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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You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. Superior Health Plan - Specialty Therapy Services NOTE: Candidates must reside in the state of Texas Position Purpose: Analyzes all prior authorization requests to determine medical necessity of service and appropriate level of care in accordance with national standards, contractual requirements, and a member's benefit coverage. Provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care. Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria Works with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care Coordinates as appropriate with healthcare providers and interdepartmental teams, to assess medical necessity of care of member Escalates prior authorization requests to Medical Directors as appropriate to determine appropriateness of care Assists with service authorization requests for a member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities Collects, documents, and maintains all member’s clinical information in health management systems to ensure compliance with regulatory guidelines Assists with providing education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care to members Provides feedback on opportunities to improve the authorization review process for members Performs other duties as assigned Complies with all policies and standards Education/Experience: Requires Graduate from an Accredited School of Nursing degree 2 – 4 years of related experience. Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. Preferred Experience: 4+ years of Registered (RN) experience with direct patient care with PDN/Home Health members/patients License/Certification: For Superior Health Plan: RN license required LPN - Licensed Practical Nurse - State Licensure required Pay Range: $27.02 - $48.55 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. Superior Health Plan - Specialty Therapy Services NOTE: Candidates must reside in the state of Texas Position Purpose: Analyzes all prior authorization requests to determine medical necessity of service and appropriate level of care in accordance with national standards, contractual requirements, and a member's benefit coverage. Provides recommendations to the appropriate medical team to promote quality and cost effectiveness of medical care. Performs medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and criteria Works with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care Coordinates as appropriate with healthcare providers and interdepartmental teams, to assess medical necessity of care of member Escalates prior authorization requests to Medical Directors as appropriate to determine appropriateness of care Assists with service authorization requests for a member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities Collects, documents, and maintains all member’s clinical information in health management systems to ensure compliance with regulatory guidelines Assists with providing education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care to members Provides feedback on opportunities to improve the authorization review process for members Performs other duties as assigned Complies with all policies and standards Education/Experience: · Requires Graduate from an Accredited School of Nursing degree · 2 – 4 years of related experience. · Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred. · Knowledge of Medicare and Medicaid regulations preferred. · Knowledge of utilization management processes preferred. Strongly Preferred Experience: · 4+ years of Registered (RN) experience with direct patient care with PDN/Home Health members/patients License/Certification: · For Superior Health Plan: RN license required · LPN - Licensed Practical Nurse - State Licensure required Pay Range: $27.02 - $48.55 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
Description Job Description Join PeaceHealth in advancing compassionate, mission-driven care from wherever you are. PeaceHealth is looking for a skilled and motivated Registered Nurse Utilization Management (UM) Reviewer to join our dedicated team in a Per Diem, Day Shift role. If you enjoy analytical work and are energized by helping ensure patients receive the right care at the right time, this remote opportunity may be the perfect next step in your nursing career. Coverage needed could include weekdays, weekends and holidays. Why You’ll Love This Role As a Utilization Management Reviewer at PeaceHealth, you will play a key part in supporting safe, high-quality, and efficient patient care across our healthcare system. This position centers on concurrent and retrospective UM reviews , leveraging clinical expertise, payer policy knowledge, and technology tools to guide patient status determinations and promote appropriate utilization of hospital resources. You’ll work fully remote*, with PeaceHealth-provided computer equipment—empowered by a collaborative team, supportive leadership, and a strong organizational commitment to diversity, cultural humility, and caregiver well-being. Must reside in Washington, Oregon, or Alaska. PeaceHealth will provide the caregiver with necessary computer equipment. It is the responsibility of the caregiver to provide Internet access. PeaceHealth is committed to the overall wellbeing of our caregivers. Pay Range: $48.52 – $72.78/hour plus a per diem differential. The benefits included in positions less than 0.5 FTE are 403b retirement plan for caregiver contributions; wellness benefits, discount program, and expanded EAP and mental health program. What You’ll Do Coordinate accurate patient status identification and documentation Ensure correct admission status and reimbursement through certification and clinical review Gather additional clinical documentation to validate treatment plans and level of care Collaborate closely with physicians, clinicians, and multidisciplinary teams Apply UM criteria using the Xsolis Dragonfly™ platform and PeaceHealth Care Level Score tools Conduct pre-admission status reviews in the ED, patient access areas, and elective settings Communicate with third-party payers regarding medical necessity and discharge progress Support denial and appeal processes; refer cases for physician advisor review when appropriate Participate in UM Committee work, quality initiatives, and performance improvement Identify DRGs with complications/comorbidities and recommend documentation improvements Promote responsible hospital resource utilization, length-of-stay optimization, and care efficiency Perform other duties as needed to support UM and organizational goals What You Bring Education Required: Bachelor of Science in Nursing (BSN) Preferred: Master of Science in Nursing (MSN) Experience 3+ years of acute care hospital experience with strong clinical knowledge In-depth understanding of Medicare/Medicaid UM regulations, RAC, QIO, MAC, and denial/appeals processes Preferred: Prior experience in utilization management or case management Credentials Active RN license in your state of residence (WA, OR, or AK) Ready to Make a Meaningful Impact? Bring your clinical expertise, attention to detail, and passion for patient advocacy to a mission-driven healthcare system that believes in caring for caregivers as much as patients. For full consideration, please attach a current resume with your application. PeaceHealth is an EEO Affirmative Action Employer/Veterans/Disabled following all applicable state, local, and federal laws.
