patients and colleagues. Health & Immunizations: To protect employees, patients, and our community, MarinHealth requires measles, mumps, varicella, and annual influenza immunizations as a condition of employment (and annually thereafter). COVID-19 vaccination/booster remains strongly recommended. Medical or religious exemptions will be considered consistent with applicable law. Compensation: The posted pay range complies with applicable law and reflects what we reasonably expect to pay for this role. Individual pay is set by skills, experience, qualifications, and internal/market equity, consistent with MarinHealth’s compensation philosophy. Positions covered by collective bargaining agreements are governed by those agreements. Equal Employment: All qualified applicants will receive consideration for employment without regard to race, color, religion, national origin, sexual orientation, gender identity, protected veteran status or disability status, and any other classifications protected by federal, state, and local laws.
Job Summary: Works collaboratively with an MD to coordinate and screen for the appropriateness of admissions and Continued stays. Makes recommendations to the physicians for alternate levels of care when the patient does not meet the medical necessity for Inpatient hospitalization. Interacts with the family, patient and other disciplines to coordinate a safe and acceptable discharge plan. Functions as an indirect caregiver, patient advocate and manages patients in the most cost effective way without compromising quality. Transfers stable non-members to planned Health care facilities. Responsible for complying with AB 1203, Post Stabilization notification. Complies with other duties as described. Must be able to work collaboratively with the Multidisciplinary team, multitask and in a fast pace environment. Essential Responsibilities: Plans, develops, assesses and evaluates care provided to members. Collaborates with physicians, other members of the multidisciplinary health care team and patient/family in the development, implementation and documentation of appropriate, individualized plans of care to ensure continuity, quality and appropriate resource use. Recommends alternative levels of care and ensures compliance with federal, state and local requirements. Assesses high risk patients in need of post-hospital care planning. Develops and coordinates the implementation of a discharge plan to meet patients identified needs; communicates the plan to physicians, patient, family/caregivers, staff and appropriate community agencies. Reviews, monitors, evaluates and coordinates the patients hospital stay to assure that all appropriate and essential services are delivered timely and efficiently. Participates in the Bed Huddles and carries out recommendations congruent with the patients needs. Coordinates the interdisciplinary approach to providing continuity of care, including Utilization management, Transfer coordination, Discharge planning, and obtaining all authorizations/approvals as needed for outside services for patients/families. Conducts daily clinical reviews for utilization/quality management activities based on guidelines/standards for patients in a variety of settings, including outpatient, emergency room, inpatient and non-KFH facilities. Acts as a liaison between in-patient facility and referral facilities/agencies and provides case management to patients referred. Refers patients to community resources to meet post hospital needs. Coordinates transfer of patients to appropriate facilities; maintains and provides required documentation. Adheres to internal and external regulatory and accreditation requirements and compliance guidelines including but not limited to: TJC, DHS, HCFA, CMS, DMHC, NCQA and DOL. Educates members of the healthcare team concerning their roles and responsibilities in the discharge planning process and appropriate use of resources. Provides patients with education to assist with their discharge and help them cope with psychological problems related to acute and chronic illness. Per established protocols, reports any incidence of unusual occurrences related to quality, risk and/or patient safety which are identified during case review or other activities. Reviews, analyses and identifies utilization patterns and trends, problems or inappropriate utilization of resources and participates in the collection and analysis of data for special studies, projects, planning, or for routine utilization monitoring activities. Coordinates, participates and or facilitates care planning rounds and patient family conferences as needed. Participates in committees, teams or other work projects/duties as assigned.
Work From Home Work From Home Work From Home, Indiana 46544 The Utilization Review Coordinator performs admission screening for patients in a bed for medical necessity, and reviews for appropriateness of setting and utilization. WHO WE ARE With 12 ministries and access points across Indiana and Illinois, Franciscan Health is one of the largest Catholic health care systems in the Midwest. Franciscan Health takes pride in hiring coworkers that provide compassionate, comprehensive care for our patients and the communities we serve. WHAT YOU CAN EXPECT Schedule: Monday - Friday, 8am - 4:30pm Perform concurrent reviews for appropriateness of utilization to optimize clinical and financial outcomes. Communicate with physicians, patients, members of the Healthcare team, Coordinated Business Office staff, Denial Management staff, and third-party payors to justify the admission or continued stay. Notify appropriate staff members of any admission, service, length of stay, lack of medical necessity criteria, as well as denials/appeals and issuing of letters to patients. Provide Physician, Patient, Family, Staff and Student education. Act as a resource person for the case management department regarding payer rules, regulations, policies and procedures, and utilization issues. Perform admission necessity screening using criteria as established by the various federal, state and private sector programs. QUALIFICATIONS Associate degree in nursing/patient care required Bachelor's Degree in nursing/patient care preferred Registered Nurse (RN - Indiana licensure) required 3 years of nursing/patient care experience required 2 years of Utilization or Case Management experience preferred TRAVEL IS REQUIRED: Never or Rarely JOB RANGE: Utilization Review Coordinator $56971.20-$84749.60 INCENTIVE: Not Applicable EQUAL OPPORTUNITY EMPLOYER It is the policy of Franciscan Alliance to provide equal employment to its employees and qualified applicants for employment as otherwise required by an applicable local, state or Federal law. Franciscan Alliance reserves a Right of Conscience objection in the event local, state or Federal ordinances that violate its values and the free exercise of its religious rights. Franciscan Alliance is committed to equal employment opportunity. Franciscan provides eligible employees with comprehensive benefit offerings. Find an overview on the benefit section of our career site, jobs.franciscanhealth.org .