Description Job Description Join PeaceHealth in advancing compassionate, mission-driven care from wherever you are. PeaceHealth is looking for a skilled and motivated Registered Nurse Utilization Management (UM) Reviewer to join our dedicated team in a Full Time, Day Shift (1.0 FTE) role. If you enjoy analytical work and are energized by helping ensure patients receive the right care at the right time, this remote opportunity may be the perfect next step in your nursing career. Why You’ll Love This Role As a Utilization Management Reviewer at PeaceHealth, you will play a key part in supporting safe, high-quality, and efficient patient care across our healthcare system. This position centers on concurrent and retrospective UM reviews , leveraging clinical expertise, payer policy knowledge, and technology tools to guide patient status determinations and promote appropriate utilization of hospital resources. You’ll work fully remote*, with PeaceHealth-provided computer equipment—empowered by a collaborative team, supportive leadership, and a strong organizational commitment to diversity, cultural humility, and caregiver well-being. Must reside in Washington, Oregon, or Alaska. PeaceHealth will provide the caregiver with necessary computer equipment. It is the responsibility of the caregiver to provide Internet access. PeaceHealth’s Total Rewards package supports your physical, emotional, financial, social, and spiritual wellbeing . Benefits include: Pay Range: $48.52 – $72.78/hour Full medical, dental, and vision coverage 403(b) retirement plan with employer base and matching contributions Paid time off and paid disability & life insurance (with buy-up options) Tuition reimbursement and continuing education support Robust wellness benefits, EAP, and expanded mental health programs A culture grounded in Inclusivity, Respect for Diversity, and Cultural Humility What You’ll Do Coordinate accurate patient status identification and documentation Ensure correct admission status and reimbursement through certification and clinical review Gather additional clinical documentation to validate treatment plans and level of care Collaborate closely with physicians, clinicians, and multidisciplinary teams Apply UM criteria using the Xsolis Dragonfly™ platform and PeaceHealth Care Level Score tools Conduct pre-admission status reviews in the ED, patient access areas, and elective settings Communicate with third-party payers regarding medical necessity and discharge progress Support denial and appeal processes; refer cases for physician advisor review when appropriate Participate in UM Committee work, quality initiatives, and performance improvement Identify DRGs with complications/comorbidities and recommend documentation improvements Promote responsible hospital resource utilization, length-of-stay optimization, and care efficiency Perform other duties as needed to support UM and organizational goals What You Bring Education Required: Bachelor of Science in Nursing (BSN) Preferred: Master of Science in Nursing (MSN) Experience 3+ years of acute care hospital experience with strong clinical knowledge In-depth understanding of Medicare/Medicaid UM regulations, RAC, QIO, MAC, and denial/appeals processes Preferred: Prior experience in utilization management or case management Credentials Active RN license in your state of residence (WA, OR, or AK) Ready to Make a Meaningful Impact? Bring your clinical expertise, attention to detail, and passion for patient advocacy to a mission-driven healthcare system that believes in caring for caregivers as much as patients. For full consideration, please attach a current resume with your application. PeaceHealth is an EEO Affirmative Action Employer/Veterans/Disabled following all applicable state, local, and federal laws.
Description The Utilization Review (UR) Nurse has a strong clinical background blended with a well-developed knowledge and skills in Utilization Management (UM), medical necessity and patient status determination. This individual supports the UM program by developing and maintaining effective, efficient processes for determining the appropriate admission status based on regulatory and reimbursement requirements of commercial and government payers. Providence caregivers are not simply valued – they’re invaluable. Join our team at Swedish Shared Services and thrive in our culture of patient-focused, whole-person care built on understanding, commitment, and mutual respect. Your voice matters here, because we know that to inspire and retain the best people, we must empower them. Required Qualifications Bachelor's Degree in Nursing degree (BSN) from an accredited school of nursing. Upon hire: Washington Registered Nurse License 3 years of Registered nursing experience in the clinical setting. Preferred Qualifications Upon hire: ACM or CCM certification 1 year of Case management experience. Why Join Providence? Our best-in-class benefits are uniquely designed to support you and your family in staying well, growing professionally and achieving financial security. We take care of you, so you can focus on delivering our mission of improving the health and wellbeing of each patient we serve. About Providence At Providence, our strength lies in Our Promise of “Know me, care for me, ease my way.” Working at our family of organizations means that regardless of your role, we’ll walk alongside you in your career, supporting you so you can support others. We provide best-in-class benefits and we foster an inclusive workplace where diversity is valued, and everyone is essential, heard and respected. Together, our 120,000 caregivers (all employees) serve in over 50 hospitals, over 1,000 clinics and a full range of health and social services across Alaska, California, Montana, New Mexico, Oregon, Texas and Washington. As a comprehensive health care organization, we are serving more people, advancing best practices and continuing our more than 100-year tradition of serving the poor and vulnerable. Posted are the minimum and the maximum wage rates on the wage range for this position. The successful candidate's placement on the wage range for this position will be determined based upon relevant job experience and other applicable factors. These amounts are the base pay range; additional compensation may be available for this role, such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities. Providence offers a comprehensive benefits package including a retirement 401(k) Savings Plan with employer matching, health care benefits (medical, dental, vision), life insurance, disability insurance, time off benefits (paid parental leave, vacations, holidays, health issues), voluntary benefits, well-being resources and much more. Learn more at providence.jobs/benefits. Applicants in the Unincorporated County of Los Angeles: Qualified applications with arrest or conviction records will be considered for employment in accordance with the Unincorporated Los Angeles County Fair Chance Ordinance for Employers and the California Fair Chance Act. About The Team Providence Swedish is the largest not-for-profit health care system in the greater Puget Sound area. It is comprised of eight hospital campuses (Ballard, Edmonds, Everett, Centralia, Cherry Hill (Seattle), First Hill (Seattle), Issaquah and Olympia); emergency rooms and specialty centers in Redmond (East King County) and the Mill Creek area in Everett; and Providence Swedish Medical Group, a network of 190+ primary care and specialty care locations throughout the Puget Sound. Whether through physician clinics, education, research and innovation or other outreach, we’re dedicated to improving the wellbeing of rural and urban communities by expanding access to quality health care for all. Providence is proud to be an Equal Opportunity Employer. We are committed to the principle that every workforce member has the right to work in surroundings that are free from all forms of unlawful discrimination and harassment on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law. We believe diversity makes us stronger, so we are dedicated to shaping an inclusive workforce, learning from each other, and creating equal opportunities for advancement. For any concerns with this posting relating to the posting requirements in RCW 49.58.110(1), please click here where you can access an email link to submit your concern. Requsition ID: 413245 Company: Swedish Jobs Job Category: Health Information Management Job Function: Revenue Cycle Job Schedule: Full time Job Shift: Day Career Track: Nursing Department: 3900 SS CASE MANAGEMENT Address: WA Seattle 1730 Minor Ave Work Location: Swedish Metropolitan Park East-Seattle Workplace Type: On-site Pay Range: $52.26 - $81.13 The amounts listed are the base pay range; additional compensation may be available for this role, such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities.
Job Description To maintain high-quality, medically necessary, evidence-based care, and efficient treatment of all patients, regardless of payment source, by ensuring the patients receive the right care, at the right time, in the right place. Case Management Model: utilize an Integrated Case Management Model. Under this model the Case Managers will follow patients through the continuum while facilitating the functions of utilization review, utilization management, and cost containment. Track and trend denials and payor issues to provide feedback and education to payer relations and the case management department. Responsibilities Clinical review of 100% acute bedded patients admitted to Inpatient or Observation status at The Christ Hospital against medical necessity criteria (Interqual and MCG) for appropriateness of admission. Demonstrate understanding of evidenced based medical necessity criteria. Maintains efficient methods of ensuring the medical necessity and appropriateness of all hospital admissions. Identify/facilitate patient status from observation to inpatient as patient clinical condition warrants. Compliance with all Medicare regulatory requirements Work with external payers completing/securing authorization for all services provided. Monitors cases for appropriateness of continued stay, level of care and services, and quality of care using approved screening criteria. Communicate with physicians when alternatives to inpatient care are indicated by clinical review. Identify cases needed for second level of review- refers cases to the Physician Advisor that do not meet established guidelines for admission or continued stay. Consistent collaboration with the RN Case Manager to prevent extended length of stays and appropriate status determination. Identifies potential delays in service or treatment and refers to the appropriate individuals within the multidisciplinary patient care teams for action/resolution. Track and trends avoidable day information in Midas per process. Identifies problems related to the quality of patient care and refers such problems to the Performance Improvement Department. Adherence to department productivity standards. Initial, concurrent, and retro reviews should be completed timely including all necessary information for approval of claims. All reviews should contain information only pertinent to IS/SI (Intensity of Service/Severity of Illness). Compliance with documentation methods for monthly reporting and statistics for presentation to the Utilization Review Committee. Interfaces with patient registration and patient financial services etc. to collaborate on financial issues. Establish an effective rapport and relationship with third party payers to promote cost effective clinical outcomes. Assist in denial and appeal process Performs other duties as assigned, including but not limited to: Demonstrates professional responsibility required for a Utilization Review Nurse Complies with department and hospital policies at all times Maintains compliance with State/Federal Guidelines and standards Conforms to all requirements of Medicare Keep current on changing laws and requirements of Medicare Demonstrate a positive attitude at all times Qualifications KNOWLEDGE AND SKILLS: Please describe any specialized knowledge or skills, which are REQUIRED to perform the position duties. Do not personalize the job description, credentials, or knowledge and skills based on the current associate. List any special education required for this position. EDUCATION: Bachelor’s Degree. Graduate of an accredited school of nursing with current licensure OR actively enrolled in a BSN program with completion date within 3 years of hire date and a graduate of an accredited school of nursing with current licensure. YEARS OF EXPERIENCE: 3-5 years of medical/surgical nursing necessary and a minimum of 3 years of utilization review experience required. REQUIRED SKILLS AND KNOWLEDGE: Experience with case management, utilization review, and discharge planning that is related to the clinical or operational functional areas. Knowledge and application of a wide variety of advanced case management tools and methods. Knowledge of clinical and operations research methodology and design. Proficient in state of the art business trends, benchmarking, and case management tools and techniques. Ability to operate PC based software programs or automated database management systems. Expertise in meeting regulatory and accreditation requirements. Strong presentation, written and oral communication skills, with strong analytical and problem-solving skills as well as time/project management skills. Ability to work with a variety of disciplines and levels of staff across departments and the organization is required. LICENSES & CERTIFICATIONS: Licensed to practice in the State of Ohio Certified Case Management (CCM) or Accredited Case Management (ACM) preferred.
$5,000 SIGN ON BONUS (for external candidates only) Utilization management (UM ) is the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of the applicable health benefits plan. Prior authorization that allow payers, particularly health insurance companies to manage the cost of health care benefits by assessing its appropriateness before it is provided using evidence-based criteria or guidelines. Strong utilization management process can reduce payment denials. Clinical documentation specialists is designed to improve the physician’s documentation in the patient’s medical record, supporting the appropriate severity of illness, expected risk of mortality and complexity of care of the patient. Clinical documentation is responsible for extensive collaboration with physician is, nursing staff, support staff, other patient caregiver and medical records coding staff. Employee insurance liaison Meadville Medical Center has self-funded insurance. One staff member is assigned to work with Human resources, Highmark Liaison, Medical director and employees. Set process is to call medical procedures out of network and employee needs to request a waiver from our current liaison. The liaison will review the requested procedure with our current medical director. If the request is approved the liaison of UM will notify the employee and out Highmark Liaison. Medical necessity rules will be reviewed, urgency and medical history. The decision will be called to the employee. If it is not favorable, this can be appealed to human resources If this process is not followed, and the employee gets a bill. The liaison will review what was performed. They will review with the medical director and make a decision to override the out of network rules. The liaison support HR represented as needed. Applicate: Curious and Detailed Oriented. Actively seek out new ideas, possibilities, and answers to the tough questions. Pays meticulous attention to detail. Committed to life-long learning UM Process Payors may use different criteria and may require their data set be applied for their population. Utilization management is a strategy for managing cost and quality under the latest CMS reimbursement Reviews precertification requests for medical necessity, referring to the Medical Director those that require additional expertise. Reviews Clinical information for concurrent reviews, extending the length of stay for inpatients as appropriate. Establishes effective rapport with other employees, professional support service staff, customers, clients, patient’s families and physicians. Use effective relationship management, coordination of services, resource management, education, patient advocacy and related interventions. CDS-Inpatients Advanced clinical expertise and extensive knowledge of complex disease processes with a broad clinical experience in an inpatient setting required Pursues a subsequent review of records every 3 days to support and assign a working DRG assignment upon discharge. Formulates queries when it is determined there is missing documentation, conflicting documentation or unclear documentation. Provides on-going education to physicians and essential healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the patient's record. Use of coding nomenclature demonstrated knowledge of ICD-10 classifications, and thorough understanding of the effect coded data has prospective payment, outcome models, utilization, and reimbursement. Participates in the analysis and trending of statistical data for specified patient population; identifies opportunity for improvement. Promotes a partnership with the inpatient-coding professionals to ensure the accuracy of principal diagnosis, procedures and completeness of supporting documentation to determine the working and final DRG, severity of illness and risk of mortality. Acts as a resource person for the interdisciplinary team in order to promote collaboration and coordination of patient care considering age specific, developmental, cultural, and spiritual needs of the patient. Overall department goals Promotes improved quality of care and/or life. Promotes cost effective medical outcomes. Prevents hospitalization when possible and appropriate. Promotes decreased lengths of observation stays or inpatient stays when appropriate. Provides for continuity of care. Assures appropriate levels of care are received by our patients. Participates in rounding on the nursing floors. Works with HIM on coding issues. Provides advice and counsel to precertification staff in physician offices or in house. Identifies appropriate alternative resources and demonstrate creativity in managing each case to fully utilize all available resources. Maintains accurate records of all communications and interventions. Other duties as assigned. MINIMUM EDUCATION, KNOWLEDGE, SKILLS, AND ABILITIES REQUIRED Proof of successful completion of education requirements for board certified registered nurse as defined by the state in which the employee is to practice as well as proof of such licensure in good standing. 5 years’ experience as a Registered Nurse is preferred. Ability to read analyze and interpret documents, reports, technical procedures, governmental regulations and correspondence BLS required. Certification for UM nurse and CDI specialists is encouraged.