About Us Bakersfield Behavioral Healthcare Hospital, located in Bakersfield, California, is an acute psychiatric and behavioral 90-bed facility situated on 8.8 acres. We offer inpatient and outpatient services for children, adolescents, and adults needing mental/behavioral health, chemical dependency; and co-occurring disorders treatment through our medically supervised detoxification. Within our Workplace Community, BBHH is striving daily to be one of the BEST PLACES TO WORK not just here in Kern County, but throughout the Behavioral Healthcare Community. By offering amazing benefits, encouraging individual growth and development, and incorporating our CARES values system into our daily operations, we are creating a JUST workplace culture where people enjoy coming to work each day. BBHH CARES about your experience as a candidate and we encourage you to apply to our open positions. Compassion Acceptance Respect Empowerment Sincerity Job Summary Our progressive and dedicated healthcare team strives to change the lives of our patients and provide exceptional care. This RN position is in our Inpatient units. The attention to detail and level of situational awareness required of the staff in the Inpatient Unit is paramount to the success of all patient outcomes. Our CARES values system must be on display in every act of patient care, no matter the circumstances. BBHH is a fast-paced environment that requires critical thinking, teamwork, and excellent communication between staff and patients. We are looking for a Registered Nurse to provide excellent care and to join our Workplace Community in our effort to be the best hospital we can be. POSITION SUMMARY: The Admissions RN (Intake Packet Reviewer) is responsible for conducting comprehensive clinical reviews of referral packets to determine patient eligibility for admission to Bakersfield Behavioral Healthcare Hospital (BBHH). This position evaluates medical history, psychiatric diagnosis, acuity level, risk factors, exclusionary criteria, and medical stability to ensure the hospital can safely and appropriately meet the patient’s needs. The role requires sound clinical judgment, knowledge of psychiatric standards of care, regulatory awareness, and the ability to assess admission risk in alignment with California law, CMS Conditions of Participation, and Joint Commission standards. Some of the fundamentals we're looking for in those who apply to this position include: Someone who demonstrates sound leadership skills and utilizes these skills in organizing the activities and schedules for medical and/or non-medical tasks on the unit. A caring, compassionate human being with a record of consistently showcasing high-quality clinical and interpersonal skills to be an exemplary role model to others Someone capable of displaying basic knowledge of treatment procedures; interventions common to acute psychotic as well as non-violent crisis intervention practice; A person with basic knowledge of abnormal psychology, application of this knowledge to the care of our patients, and fluency in medical terminology in psychiatric care; Someone with thorough familiarity of psych and the use of psychotropic medications, basic teaching and training skills helpful; problem-solving; An organized individual with exceptional organizational and time management skills; crisis intervention skills; Someone with strong written and oral communication skills in the English language; skills in facilitating and/or co-facilitating process-oriented and didactic groups. WHAT WE'RE LOOKING FOR Simply put: HUMANS WHO CARE Though we do need to meet some minimum requirements for the position such a High School Diploma or Equivalent, and a current California RN License we're really looking for people who bring their HEART to work. If you have previous experience in a mental healthcare hospital environment where your attention was focused on the assessments of human behavior, psychiatry, psychology, or other mental healthcare situations, then your application to this position will be moved to the shortlist of candidates. Minimum of two (2) years psychiatric nursing experience (acute inpatient preferred). • Strong knowledge of psychiatric diagnoses, risk stratification, and medical comorbidities. • Demonstrated ability to independently analyze clinical information and exercise sound judgment. • Working knowledge of Title 22, CMS, and Joint Commission standards related to psychiatric facilities. • Strong written documentation skills. • Experience reviewing referral packets or conducting medical necessity reviews. Our patients, our community, and our co-workers RELY on us to be committed to their wellness, Through prevention, intervention, treatment, and education, we can and we will make a difference not just here in Bakersfield, but throughout our extended communities. You should have a current CPR certification when you apply or obtain certification prior to your start date. If you don't have a current CPR certification, just let us know and we'll make sure you get it before you start -- and even cover the cost for you. Additionally, you'll complete a "Handle-With-Care" Physical Restraint Technique Training during your orientation so that you know how and when to engage when such an event occurs. You should know that this position operates on an Alternate Work Schedule of 12-hour shifts from 6:00am to 6:30pm or 6:00pm to 6:30am. SPECIFIC SCHEDULE REQUIREMENTS: Monday 6a-6:30p, Tuesday 6a-6:30p and every other Saturday 6a-6:30p. BBHH encourages ALL qualified candidates to apply. The RN position pays between $44.00-$61.38 per hour based on the experience you bring with you. We look forward to reviewing your application TODAY! Bakersfield Behavioral Healthcare Hospital is proud to offer a suite of benefits to those who join our workplace community. *Benefits eligibility varies based on employment status (full-time, part-time, per diem, temporary, etc.). Some of the benefits you can expect as a Full-Time employee include: Paid Time Off over THREE WEEKS of Paid Time Off in your first year!!! Life Insurance Short-Term Disability Insurance Long-Term Disability Insurance Medical Insurance Dental Insurance Vision Insurance Pet Insurance Accident Insurance 401k Retirement Plan Discounted Meals Employee Assistance Program TUITION Assistance
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 Nurse Reviewer Appeals and Hearings to coordinate and perform all appeal related duties including analyzing and responding appropriately to appeals from providers; reviewing documentation to ensure all aspects of the appeal have been addressed properly and accurately; prepare case files and case summaries for hearings; and participate in in virtual and on-site hearings. Your role in our mission Reviews provider appeals and redeterminations using approved clinical and coding guidelines and documents appeal determinations clearly and concisely. Analyzes and reviews appeal documentation to ensure all aspects of the appeal have been addressed properly and accurately while maintaining production goals and quality standards. Prepares case files and case summaries for hearings and actively participates in hearings in conjunction with the Medical Director. Assist management with training new reviewers to include daily monitoring, mentoring, feedback and education. Maintains current knowledge of clinical criteria guidelines and/or coding guidelines; successfully completes required CEUs to maintain RN license and/or coding certification. Responsible for attending training and scheduled meetings to enhance skills and working knowledge of clinical policies, procedures, rules, and regulations. Actively cross-trains to perform reviews of multiple claim types to provide a flexible workforce to meet client needs. What we're looking for Active, Unrestricted RN license from the United States and in the primary home residency, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), 5+ years clinical experience or 5+ years medical record coding experience required 3+ years utilization review experience or claims auditing required Working knowledge of the appeals and hearings process Experience using MCG or InterQual criteria preferred Excellent written communication skills including ability to write clear, concise, accurate, and fact-based rationales in support of appeal determinations. Excellent oral communication skills with particular emphasis on verbally presenting case summaries and decisions. Ability to multi-task in a fast-paced production environment. What you should expect in this role Work Location: Remote within the United States Travel Requirement: Up to 25% Travel for onsite hearing testimony Applications will be accepted through April 17, 2026. The pay range for this position is $84,000.00 - $95,000.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits , and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities. We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings. Gainwell Technologies is an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. Gainwell Technologies defines “wages” and “wage rates” to include “all forms of pay, including, but not limited to, salary, overtime pay, bonuses, stock, stock options, profit sharing and bonus plans, life insurance, vacation and holiday pay, cleaning or gasoline allowances, hotel accommodations, reimbursement for travel expenses, and benefits.