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. Work Schedule (Central Time): 8:30 AM–5:30 PM, Monday–Friday, with rotating weekends and holidays Location Requirement: Must reside in Oklahoma Program: Medicaid (Oklahoma) Conduct clinical reviews for medical necessity (utilization review) Demonstrate strong provider relations skills Communicate with providers to obtain/clarify clinical information and support timely decisions Collaborate with cross-functional partners to resolve cases and support member/provider needs Position Purpose: Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member. Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines Reviews member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities Collaborates with care management on referral of members as appropriate Performs other duties as assigned Complies with all policies and standards Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience. 2+ years of acute care experience required. Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. License/Certification :LPN - Licensed Practical Nurse - State Licensure required Pay Range: $27.02 - $48.55 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
Who Are We? Taking care of our customers, our communities and each other. That’s the Travelers Promise. By honoring this commitment, we have maintained our reputation as one of the best property casualty insurers in the industry for over 170 years. Join us to discover a culture that is rooted in innovation and thrives on collaboration. Imagine loving what you do and where you do it. Job Category Claim, Nurse - Medical Case Manager Compensation Overview The annual base salary range provided for this position is a nationwide market range and represents a broad range of salaries for this role across the country. The actual salary for this position will be determined by a number of factors, including the scope, complexity and location of the role; the skills, education, training, credentials and experience of the candidate; and other conditions of employment. As part of our comprehensive compensation and benefits program, employees are also eligible for performance-based cash incentive awards. Salary Range $81,500.00 - $134,500.00 Target Openings 1 What Is the Opportunity? This position is responsible for conducting in-house utilization review with emphasis on determining medical necessity for prospective, concurrent, retrospective and appeal treatment requests for workers compensation claims. Responsible for helping to ensure the appropriate treatment is directly related to the compensable injury and for adhering to multi-jurisdictional Utilization Review criteria. What Will You Do? Interpret routine, complex or unique medical information. Evaluate medical treatment to determine whether it was/is reasonable, necessary and causally related based upon jurisdictional guidelines. Submit accurate billing documentation on all activities as outlined in established guidelines. Engage specialty resources, as needed, to reach final determination of medical necessity. Utilize internal Claim Platform Systems to manage all claim activities on a timely basis. Utilize Preferred Provider Network per jurisdictional guidelines. Research medical information to support the claim review process. Occasional contact with provider to ensure the injured employee is actively participating in a viable treatment plan. Keep claim professional apprised of medical treatment request status. In order to perform the essential functions of this job, acquisition and maintenance of Insurance License(s) may be required to comply with state and Travelers requirements. Generally, license(s) must be obtained within three months of starting the job and obtain ongoing continuing education credits as mandated. Perform other duties as assigned. What Will Our Ideal Candidate Have? Working knowledge of medical causation and relatedness. Working knowledge of jurisdiction-specific medical guidelines. Prior clinical experience. Intermediate medical knowledge of the nature and extent of injuries, periods of disability, and treatment. Intermediate customer service: ability to build and maintain productive relationships with medical providers as well as internal claim handlers. Working knowledge of URAC standards. Intermediate planning & Organizing: ability to establish a plan/course of action and contingencies for self or others to meet current or future goals. Intermediate teamwork: ability to work together in situations when actions are interdependent and a team is mutually responsible to produce a result. Intermediate analytical thinking: Identifies current or future problems or opportunities; analyzes, synthesizes and compares information to understand issues; identifies cause/effect relationships; and explores alternative solutions that support sound decision-making. Intermediate communication skills: Expresses, summarizes and records thoughts clearly and concisely orally and in writing by applying proper content, format, sentence structure, grammar, language and terminology. Basic negotiation: ability to understand alternatives, influence stakeholders and reach a fair agreement through discussion and compromise. Basic principles of investigation: follows a logical sequence of inquiry determine if the treatment request is related to the compensable injury and medically necessary per jurisdictional guidelines. Basic legal knowledge: understanding and application of state, federal and regulatory laws and statutes. Basic worker’s compensation technical ability to apply available resources and technology to manage treatment plans. Demonstrate a clear understanding and ability to work within jurisdictional parameters within their assigned state. What is a Must Have? Registered Nurse; Licensed Practical Nurse or Licensed Vocational Nurse. What Is in It for You? Health Insurance : Employees and their eligible family members – including spouses, domestic partners, and children – are eligible for coverage from the first day of employment. Retirement: Travelers matches your 401(k) contributions dollar-for-dollar up to your first 5% of eligible pay, subject to an annual maximum. If you have student loan debt, you can enroll in the Paying it Forward Savings Program. When you make a payment toward your student loan, Travelers will make an annual contribution into your 401(k) account. You are also eligible for a Pension Plan that is 100% funded by Travelers. Paid Time Off: Start your career at Travelers with a minimum of 20 days Paid Time Off annually, plus nine paid company Holidays. Wellness Program: The Travelers wellness program is comprised of tools, discounts and resources that empower you to achieve your wellness goals and caregiving needs. In addition, our mental health program provides access to free professional counseling services, health coaching and other resources to support your daily life needs. Volunteer Encouragement: We have a deep commitment to the communities we serve and encourage our employees to get involved. Travelers has a Matching Gift and Volunteer Rewards program that enables you to give back to the charity of your choice. Employment Practices Travelers is an equal opportunity employer. We value the unique abilities and talents each individual brings to our organization and recognize that we benefit in numerous ways from our differences. In accordance with local law, candidates seeking employment in Colorado are not required to disclose dates of attendance at or graduation from educational institutions. If you are a candidate and have specific questions regarding the physical requirements of this role, please send us an email so we may assist you. Travelers reserves the right to fill this position at a level above or below the level included in this posting. To learn more about our comprehensive benefit programs please visit http://careers.travelers.com/life-at-travelers/benefits/ .
Description Maine Medical Center Nursing Req #: 67833 This is a Clinical Nurse II vacancy open to candidates with greater than 1 year of RN work experience This is a Bargaining Unit Position Date Posted: 2/9/2026 *Knowledge ofboth Inter-qual and MCG criteria preferred. Previous Care Manager experience preferred* Pleasenote,this position does not include discharge planning Role The CaseManager I is accountable for a designated patient caseload and plans effectivelyin order to meet patient needs, manage the length of stay, and promote efficient utilization of resources. Specific functions within this role include but are not limited to: Facilitation of the collaborative management of patient care across the continuum, intervening as necessary to address barriers totimelyand efficient care delivery,flowand reimbursement Application of process improvement methodologies in evaluating outcomes of care Support and coaching of clinical documentation efforts Coordinating communication with the interdisciplinary care team Must be able todemonstrateknowledge and skills necessary to provide careappropriate tothe patient served. Mustdemonstrateknowledge of the principles of growth and development as it relates to the different life cycles. Summary The purpose of the Case Manager I position is to support the interdisciplinary team in facilitating patient care, with the underlying objective of enhancing the quality of clinical outcomes and patient satisfaction while managing the cost of care and providing timely and accurate information to payors. The role integrates and coordinates utilization management, care facilitation and discharge planning functions. This work is performed under general supervision in accordance with the Maine Medical Center (MMC) institutional policies and Care Management Department policies. The Case Manager I is accountable for a designated patient caseload and plans effectively in order to meet patient needs, manage the length of stay, and promote efficient utilization of resources. Specific functions within this role include but are not limited to: Facilitation of the collaborative management of patient care across the continuum, intervening as necessary to address barriers to timely and efficient care delivery, flow and reimbursement Application of process improvement methodologies in evaluating outcomes of care Support and coaching of clinical documentation efforts Coordinating communication with the interdisciplinary care team Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the patient served. Must demonstrate knowledge of the principles of growth and development as it relates to the different life cycles. Required Minimum Knowledge, Skills, And Abilities (KSAs) Education: BSN or must matriculate into a BSN program within one year of hire and completion attained within 5 years of hire. License/Certifications: Current and valid license to practice as a Registered Nurse in the state of Maine. Professional certification as a Case Manager preferred. Experience: One to three years clinical experience in clinical practice area, three to five years preferred. Excellent interpersonal communication and negotiation skills. Strong analytical, data management and PC skills. Working knowledge of discharge planning, utilization management, case management, performance improvement and managed care reimbursement preferred. Understanding of pre-acute and post-acute venues of care and post-acute community resources preferred. Strong organizational and time management skills. Ability to work independently and exercise sound judgment in interactions with interprofessional team, payors, and patients and their families. Demonstrate commitment to organizational values. Perform duties in a manner to promote quality patient care and customer service/satisfaction, while promoting safety, cost efficiency, and a commitment to the quality process. Additional Information With a career at any of the MaineHealth locations across Maine and New Hampshire, you’ll be working with health care professionals that truly value the people around them – both within the walls of the organization and the communities that surround it. We offer benefits that support an individual's needs for today and flexibility to plan for tomorrow – programs such as paid parental leave, a flexible work policy, student loan assistance, training and education, along with well-being resources for you and your family. MaineHealth remains focused on investing in our care team and developing an inclusive environment where you can thrive and feel supported to realize your full potential. If you’re looking to build a career in a place where people help one another deliver best-in-class care, apply today. If you have questions about this role, please contact nicole.chapman@mainehealth.org
Introduction Do you want to join an organization that invests in you as a(an) Clinical Nurse Reviewer? At Methodist Hospital, you come first. HCA Healthcare has committed up to 300 million in programs to support our incredible team members over the course of three years. Benefits Methodist Hospital offers a total rewards package that supports the health, life, career and retirement of our colleagues. The available plans and programs include: Comprehensive medical coverage that covers many common services at no cost or for a low copay. Plans include prescription drug and behavioral health coverage as well as free telemedicine services and free AirMed medical transportation. Additional options for dental and vision benefits, life and disability coverage, flexible spending accounts, supplemental health protection plans (accident, critical illness, hospital indemnity), auto and home insurance, identity theft protection, legal counseling, long-term care coverage, moving assistance, pet insurance and more. Free counseling services and resources for emotional, physical and financial wellbeing 401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service) Employee Stock Purchase Plan with 10% off HCA Healthcare stock Family support through fertility and family building benefits with Progyny and adoption assistance. Referral services for child, elder and pet care, home and auto repair, event planning and more Consumer discounts through Abenity and Consumer Discounts Retirement readiness, rollover assistance services and preferred banking partnerships Education assistance (tuition, student loan, certification support, dependent scholarships) Colleague recognition program Time Away From Work Program (paid time off, paid family leave, long- and short-term disability coverage and leaves of absence) Employee Health Assistance Fund that offers free employee-only coverage to full-time and part-time colleagues based on income. Learn more about Employee Benefits Note: Eligibility for benefits may vary by location. You contribute to our success. Every role has an impact on our patients’ lives and you have the opportunity to make a difference. We are looking for a dedicated Clinical Nurse Reviewer like you to be a part of our team. Job Summary and Qualifications Recruiter to insert Job Summary and requirements here Recruiter to check inserted requirements to ensure it included all credentials below. Then they should delete the credentials What qualifications you will need: (LPN/LVN) Licensed Practical or Vocational Nurse, or (RN) Registered Nurse " Parallon provides full-service revenue cycle management, or total patient account resolution, for HCA Healthcare. Our services include scheduling, registration, insurance verification, hospital billing, revenue integrity, collections, payment compliance, credentialing, health information management, customer service, payroll and physician billing. We also provide full-service revenue cycle management as well as targeted solutions, such as Medicaid Eligibility, for external clients across the country. Parallon has over 17,000 colleagues, and serves close to 1,000 hospitals and 3,000 physician practices, all making an impact on patients, providers and their communities. HCA Healthcare has been recognized as one of the World’s Most Ethical Companies® by the Ethisphere Institute more than ten times. In recent years, HCA Healthcare spent an estimated 3.7 billion in cost for the delivery of charitable care, uninsured discounts, and other uncompensated expenses. " "Good people beget good people." - Dr. Thomas Frist, Sr. HCA Healthcare Co-Founder We are a family 270,000 dedicated professionals! Our Talent Acquisition team is reviewing applications for our Clinical Nurse Reviewer opening. Qualified candidates will be contacted for interviews. Submit your resume today to join our community of caring! We are an equal opportunity employer. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.