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours. Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function. Typical office working environment with productivity and quality expectations. Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor. Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment. Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding. Effective communication skills, both verbal and written Required Qualifications - 2+ years of experience as a Registered Nurse in adult acute care/critical care setting - Must have active current and unrestricted RN licensure in state of residence - Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours Preferred Qualifications - 2+ years of clinical experience required in med surg or specialty area - Managed Care experience preferred, especially Utilization Management - Preference for those residing in Central Time zones Education Associates Degree required BSN preferred Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $26.01 - $56.14 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan . No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 03/27/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
St. Luke's is proud of the skills, experience and compassion of its employees. The employees of St. Luke's are our most valuable asset! Individually and together, our employees are dedicated to satisfying the mission of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care. The RN DRG Downgrades Appeals Review Specialist is responsible for the retrospective clinical review and defense of inpatient DRG downgrades, clinical validation denials, and medical necessity determinations issued by governmental and commercial payers. JOB DUTIES AND RESPONSIBILITIES: Conduct retrospective clinical record reviews to evaluate DRG downgrades, clinical validation denials, and medical necessity determinations. Analyze documentation in conjunction with MS-DRG logic and ICD-10-CM/PCS coding guidelines to determine appeal opportunity. Develop and submit defensible first- and second-level appeal letters using clinical evidence, regulatory guidance, coding standards, and payer policy. Collaborate with Physician Advisors, Coding leadership, and CDI to support higher-level appeals (e.g., IRO, ALJ, payer conferences). Identify denial trends and provide structured feedback to Coding and CDI leadership to reduce future payer vulnerability. Participate in payer audit response processes (RAC, QIO, MIC, commercial auditors) and assist in preparation for formal appeal proceedings. Maintain accurate documentation within EPIC, payer audit platforms, and internal tracking tools to support reporting and performance monitoring. Review denial data and appeal outcomes to assist leadership in assessing revenue impact, case resolution trends, and operational improvement opportunities. Maintain current knowledge of MS-DRG methodology, ICD-10-CM/PCS coding guidelines, clinical validation standards, federal and commercial payer policies, and medical necessity criteria. Serve as a clinical resource regarding documentation specificity and disease process validation as it relates to reimbursement defense. PHYSICAL AND SENSORY REQUIREMENTS: Sitting, standing and light lifting. Repetitive arm/finger use retrieving/viewing computerized patient medical record and abstracting of patient information. Corrected vision and hearing to within normal range. Hearing as it relates to normal conversation. Works inside with adequate lighting, comfortable temperature and ventilation. EDUCATION: Registered Nurse required. BSN preferred. Active RN license required. CDI certification (CDIP, CCDS) preferred. TRAINING AND EXPERIENCE: Minimum five (5) years RN experience in adult inpatient acute care (medical/surgical or critical care). Strongly preferred: Clinical Documentation Improvement (CDI) experience. Strongly preferred: DRG downgrade or clinical validation denial experience. Strongly preferred: Utilization review or payer medical review experience. Familiarity with MS-DRG reimbursement methodology. Demonstrated understanding of disease pathophysiology and documentation specificity requirements. Working knowledge of ICD-10-CM/PCS fundamentals. Understanding of payer audit and appeal processes. Experience with EPIC and encoder tools (e.g., 3M) preferred. Please complete your application using your full legal name and current home address. Be sure to include employment history for the past seven (7) years, including your present employer. Additionally, you are encouraged to upload a current resume, including all work history, education, and/or certifications and licenses, if applicable. It is highly recommended that you create a profile at the conclusion of submitting your first application. Thank you for your interest in St. Luke's!! St. Luke's University Health Network is an Equal Opportunity Employer.
Summary GENERAL SUMMARY: Conducts day-to-day activities for the clinical, financial and utilization coordination of the patient’s hospital experience. Proactively consults with the interdisciplinary team which includes, but is not limited to, hospital patient care staff, physicians, patient support and family to ensure the patient’s hospital stay meets medical necessity and insurance authorizations are obtained in order to facilitate the patient’s and hospitals financial well-being. PRINCIPAL JOB FUNCTIONS: 1. *Commits to the mission, vision, beliefs and consistently demonstrates our core values. 2. *Performs utilization review activities, including concurrent and retrospective reviews as required. 3. *Determines the medical necessity of request by performing first level reviews, using approved evidence based guidelines/criteria. 4. *Collaborates with the patient’s provider and other healthcare team members in managing the patient’s length of stay and determining the continuing medical necessity of continued stays. 5. *Refers cases to reviewing physician when the treatment request does not meet criteria per appropriate algorithm. 6. *Participates in concurrent and retrospective denials and appeals process by researching issues surrounding the denial, participating in all levels of the appeal and process follow-up. 7. *Serves as an internal and external resource regarding appropriate level of care; admission status/classification; Medicare/Medicaid rules, regulations, and policies; 3rd party and managed care contracts; discharge planning; and length of stay. 8. Ensures appropriate resource utilization relevant to the financial, regulatory and clinical aspects of care; proposes alternative treatment to ensure a cost effective and efficient plan of care. 9. *Maintains awareness of financial reimbursement methodology, utilization management, payer/reimbursement practices and regulations and participates in resource stewardship. 10. *Promotes quality improvement initiatives and health care outcomes based on currently accepted clinical practice guidelines and total quality improvement initiatives. 11. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise. 12. Participates in meetings, committees and department projects as assigned. 13. Performs other related projects and duties as assigned. REQUIRED KNOWLEDGE, SKILLS AND ABILITIES: 1. Maintains clinical competency as required for the unit including but not limited to age-specific competencies relative to patient’s growth and developmental needs, annual skill competency verification and mandatory education and competencies. 2. Knowledge of governmental and third party payer regulations and requirements related to patient hospitalization and acute rehabilitation admission, stay and discharge activities, i.e., CMS, CARF, FIM (TM). 3. Knowledge of computer hardware equipment and software applications relevant to work functions. 4. Skill in conflict diffusion and resolution. 5. Ability to communicate effectively both verbally and in writing. 6. Ability to perform crucial conversations with desired outcomes. 7. Ability to establish and maintain effective working relationships with all levels of personnel and medical staff. 8. Ability to problem solve and engage independent critical thinking skills. 9. Ability to maintain confidentiality relevant to sensitive information. 10. Ability to prioritize work demands and work with minimal supervision. 11. Ability to perform crucial conversations with desired outcomes. 12. Ability to maintain regular and punctual attendance. EDUCATION AND EXPERIENCE: Current Registered Nurse licensure from the State of Nebraska or approved compact state of residence as defined by the Nebraska Nurse Practice Act. Minimum of two (2) years recent clinical experience required. Prior care coordination and/or utilization management experience preferred. OTHER CREDENTIALS / CERTIFICATIONS: Basic Life Support (CPR) certification required. Bryan Health recognizes American Heart Association (for healthcare professionals), American Red Cross (for healthcare professionals) and the Military Training Network.
RESPONSIBILITIES I. JOB SUMMARY/RESPONSIBILITIES: • Facilitates peer review and performance improvement activities (case review, professionalism review, practitioner health, OPPE reports) for the Medical Staff in accordance with the mission of The Queen’s Health System (QHS). • Produces reports for the medical staff reappointment process. • Facilitates activities of the Professional Practice Evaluation Committee (PPEC) and Leadership Council. • Meets requirements of regulatory and accreditation agencies. II. TYPICAL PHYSICAL DEMANDS: • Essential: seeing, hearing, speaking. • Constant: sitting. • Occasional: standing, walking, finger dexterity. • Infrequent: kneeling, climbing stairs, stooping/bending, lifting, pushing/pulling and carrying usual weight of 10 pounds, reaching above, at and below shoulder level. • Operates computer, copier, facsimile, and telephone. III. TYPICAL WORKING CONDITIONS: • Not substantially subjected to adverse environmental conditions. • Work environment may be stressful due to workload. IV. MINIMUM QUALIFICATIONS: A. EDUCATION/CERTIFICATION AND LICENSURE: • Bachelor's degree in health care related field. B. EXPERIENCE: • One (1) year medical staff peer review and performance improvement experience in a healthcare facility; or two (2) years clinical experience with competency in summarizing patient’s medical history. • Knowledge of regulatory and licensing agency standards, medical staff bylaws, and rules/regulations. Ability to interpret and apply guidelines and procedures. • Knowledge and skill in data collection, data entry, data analysis, data presentation and reporting. • Skill in establishing and maintaining effective working relationships with staff, physicians, consultants, hospital committees, administrators, and staff. • Ability to communicate effectively both orally and in writing with all levels throughout the organization. • Proficiency with Microsoft office applications, i.e. Word, Excel, Outlook, etc. • Prior experience in medical staff credentialing/reappointment preferred. Equal Opportunity Employer/Disability/Vet
Are you looking to make a difference in patients’ lives with a company that values your expertise? Join us in our mission of delivering compassionate healthcare where it matters most –– at home. Pinnacle Home Care Holdings, LLC ("Pinnacle") is a leading Florida-based provider of home healthcare services. We're seeking an experienced Clinical Review Specialist to join our growing team and ensure every patient's care plan starts with clinical excellence, regulatory compliance, and a compassionate touch. Key Responsibilities Review all incoming home health orders for clinical appropriateness. Determine appropriate disciplines, frequencies, and visit types in line with agency protocols and referral source requirements. Confirm compliance with CMS guidelines, Medicare Conditions of Participation (COPs), and internal agency standards. Take and document verbal orders from physicians and referral sources accurately and efficiently. Perform patient welcome calls to ensure a smooth, positive onboarding experience. Triage and troubleshoot patient needs or concerns during intake conversations. Maintain a warm, empathetic, and professional phone presence to reassure patients and referral partners. Accurately document all intake and order-related activities in the EMR (WellSky/KanTime or similar). Ensure physician orders, care plans, and required documentation are completed, accurate, and properly uploaded. Maintain an up-to-date understanding of home health regulatory requirements, including Medicare, CMS, and state guidelines. Proficient in EMR data entry (KanTime experience preferred; WellSky training provided). Comfortable using Microsoft Outlook, Teams, and internal reporting tools. Follow daily reporting and tracking requirements to support transparency. Partner closely with Intake, Care Coordination, and Branch leadership to ensure timely patient starts of care. Escalate clinical concerns or regulatory issues promptly to the Clinical Review Manager. Support branch and central teams with troubleshooting and guidance on referral-related issues. Qualifications Current LPN with equivalent experience in home health intake/clinical review. 2+ years of clinical experience in home health, intake, or care coordination. Knowledge of Medicare COPs, CMS guidelines, and general home health regulations. Strong critical thinking and clinical decision-making skills. Excellent communication and phone skills; ability to build trust with patients, referral sources, and colleagues. Proficiency with EMR systems (WellSky/KanTime preferred) and Microsoft Office Suite (Outlook, Teams, Excel). Ability to work in a fast-paced, high-volume environment with accuracy and composure. Why Choose Pinnacle? Growth & Stability : Over two decades as Florida’s largest independent home health agency. Ongoing Professional Development : Free Continuing Education Units (CEUs) to support licensure and career advancement. Competitive Benefits & Perks : Including an employee referral program where you can earn rewards. Recognized Excellence : Ranked as a USA Today Top Workplace. Supportive & Fun Culture : Join a collaborative, forward-thinking team that values both professional excellence and personal fulfillment. Pinnacle promotes an inclusive environment and is an equal opportunity employer. We prohibit discrimination or harassment based on race, religion, age, gender, national origin, disability, veteran status, or other legally protected characteristics. Be part of a company that empowers clinicians to make a difference in the lives of over 10,000 patients across Florida every day. Apply now!
JOB DESCRIPTION Job SummaryProvides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care. Must be licensed in CA. Essential Job Duties • Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines. • Analyzes clinical service requests from members or providers against evidence based clinical guidelines. • Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. • Conducts reviews to determine prior authorization/financial responsibility for Molina and its members. • Processes requests within required timelines. • Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner. • Requests additional information from members or providers as needed. • Makes appropriate referrals to other clinical programs. • Collaborates with multidisciplinary teams to promote the Molina care model. • Adheres to utilization management (UM) policies and procedures. Required Qualifications • At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience. • Registered Nurse (RN). License must be active and unrestricted in state of practice. • Ability to prioritize and manage multiple deadlines. • Excellent organizational, problem-solving and critical-thinking skills. • Strong written and verbal communication skills. • Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications • Certified Professional in Healthcare Management (CPHM). • Recent hospital experience in an intensive care unit (ICU) or emergency room. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $30.37 - $59.21 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
JOB DESCRIPTION Job SummaryProvides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care. Must be licensed in CA. Essential Job Duties • Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines. • Analyzes clinical service requests from members or providers against evidence based clinical guidelines. • Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. • Conducts reviews to determine prior authorization/financial responsibility for Molina and its members. • Processes requests within required timelines. • Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner. • Requests additional information from members or providers as needed. • Makes appropriate referrals to other clinical programs. • Collaborates with multidisciplinary teams to promote the Molina care model. • Adheres to utilization management (UM) policies and procedures. Required Qualifications • At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience. • Registered Nurse (RN). License must be active and unrestricted in state of practice. • Ability to prioritize and manage multiple deadlines. • Excellent organizational, problem-solving and critical-thinking skills. • Strong written and verbal communication skills. • Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications • Certified Professional in Healthcare Management (CPHM). • Recent hospital experience in an intensive care unit (ICU) or emergency room. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $30.37 - $59.21 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