PIH Health is a nonprofit, regional healthcare network that serves approximately 3 million residents in the Los Angeles County, Orange County and San Gabriel Valley region. The fully integrated network is comprised of PIH Health Hospital - Whittier, PIH Health Hospital - Downey and PIH Health Good Samaritan Hospital, 27 outpatient medical locations, a multispecialty medical (physician) group, home healthcare services and hospice care, as well as heart, cancer, women’s health, urgent care and emergency services. The organization is recognized by Watson Health as one of the nation’s Top Hospitals, and College of Healthcare Information Management Executives (CHIME) as one of the nation’s top hospital systems for best practices, cutting-edge advancements, quality of care and healthcare technology. PIH Health is certified as a Great Place to Work TM . For more information, visit PIHHealth.org or follow us on Facebook , Twitter , or Instagram . The Emergency Prospective Review (EPR) Nurse – RN has the responsibility to conduct a review of all patients requiring hospital admission from the emergency room at all PIH and non-PIH facilities (for PHP members) after stabilizing care has been initiated for medical necessity and appropriateness. Also, the EPR-RN is responsible for reviewing all interfacility transfer request from non-PIH facility in accordance to transfer policies, Health and Safety Codes, and applicable laws (COBRA/EMTALA). The EPR-RN performs, and supervises the EPRN-LVN, in utilization review with a prominent level of expertise by using approved criteria that demonstrates medical necessity to achieve appropriate authorization and reimbursement for services for the appropriate level of care and status (Inpatient, Observation, or Outpatient). EPR-RN Communicates medical necessity criteria effectively to outside insurance providers to obtain appropriate authorization for services up front or engages in disagreement of care in accordance with Health and Safety Codes. Additionally, EPR-RN collaborates closely with patient’s insurance and various payors to coordinate and assist with reparation/transfer of out-of-network patients from PIH facility to the patient’s contracted facility including coordination of post-emergency discharge needs, as necessary. EPR-RN is also responsible for the repatriation of all PHP risk patients from non-PIH facilities to any one of the PIH facilities in an expeditious manner. EPR-RN conducts emergency physician-to-emergency physician discussions of members and provides authorization for post-stabilization care of PHP members presenting at a non-PIH facility and is required to assist in making other appropriate arrangements to promote/enhance continuity of care. Similarly, EPR -RN is responsible for the issuance of post stabilization care (PSC) denial to facilities and providers who fail to meet requirements in accordance with Health and Safety Codes. Lastly, the EPR-RN Works collaboratively with House Supervisor or designee in ensuring timely bed assignment and placement of patient admissions or transfers from PIH ED or outside facility. The position serves as a liaison between patients, families, providers, payors, and PIH Health leadership to optimize resource utilization and patient outcomes. This position is considered hybrid with remote and in-office assignment. Required Skills Excellent verbal and written communication skills Ability to follow chain of command Knowledge of hospital operations especially from an ER, ICU, nursing unit, environmental services and financial perspective. Knowledge of EMTALA regulations Advanced ability to multi-task and maintain focus Proactive, can-do approach and desire to build positive working relationships through collaborative problem-solving Self-motivated and results oriented. Must be able to demonstrate sound decision making, flexibility and prioritization skills. Strong organizational skills Basic computer skills; Outlook, Word, and Excel Required Experience Maintain an active California RN Minimum of two (2) years of acute hospital nursing experience or similar field Preferred: CCM or ACM (Certified Case Manager, Accredited Case Manager) Minimum of one (1) year acute hospital nursing experience in Critical Care or Emergency Department Previous experience in case management, access management or utilization management Knowledge of payer requirements Address 11500 Brookshire Ave. Salary 55.00-87.50 Shift Nights Zip Code 90241
Description Become part of an inclusive organization with over 40,000 teammates, whose mission is to improve the health and well-being of the unique communities we serve. Summary: The Utilization Manager (UM) assesses new admissions, continued stay and discharge review cases for medical necessity, appropriate class and level of care (LOC). This position works collaboratively with an interdisciplinary team (including physicians, other care providers, payers, etc.) to ensure the patient’s needs are met and care delivery is coordinated. The UM completes utilization reviews in accordance with federal regulations and the health system’s Utilization Review Plan. Responsibilities: Uses approved criteria and conducts admission review/class change review as trigger by patient admission to the hospital to ensure appropriateness of the setting and timely implementation of the plan of care. Identifies and obtains observation services as appropriate . Partners with physicians, nursing, and other care providers to help ensure timely and accurate documentation of patient data and treatments. Communicates daily with the Care Manager to manage level of care transitions & appropriate utilization of services. Coordinates with the appropriate staff/payers to assure third party payer pre-certification and/or re-certifications when required . Discharge Facilitation: Utilizes high risk screening criteria to make appropriate referrals . Identifies patient/families with the complex psychosocial, on-going medical transition planning issues , continuing care needs by initiating appropriate care management referrals. Initiates appropriate social work referrals. Performs utilization management assessments and interventions, using collaboration with interdisciplinary team approach, on assigned patients as appropriate to ensure optimal patient outcomes. Using approved criteria, conducts initial and continued stay reviews to monitor the patient's progress along the continuum of care and intervenes as necessary to ensure appropriateness of setting and that the services provided are quality-driven, efficient, and effective. Enters all pertinent review data into the correct computer system in a timely manner . Consults with Physician Advisor as necessary to resolve barriers through appropriate administrative and medical channels. Monitors and guides to trend interdisciplinary documentation and guides medical staff in documentation that will assist in coding accuracy, enhance quality of care, reflect accurate severity of illness and appropriate reimbursement . Facilitates patient movement to appropriate (acuity) level of care including observation services issues through collaboration with patient/patient representative, multidisciplinary team, third party payers and care managers/social workers. Provides information regarding denials and approvals to appropriate staff and/or designated entities. Documents and delivers notifications to patients, patient representative and/or appropriate staff . Reviews Pre-Scheduled surgery admissions for proper status order for inpatient-only procedures. Collaborates to problem-solve issues with complex patients and identify trends. Formulates potential solutions with Care Manager and Social Worker and continuously monitors cases/follows up on all action items. Proactively identify high risk cases that need to be escalated to the list that are not scheduled for discussion that week. PARDEE Other information: Required Must be licensed to practice as a Registered Nurse in the state of North Carolina or one of compact states. Two (2) years of experience working as a Registered Nurse. Strong verbal and written communication. Basic Life Support (BLS) certification. Preferred Bachelor's of Science in Nursing (BSN) Certification in Case Management 01.6015.1542 Job Details Legal Employer: Pardee - HCHC Entity: Pardee UNC Health Care Organization Unit: Acute Care Case Management Work Type: Full Time Standard Hours Per Week: 40.00 Work Assignment Type: Onsite Work Schedule: Day Job Location of Job: PARDEEHOSP Exempt From Overtime: Exempt: No Qualified applicants will be considered without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, status as a protected veteran or political affiliation.