Our Mission To improve the health of the communities we serve through contemporary, innovative, quality healthcare solutions. Schedule : Monday - Friday (40hrs/week) About Us – Physician Reimbursement Center (PRC) Located inside the Freeman Business Center Vital part of our revenue cycle Our team consists of over eighty professionals that assure reimbursement for the valued services our clinicians provide What You’ll Do Performs a variety of duties in support of the quality assurance and compliance function of the Physician Reimbursement Center. Performs prospective chart reviews to ensure medical record accurately reflects the patient’s level of service, severity of illness and risk of mortality. Works closely with Medical Staff to clarify, assist and educate with documentation of evaluation and management coding. Requirements Minimum of 3 years of clinical experience in an acute care setting, (ICU, Medical/Surgical or Emergency Department nursing preferred). If homebound, must reside in one of the following states: Arkansas, Kansas, Missouri or Oklahoma. Current Missouri Registered Nurse license or current Registered Nurse license from a compact state. If a compact license is held, it must be in the nurse state of residence. Experience and skills in coding, billing and compliance. Preferred Requirements COSC Certification Freeman Perks and Programs For eligible full time and part time employees Freeman offers a wide variety of career opportunities, a great work culture and generous benefits, most starting day one! Health, vision, dental insurance Retirement with employer match Wellness program with discounts to Health Insurance or Cash Bonus with Participation Milestone payments with longevity of employment Paid Time Off (PTO) or Flex time off (FTO) Extended sick pay Learning Center designated only for Freeman Family members Payroll deduction at different locations such as The Daily Grind, Freeman Gift Shop, Cafeteria, etc
Anticipated End Date: 2026-03-31 Position Title: Wound Care Utilization Management RN Job Description: Wound Care Utilization Management RN Carelon, a proud member of the Elevance Health family of companies, is a healthcare services organization that takes a whole-health approach to making care more integrated, personalized, and affordable. We put people at the center—connecting physical, behavioral, social, and pharmacy services, along with clinical expertise, research, operations, and advanced technology to help care work better, together. Among us are specialty-care physicians, nurse practitioners, pharmacists, engineers, data scientists, and other dedicated and caring health professionals. While our roles may differ, our purpose is shared: to make a positive impact on whole health. 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. 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. Work Shift Hours: Monday through Friday, 8:00AM to 4:30PM (CST). The Wound Care UM RN is responsible for performing pre-certification certification and/or authorization activities for Home Health Services for members with wound care needs included as contracted services that meet eligibility and benefits coverage. Oversees members who have complex wound needs to determine if the member has the appropriate wound care for the type of wound. Identifies and monitors delivery of home-based services responds to a members total health needs and ensures the highest quality of continuity of care. How you will make an impact: Develops coordinated collaborative care plans with all involved providers. Reviews Home based services for clinical appropriateness of the continued care. Performs reviews telephonically using the members medical records discussion with the members physician and/or discussion with Home health agency staff. Contacts the home care agency and ordering physician to discuss changing the member plan of care for wound care. Promotes healing and decrease home care utilization. Responsible for certification determinations and sending written authorizations to referring physician and home health care provider. Requests additional clinical information from members care providers as necessary. Facilitates timely discharges and transfers based on individual needs and care requirements. Educates patients to help them understand their health choices and assists them in making informed decisions about their health care. Serves as an information resource to patients health care professionals facilities health plan representatives care givers and family members. Monitors cost-effective use of resources and uses clinical expertise to make recommendations for alternate resources as needed. Refers requests that do not meet coverage guidelines criteria to Physician for review. Uses clinical judgment in authorizations that fall outside of guideline parameters. Minimum Requirements: Requires a HS diploma or equivalent and a minimum of 5 years of experience in a variety of health care settings; or any combination of education and experience which provides an equivalent background. Current active valid unrestricted RN license to practice as a health professional within the scope of practice in applicable state(s) or territory of the United States required. Certifications relevant to wound care such as WOCN or CWS required. For the Wound Care Connect program, in addition to Wound Care Certification requirements above, Ostomy training through accredited program such as WOCN or ABWM and ostomy experience is also required. Preferred Skills, Capabilities and Experiences: WOCNCB certification preferred. Home health experience preferred. 1 year of Utilization Management experience preferred. Compact license would be preferred but not required for consideration. Prior Home Health experience preferred. Intermediate knowledge of MS Office Suite products preferred. For candidates working in person or virtually in the below location(s), the salary* range for this specific position is $39.34/hr. to $67.44/hr. Locations: California, District of Columbia (Washington, DC); Illinois, New Jersey, Massachusetts and Nevada. 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: 1st Shift (United States of America) 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. Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration .
Job Summary: Clinical Care Reviewer II – Behavioral Health is responsible for processing medical necessity reviews for appropriateness of authorization for behavioral health care services, assisting with discharge planning activities (i.e. outpatient services, home health services) and care coordination for members. Essential Functions: Complete prospective, concurrent and retrospective review of Behavioral Health services Identify, document, communication and coordinate care engaging collaborative care partners to facilitation transition to an appropriate level of care Engage with medical director when additional clinical expertise if needed Maintain knowledge of state and federal regulations, including State Contracts and Provider Agreements, benefits, and accreditation standards Identify and refer quality issues to Quality Improvement Identify and refer appropriate members for Care Management Provide guidance to non-clinical staff Provide guidance and support to LPN staff Attend medical advisement and State Hearing meetings, as requested Assist Team Leader with special projects or research, as requested Perform any other job related duties as requested. Education and Experience: Associates of Science (A.S) in Nursing required or Bachelor of Science (B.S) in Social Work required Three (3) years clinical experience required Utilization Management/Utilization Review experience preferred Medicaid/Medicare/Commercial experience preferred Competencies, Knowledge and Skills: Proficient data entry skills and ability to navigate clinical platforms successfully Working knowledge of Microsoft Outlook, Word, and Excel Effective oral and written communication skills Ability to work independently and within a team environment Attention to detail Proper grammar usage and phone etiquette Time management and prioritization skills Customer service oriented Decision making/problem solving skills Strong organizational skills Change resiliency Licensure and Certification: Current, unrestricted Registered Nurse (RN) Licensure or Licensed Social Worker (LSW) required MCG Certification is required or must be obtained within six (6) months of hire required Working Conditions: General office environment; may be required to sit or stand for extended periods of time Travel is not typically required Compensation Range: $62,700.00 - $100,400.00 CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package. Compensation Type (hourly/salary): Hourly Organization Level Competencies Fostering a Collaborative Workplace Culture Cultivate Partnerships Develop Self and Others Drive Execution Influence Others Pursue Personal Excellence Understand the Business This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds. #LI-JM1
Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job Summary The Utilization Management Nurse Specialist RN II facilitates, coordinates, and approves medically necessary referrals that meet established criteria. Assures timely and accurate determination and notification of referrals and reconsiderations based on the referral determination status. Generates approval, modification and denial communications, to include member and provider notification of referral determination. Actively monitors for admissions in any inpatient setting. Performs telephonic and/or onsite admission and concurrent review, and collaborates with onsite staff, physicians, providers, member/family interaction to develop and implement a successful discharge plan. Works with the UM Manager and Physician Advisor on case reviews for pre-service, concurrent, post-service and retrospective claims medical review. Monitors and oversees the collection and transfer of data (medical records) and referral requests by Providers. Acts as a department resource for medical service requests /referral management and processes. Receives incoming calls from providers, professionally handles complex calls, researches to identify timely and accurate resolution steps. Follows up with caller to provide response or resolution steps. Answers all inquiries in a professional and courteous manner. Duties Promote and support team engagements, programs and activities to create and ensure a positive and productive workplace environment. Perform telephonic and/or onsite admission and concurrent review, and collaborates with onsite staff, physicians, providers, the member and significant others to develop and implement a successful discharge plan. Process, finalize and facilitate inbound requests that are received from providers. Generate appropriate member and provider communication for all determinations within the required timelines as defined by the most current department policy. Facilitate/review requests for Higher level of care or skilled nursing/discharge planning needs. Research for appropriate facilities, specialty providers and ancillary providers to utilize for all lines of business. Identification of potential areas of improvement within the provider network. Identify and initiate referrals for appropriate members to the various L.A. Care programs/processes and external community based programs or Linked and Carve Out Services (e.g. DDS/CCS/MH). Potential quality of care/potential fraud issues are identified and documented per L.A. Care policy. High risk/high cost cases and reports are maintained and referred to the Physician Advisor/UM Director. Document in platform/system of record. Utilize designated software system to document reviews and/or notes. Receive incoming calls from providers, professionally handle complex calls, research to identify timely and accurate resolution steps. Follow up with caller to provide response or resolution steps. Answer all inquiries in a professional and courteous manner. Perform other duties as assigned. Duties Continued Education Required Associate's Degree in Nursing Education Preferred Bachelor's Degree in Nursing Experience Required: At least 5 years of varied RN clinical experience in an acute hospital setting. At least 2 years of Utilization Management/Case Management experience in a hospital or HMO setting . Preferred: Managed Care experience performing UM and CM at a medical group or management services organization. Experience with Managed Medi-Cal, Medicare, and commercial lines of business. Skills Required: Must be computer literate, with expertise in Outlook, Word, Excel, PowerPoint. Effectively utilizes computer and appropriate software and interacts as needed with L.A. Care Information System. Knowledge of personal computer, keyboarding, and appropriate software to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment. Prepare clear, comprehensive written and oral reports and materials. Provision of excellent customer service required due to frequent communication with providers and other members of the interdisciplinary team Excellent time management and priority-setting skills. Maintains strict member confidentiality and complies with all HIPAA requirements. Strong verbal and written communication skills. Preferred: Knowledge of National Committee for Quality Assurance (NCQA) requirements for Utilization Management or Care Management (CM). Knowledge of Department of Health Care Services (DHCS) or Centers for Medicare and Medicaid Services(CMS) requirements for health plan compliance with UM or CM. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California License Licenses/Certifications Preferred Certified Case Manager (CCM) Required Training Physical Requirements Light Additional Information May work on occasional weekends and some holidays depending on business needs. Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. L.A. Care offers a wide range of benefits including Paid Time Off (PTO) Tuition Reimbursement Retirement Plans Medical, Dental and Vision Wellness Program Volunteer Time Off (VTO)
Welcome to Montage Health’s application process! Job Description: Under the leadership of the department director the Utilization Review Nurse facilitates quality care by screening the admission and continued stay of patients utilizing Intensity of Service/Severity of Illness criteria. The Utilization Nurse complies with regulatory requirements and supports systems and processes to meet regulations. Important dimensions of this position consist of quality, professional commitment, teamwork, interpersonal skills, safety, good public/customer relations and a broad clinical knowledge. Experience Must have 5 years current acute care hospital experience. Broad clinical expertise to evaluate patient diagnosis and treatment plan and outcomes utilizing established criteria. Effective communication and public relations skills. Ability to work as an integral member of the interdisciplinary assessment team. Strong organization skills. Knowledge of financial reimbursement — state, federal and commercial insurance requirements preferred. Knowledge of Government programs, rules and regulations, and commercial insurance requirements preferred. Education Bachelor’s degree in nursing preferred. Licensure/Certifications State of California RN license required. Equal Opportunity Employer #LI-AC1 Assigned Work Hours: Full time (On-site) Position Type: Regular Pay Range (based on years of applicable experience): $71.69 to $95.88 The hours employees work determine when a shift differential is paid. Hourly Evening Shift Differential: $5.50 Hourly Night Shift Differential: $8.00
Capital Health is the region's leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advanced technology. Capital Health is a five-time Magnet-Recognized health system for nursing excellence and is comprised of 2 hospitals. Capital Health Medical Group is made up of more than 250 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region. Capital Health recognizes that attracting the best talent is key to our strategy and success as an organization. As a result, we aim for flexibility in structuring competitive compensation offers to ensure we can attract the best candidates. The listed pay range or pay rate reflects compensation for a full-time equivalent (1.0 FTE) position. Actual compensation may differ depending on assigned hours and position status (e.g., part-time). Pay Range: $39.40 - $59.19 Scheduled Weekly Hours: 40 Position Overview Shift: Fri, Sat, Sun or Sat, Sun, Mon (8:00am-8:00pm) Performs chart review of identified patients to identify quality, timeliness and appropriateness of patient care. Conducts admission reviews for Medicare, Medicaid beneficiaries, as well as private insurers and self pay patients, based on appropriate guidelines. Uses these criteria guidelines to screen for appropriateness for inpatient level of care or observation services based on physician certification (physicians H&P, treatment plan, potential risks and basis for expectation of a 2 midnight stay). Refers cases as appropriate, to the UR physician advisor for review and determination. Gathers clinical information to conduct continued stay utilization review activities with payers on a daily basis. Performs concurrent and retrospective clinical reviews with various payers, utilizing the appropriate guidelines as demonstrated by compliance with all applicable regulations, policies and timelines. Adheres to CMS guidelines for utilization reviews as evidenced by utilization of the relevant guidelines and appropriate referrals to the physician advisor and the UR Committee. Identifies, develops and implements strategies to reduce length of stay and resource consumption. . Confers proactively with admitting physician to provide coaching on accurate level of care determinations at point of hospital entry. Keeps current on all regulatory changes that affect delivery or reimbursement of acute care services. Uses knowledge of national and local coverage determinations to appropriately advise physicians. Understands and applies federal law regarding the use of Hospital Initiated Notice of Non-Coverage (HINN) and Lifetime Reserve Days letters. Identifies and records consistently any information on any progression of care or patient flow barriers using the Avoidable Days tool in the Utilization software program. Consults with medical staff, care team and case managers as necessary to resolve immediate progression of care barriers through appropriate administrative and medical channels. Engages care team colleagues in collaborative problem solving regarding appropriate utilization of resources. Recognizes and responds appropriately to patient safety and risk factors. Represents Utilization Management at various committees, professional organizations an physician groups as needed. Promotes the use of evidence based protocols and or order sets to influence high quality and cost effective care. Identifies, develops and implements strategies to reduce lengths of stay and resource consumption in the patient population. Participates in performance improvement activities. Promotes medical documentation that accurately reflects findings and interventions, presence of complication or comorbidities, and patient's need for continued stay. Identifies and records episodes of