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 (UM) Admissions Liaison RN II is primarily responsible for receiving/reviewing admission requests and higher level of care (HLOC) transfer requests from inpatient facilities within regular timelines. Reviews clinical data in real-time and post admission to issue a determination based on clinical criteria for medical necessity. Assures timely, accurate determination and notification of admission and inter-facility transfer requests. Generates approval, modification, and denial communications for inpatient admission requests. Actively monitors for appropriate level of care (inpatient vs. observation) admission in the acute setting. Works with UM leadership, including the Utilization Management Medical Director, on requests where determination requires extended review. Collaborates with the inpatient care team for facilitation/coordination of patient transfers between acute care facilities. Acts as a department resource for medical service requests/referral management and processes. Actively participates in the discharge planning process, including providing clinical review and authorization for alternate levels of care, home health, durable medical equipment, and other discharge needs. Provides support to the inpatient review team as necessary to ensure timely processing of concurrent reviews. Duties Provides the primary clinical point of contact for inpatient acute care hospitals requesting Inpatient care/post-stabilization admission requests, Higher level of care transfers and other emergent transfers or needs. Ensures appropriate determination for admission requests/HLOC transfers based on clinical data presented and established criteria/guidelines, escalating to the medical director if needed. Triages and assesses members for admission needs, including, but not limited to, bed and accepting physician availability. (40%) Establishes and maintains ongoing communication with internal stakeholders and external customers while securing the L.A. Care member's admission or inter-facility transfer. Interfaces with physicians, house supervisors, and other hospital delegates to ensure that telephone triage results in appropriate patient placement. (10%) Applies clinical expertise and the nursing process to triage and prioritize admission acuity, servicing as an expert clinical resource for patient placement while utilizing medical knowledge and experience to facilitate consensus-building and development of satisfactory outcomes (10%) Continually seeks new ways to improve processes and increase efficiencies. Takes the initiative to communicate recommendations to UM Leadership. (5%) Completes all inpatient and discharge planning requests appropriately and timely including, but not limited to: Skilled nursing facility, outpatient needs (home health, physical therapy, infusion), and case management referrals (5%) Performs prospective, concurrent, post-service, and retrospective claim medical review processes. Utilizes clinical judgement, independent analysis, critical-thinking skills, detailed knowledge of medical policies, clinical guidelines and benefit plans to complete reviews and determinations within required turnaround times specific to the case type. Identifies requests needing medical director review or input and presents for second level review (20%) Performs other duties as assigned. (10%) Duties Continued Education Required Associate's Degree in Nursing Education Preferred Bachelor's Degree in Nursing Experience Required: Minimum of 7 years of clinical experience in an acute hospital setting. Previous experience to have a strong understanding of Utilization Management/Case Management practices including, but not limited to, placement (with level of care) criteria (MCG, InterQual), concurrent review, and discharge planning. Preferred: Consistent Critical Care experience (Emergency Department, Intensive Care, Labor & Delivery) background highly desirable. Experience in bed placement decision-making highly desirable. Skills Required: Must be computer literate, with expertise in Outlook, Word, Excel, PowerPoint. Provision of excellent customer service required due to frequent communication with providers and other members of the interdisciplinary team 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. 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 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) American Case Management Association (ACM) Required Training Physical Requirements Light Additional Information Required: Attend mandatory department trainings as scheduled Financial Impact: Management of all medical services has a tremendous potential impact on the cost of health care and budget. This position manages determinations to ensure services requested are medically appropriate and provided in the most cost effective manner without compromising quality healthcare delivery. Types of Shift: Day (7:00am - 3:30pm), Evening (3:00pm -11:30 pm), Night (11:00pm -7:30am). Float (Varies)* *All possible shifts. 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)
Current Employees: If you are a current Staff, Faculty or Temporary employee at the University of Miami, please click here to log in to Workday to use the internal application process. To learn how to apply for a faculty or staff position, please review this tip sheet . UMHC-SCCC has an exciting opportunity for a Utilization Case Manager position. The incumbent is to complete ongoing reviews for clinical utilization and identifying the need for continued authorization. The Utilization Case Manager coordinates with the Nurse Case Manager as well as the Healthcare team for optimal patient outcomes, while avoiding potential treatment delays and authorization denials. The Utilization Case Manager is accountable for a designated patient caseload and ensures that all necessary criteria for continued authorization remains in place. At all times the case manager provides communication of progress and or determination to the clinical team and or the patient. CORE JOB FUNCTIONS Adhere and perform timely reviews for services requiring an authorization for continuation of care Follows the authorization process using established criteria as set forth by the payer or clinical guidelines Accurate review of coverage benefits and limitations to determine continued appropriateness of services requested Facilitates interdepartmental communication regarding status of continued authorization in advance of patient’s appointment. Maintains effective communication regarding authorization status and determination to the clinical team and on occasion the patient. Identifies potential delays in treatment by reviewing the treatment plan and proactively communicates with the healthcare team and or patient regarding the potential treatment barrier Maintains knowledge regarding payer reimbursement policies and clinical guidelines. Adheres to University and department level policies and procedures and safeguards University assets. This list of duties and responsibilities is not intended to be all-inclusive and may be expanded to include other duties or responsibilities as necessary. CORE QUALIFICATIONS Bachelor’s degree in relevant field; or equivalent Minimum of 2 years of relevant experience #LI-GD1 The University of Miami offers competitive salaries and a comprehensive benefits package including medical, dental, tuition remission and more. UHealth-University of Miami Health System, South Florida's only university-based health system, provides leading-edge patient care powered by the ground breaking research and medical education at the Miller School of Medicine. As an academic medical center, we are proud to serve South Florida, Latin America and the Caribbean. Our physicians represent more than 100 specialties and sub-specialties, and have more than one million patient encounters each year. Our tradition of excellence has earned worldwide recognition for outstanding teaching, research and patient care. We're the challenge you've been looking for. The University of Miami is an Equal Opportunity Employer. Applicants and employees are protected from discrimination based on certain categories protected by Federal law. Job Status: Full time Employee Type: Staff