preventable delays or avoidable days due to failure of progression of care processes. Maintains appropriate documentation in the Utilization software system on each patient to include specific information of all resource utilization activities. Participates actively in daily huddles, patient care conferences, and hospitalist or nurse handoff reports to maintain knowledge about intensity of services and the progression of care. Identifies potentially wasteful or misused resources and recommends alternatives if appropriate by analyzing clinical protocols. Maintains related continuing education credits = 15 per calendar year. MINIMUM REQUIREMENTS Education: Minimum of Associate's degree in Nursing. Graduate of an accredited school of nursing. CPHQ, CCM or CPUR preferred. Experience: Three years of clinical nursing or two years quality management, utilization review or discharge planning experience. Other Credentials: Registered Nurse - NJ Knowledge and Skills: Three years of clinical nursing or two years quality management, utilization review or discharge planning experience. CPHQ, CCM or CPUR preferred. Special Training: Basic computer skills including the working knowledge of Microsoft Office, UR software and EMR. Possesses familiarity with MCG guidelines. Mental, Behavioral and Emotional Abilities: Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form. Usual Work Day: 8 Hours PHYSICAL DEMANDS AND WORK ENVIRONMENT Frequent physical demands include: Sitting , Standing , Walking Occasional physical demands include: Climbing (e.g., stairs or ladders) , Carry objects , Push/Pull , Twisting , Bending , Reaching forward , Reaching overhead , Keyboard use/repetitive motion , Talk or Hear Continuous physical demands include: Lifting Floor to Waist 10 lbs. Lifting Waist Level and Above 5 lbs. Sensory Requirements include: Accurate Near Vision, Accurate Far Vision, Accurate Color Discrimination, Accurate Depth Perception, Accurate Hearing Anticipated Occupational Exposure Risks Include the following: N/A This position is eligible for the following benefits: Medical Plan Prescription drug coverage & In-House Employee Pharmacy Dental Plan Vision Plan Flexible Spending Account (FSA) - Healthcare FSA - Dependent Care FSA Retirement Savings and Investment Plan Basic Group Term Life and Accidental Death & Dismemberment (AD&D) Insurance Supplemental Group Term Life & Accidental Death & Dismemberment Insurance Disability Benefits – Long Term Disability (LTD) Disability Benefits – Short Term Disability (STD) Employee Assistance Program Commuter Transit Commuter Parking Supplemental Life Insurance - Voluntary Life Spouse - Voluntary Life Employee - Voluntary Life Child Voluntary Legal Services Voluntary Accident, Critical Illness and Hospital Indemnity Insurance Voluntary Identity Theft Insurance Voluntary Pet Insurance Paid Time-Off Program The pay range listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future. When determining base salary and/or rate, several factors may be considered including, but not limited to location, years of relevant experience, education, credentials, negotiated contracts, budget, market data, and internal equity. Bonus and/or incentive eligibility are determined by role and level. The salary applies specifically to the position being advertised and does not include potential bonuses, incentive compensation, differential pay or other forms of compensation, compensation allowance, or benefits health or welfare. Actual total compensation may vary based on factors such as experience, skills, qualifications, and other relevant criteria.
Description: The Nurse Case Manager - Inpatient is responsible for coordinating the care and service of assigned patients with physicians, nurses, social workers and other members of the healthcare team to facilitate the progression of care from hospital admission through discharge. The Nurse Case Manager- Inpatient is also responsible for ensuring that the patient is placed in the appropriate level of care while monitoring the utilization of healthcare resources and discharge planning to achieve the desired clinical, financial, and resource utilization outcomes. Typical Duties: Provides an assessment for all observation status patients prior to observation placement. The patient is to be assessed throughout the shift to determine discharge readiness or the need to convert to an inpatient status by using the approved medical appropriateness criteria and all third-party payer regulatory requirement. Performs initial status review and level of care placement on all patients in an inpatient status using approved medical appropriate criteria in addition to third-party payer regulatory requirements. Conducts an initial clinical assessment on assigned patients as well as discharge planning assessment prior to admission, at the time of admission, or at discharge. Meets directly with the patient, family, and/or representative to assess needs and develop an individualized discharge plan based on the patient’s medical diagnosis, treatment plan, financial resources, and psychosocial issues, etc. Reassesses the discharge plan throughout the patient’s hospitalization with input from the healthcare team and patient, family, and/or representative and modifying as needed. Collaborates with the multi-disciplinary care team to ensure all needed clinical information is provided to the appropriate entities for the assigned level of care and supports the concurrent appeal process for any reduction in level of care or denial as requested. Maintains active communication with the patient, family, and/or representative, physicians, nursing and other members of the multi-disciplinary care team to effect timely, appropriate patient management; documents each component of the case management process and related activities. Identifies appropriate services not related to admission and assists in arrangement of services on an outpatient basis. Leads the Unit’s daily interdisciplinary rounds to ensure a comprehensive plan of care is developed, including identification of patient needs, assignment of tasks to resolve clinical issues, review of discharge barriers, and identification of discharge planning options. Generates referrals to the Case Management Physician Advisor according to departmental policies. Serves as an educational resource for physician, nursing staff and others concerning case management strategies essential in meeting the organization’s quality, utilization, financial and customer satisfaction objectives. Performs other related job duties as assigned.
UM Review Nurse Department: HS - UM Employment Type: Full Time Location: 1600 Corporate Center Dr., Monterey Park, CA 91754 Reporting To: Sandra Castellon Compensation: $30.00 - $34.00 / hour Description Astrana Health is looking for a CA-licensed Utilization Review Nurse to assist our Health Services Department. In this position, you will utilize your clinical judgement to approve or deny outpatient medical services for patients based on Medical Necessity Criteria, respective to various Health Plans. This position requires open availability between Monday through Sunday, 8 A - 8 P. You would be scheduled for 5 shifts per week. This is a hybrid position where you will work at-home and in our Monterey Park office on a weekly basis. We are open to nurses without prior UM experience! Our Values: Put Patients First Empower Entrepreneurial Provider and Care Teams Operate with Integrity & Excellence Be Innovative Work As One Team What You'll Do Complete prior authorization/retrospective review of elective inpatient admissions, outpatient procedures, post-homecare services, and durable medical equipment Refer cases to Medical Directors as needed/appropriate Maintain knowledge of state and federal regulations and accreditation standards Comply with internal policies and procedures Perform any other job duties as requested Qualifications Active and unrestricted LVN license in CA. Experience with Microsoft applications such as Word, Excel, and Outlook You’ll be Great for this Role If: Two (2) years of health plan, IPA or MSO experience Strong interpersonal skills Ability to collaborate with co-workers, senior leadership, and other management Experience educating and training staff Environmental Job Requirements and Working Conditions This is a hybrid position. Our office is located at 1600 Corporate Center Drive in Monterey Park, CA. Typical business hours are Monday - Friday from 8:30 AM to 5 PM, however, this position requires open availability between 8 AM - 8 PM PST, M-Su. Your schedule will be compromised of 5 shifts per week. Nurses rotate weekend and holiday coverage. Overtime is required in this position. The national target pay range for this role is $30.00 - $34.00 per hour. Actual compensation will be based on geographic location (current or future), experience, and other job-related factors. Astrana Health is proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based on race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. All employment is decided based on qualifications, merit, and business need. If you require assistance in applying for open positions due to a disability, please email us at humanresourcesdept@astranahealth.com to request an accommodation. Additional Information: The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.
Overview Provides discharge planning and utilization review services in compliance with patient’s discharge planning needs and the hospital’s utilization review program. SAFETY SENSITIVE POSITION: This position is a designated as “Safety Sensitive Position” under Act 593 of the State of Arkansas. An employee who is under the influence of Marijuana constitutes a threat to patients/customers which Conway Regional is responsible for in providing and supporting the delivery health care related services. Responsibilities Demonstrates initiative and pursues activities which contribute to the accomplishment of goals and objectives Appropriately utilizes organizational resources to achieve the goals and objectives Considers cost implications in all decision making Promotes efficiency enhancements; actively identifies and implements cost savings/containment initiatives Apply clinical knowledge to determine appropriate acuity levels and utilization through chart review Effectively organizes workflow to consistently complete assignments in a timely manner Demonstrates ability to access and effectively utilize primary sources of data Obtains and maintains medical records in conformance with Medical Information policies Communicates with co-workers in a manner that is conducive to positive and effective working relationships. Demonstrates respect, honesty and integrity when working with other service providers Demonstrates compliance with all relevant hospital, state and federal requirements related to maintenance of confidentiality of persons, data and information systems Takes advantage of opportunities made available through CRHS and other professional organizations for continued professional growth and development Responsible for analysis of patient information for determination of necessity of admission or continuation of stay Review for medical necessity of admission on the first working day after admission using approved review criteria Reviews inpatient procedures to determine appropriate utilization and acuity level. Reviews potential for outpatient setting or swing bed utilization Reviews all patients for medical necessity of continued stay, or before the next review date, using approved review criteria Performs retroactive reviews, as necessary, and responds to the appropriate review agency or third-party payor Researches denials issued by review agencies and third-party payors and responds within the specified time frames for appeal Works with others on healthcare team to coordinate for patients discharge needs Establishes an effective utilization review process and maintains an active, effective utilization review file system. Recommends, develops and revises policies related to the utilization review process Works collaboratively with physicians, Case Management, the discharge planning process, Admissions, Central Scheduling and other CRHS associates Educates staff, physicians and other personnel regarding medical necessity requirements as defined by approved review criteria Attends 75% of staff meetings Participates in committees which promote staff and medical center facility growth as directed by Director/Manager and/or CRMC policy Attends mandatory in-services and committee meetings as assigned Adheres to dress code, conduct and attendance policies Participate in activities that promote personal development Must maintain all organizational education and work requirements (i.e., Annual Mandatory Education, Competencies, BLS Provider, etc.) Other duties as assigned by management Qualifications Registered Nurse or Licensed Practical Nurse with current, active license to practice in Arkansas, required Proof of the highest level of nursing education achieved, required At least one-year experience in the area of case management/utilization review, preferred
Baptist Health is the region’s largest not-for-profit healthcare organization, with 12 hospitals, over 28,000 employees, 4,500 physicians and 200 outpatient centers, urgent care facilities and physician practices across Miami-Dade, Monroe, Broward and Palm Beach counties. With internationally renowned centers of excellence in cancer, cardiovascular care, orthopedics and sports medicine, and neurosciences, Baptist Health is supported by philanthropy and driven by its faith-based mission of medical excellence. For 25 years, we’ve been named one of Fortune’s 100 Best Companies to Work For, and in the 2024-2025 U.S. News & World Report Best Hospital Rankings, Baptist Health was the most awarded healthcare system in South Florida, earning 45 high-performing honors. What truly sets us apart is our people. At Baptist Health, we create personal connections with our colleagues that go beyond the workplace, and we form meaningful relationships with patients and their families that extend beyond delivering care. Many of us have walked in our patients’ shoes ourselves and that shared experience fuels out commitment to compassion and quality. Our culture is rooted in purpose, and every team member plays a part in making a positive impact – because when it comes to caring for people, we’re all in. Description: Increases patient throughput to the most appropriate level of care while facilitating interdisciplinary care across the continuum while maintaining regularity compliance. The role Integrates, coordinates care facilitation throughput while working in partnership with the healthcare team. Is accountable for prioritizing, reviewing cases to determine the appropriateness of pre-admission, admission utilizing payer established criteria Assisting in identifying appropriate patient status and level of care. Identify readmissions managing per policy. Identify possible inappropriate hospitalizations and collaborate with the healthcare team to facilitate alternate Level of Care. Assist in identifying physician and staff documentation opportunities to support Quality and Pay for Performance indicators. Estimated salary range for this position is $73860.80 - $96019.04 / year depending on experience. Qualifications: Degrees: Associates. Licenses & Certifications: ACMA ACM Certification. CDMS Certified Disability Management Specialist. ACMA Case Management Administrator Certification. NACCM Care Manager Certified. ABMCM Certified Managed Care Nurse. RNCB Certified Rehabilitation Registered Nurse. ANCC Nursing Case Management. NBCC Certification in Continuity of Care, Advanced. Registered Nurse. CCMC Case Manager. Additional Qualifications: RNs hired prior to 10/1/2017 with an Associate Degree are not required to have a BSN to continue their non-leadership role as an RN, however, they are required to complete the BSN within 3 years of job entry date. A Case Management Certification required within 12 months of hire. 3 years of hospital clinical experience with a minimum of 1-3 years of hospital or payor Case management or Utilization management review experience preferred. Excellent interpersonal communication and negotiation skills. Strong analytical, data management and computer skills. Current working knowledge of discharge planning, utilization management, case management and performance improvement preferred. Understanding of pre-acute and post-acute venues of care and post-community resources preferred. Strong organizational and time management skills. Ability to work independently and exercise sound judgment. Ability to prioritize and manage multiple high-risk, complex patients. Ability to work with multiple members of a care team and maintain positive working relationships. Demonstrate the ability to solve problems in a fast-paced environment. Minimum Required Experience: BSN Required 3 Years of acute care experience required 1 year of Utilization Review experience required EOE, including disability/vets