Description The Utilization Review (UR) Nurse has a strong clinical background blended with a well-developed knowledge and skills in Utilization Management (UM), medical necessity and patient status determination. This individual supports the UM program by developing and maintaining effective, efficient processes for determining the appropriate admission status based on regulatory and reimbursement requirements of commercial and government payers. Providence caregivers are not simply valued – they’re invaluable. Join our team at Swedish Shared Services and thrive in our culture of patient-focused, whole-person care built on understanding, commitment, and mutual respect. Your voice matters here, because we know that to inspire and retain the best people, we must empower them. Required Qualifications Bachelor's Degree in Nursing degree (BSN) from an accredited school of nursing. Upon hire: Washington Registered Nurse License 3 years of Registered nursing experience in the clinical setting. Preferred Qualifications Upon hire: ACM or CCM certification 1 year of Case management experience. Why Join Providence? Our best-in-class benefits are uniquely designed to support you and your family in staying well, growing professionally and achieving financial security. We take care of you, so you can focus on delivering our mission of improving the health and wellbeing of each patient we serve. About Providence At Providence, our strength lies in Our Promise of “Know me, care for me, ease my way.” Working at our family of organizations means that regardless of your role, we’ll walk alongside you in your career, supporting you so you can support others. We provide best-in-class benefits and we foster an inclusive workplace where diversity is valued, and everyone is essential, heard and respected. Together, our 120,000 caregivers (all employees) serve in over 50 hospitals, over 1,000 clinics and a full range of health and social services across Alaska, California, Montana, New Mexico, Oregon, Texas and Washington. As a comprehensive health care organization, we are serving more people, advancing best practices and continuing our more than 100-year tradition of serving the poor and vulnerable. Posted are the minimum and the maximum wage rates on the wage range for this position. The successful candidate's placement on the wage range for this position will be determined based upon relevant job experience and other applicable factors. These amounts are the base pay range; additional compensation may be available for this role, such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities. Providence offers a comprehensive benefits package including a retirement 401(k) Savings Plan with employer matching, health care benefits (medical, dental, vision), life insurance, disability insurance, time off benefits (paid parental leave, vacations, holidays, health issues), voluntary benefits, well-being resources and much more. Learn more at providence.jobs/benefits. Applicants in the Unincorporated County of Los Angeles: Qualified applications with arrest or conviction records will be considered for employment in accordance with the Unincorporated Los Angeles County Fair Chance Ordinance for Employers and the California Fair Chance Act. About The Team Providence Swedish is the largest not-for-profit health care system in the greater Puget Sound area. It is comprised of eight hospital campuses (Ballard, Edmonds, Everett, Centralia, Cherry Hill (Seattle), First Hill (Seattle), Issaquah and Olympia); emergency rooms and specialty centers in Redmond (East King County) and the Mill Creek area in Everett; and Providence Swedish Medical Group, a network of 190+ primary care and specialty care locations throughout the Puget Sound. Whether through physician clinics, education, research and innovation or other outreach, we’re dedicated to improving the wellbeing of rural and urban communities by expanding access to quality health care for all. Providence is proud to be an Equal Opportunity Employer. We are committed to the principle that every workforce member has the right to work in surroundings that are free from all forms of unlawful discrimination and harassment on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law. We believe diversity makes us stronger, so we are dedicated to shaping an inclusive workforce, learning from each other, and creating equal opportunities for advancement. For any concerns with this posting relating to the posting requirements in RCW 49.58.110(1), please click here where you can access an email link to submit your concern. Requsition ID: 413245 Company: Swedish Jobs Job Category: Health Information Management Job Function: Revenue Cycle Job Schedule: Full time Job Shift: Day Career Track: Nursing Department: 3900 SS CASE MANAGEMENT Address: WA Seattle 1730 Minor Ave Work Location: Swedish Metropolitan Park East-Seattle Workplace Type: On-site Pay Range: $51.43 - $79.84 The amounts listed are the base pay range; additional compensation may be available for this role, such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities.
Job Summary Provides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines. • Analyzes clinical service requests from members or providers against evidence based clinical guidelines. • Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. • Conducts reviews to determine outpatient 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: $25.08 - $51.49 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
Job Summary: High-level clinical review of patients admitted to the University Hospital for the purpose of risk identification and referral to clinical departments for ongoing review of quality improvement focused on the support of the Patient Relations department. Report adverse events to the majority of regulatory agencies and conduct internal quality reviews through the institution-defined quality review process. Supports the Attorney General's office in the review and defense of medical malpractice actions brought against the state. Supports the Patient Relations department with patient complaints that require quality review and/or Risk oversight. Minimum Qualifications: Registered Nurse, NYS License and Bachelors Degree in Nursing or healthcare related field and three years acute care clinical experience or Associates Degree in Nursing and 5 years acute care clinical required. Excellent communication and customer service skills required for interface with health care payers, regulatory agencies and other health care related entities. Preferred Qualifications: CPHRM certified. Candidates with quality review experience & familiarity with DOH Regulatory reporting requirements preferred. Work Days: Monday-Friday, Days Message to Applicants: Recruitment Office: Human Resources
Job Description Job Summary Provides support for medical claim and internal appeals review activities - ensuring alignment with applicable state and federal regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Contributes to overarching strategy to provide quality and cost-effective member care. Job Duties Facilitates clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases in which an appeal has been made, or is likely to be made, to ensure medical necessity and appropriate/accurate billing and claims processing. Reevaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of relevant and applicable state and federal regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of services provided, length of stay, level of care, and inpatient readmissions. Validates member medical records and claims submitted/correct coding, to ensure appropriate reimbursement to providers. Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) issues. Identifies and reports quality of care issues. Assists with complex claim review including diagnosis-related group (DRG) validation, itemized bill review, appropriate level of care, inpatient readmission, and any opportunities identified by the payment integrity analytical team; makes decisions and recommendations pertinent to clinical experience. Prepares and presents cases representing Molina, along with the chief medical officer (CMO), for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings. Reviews medically appropriate clinical guidelines and other appropriate criteria with medical directors on denial decisions. Supplies criteria supporting all recommendations for denial or modification of payment decisions. Serves as a clinical resource for utilization management, CMOs, physicians and member/provider inquiries/appeals. Provides training and support to clinical peers. Identifies and refers members with special needs to the appropriate Molina program per applicable policies/protocols. Job Qualifications REQUIRED QUALIFICATIONS: At least 2 years clinical nursing experience, including at least 1 year of utilization review, medical claims review, long-term services and supports (LTSS), claims auditing, medical necessity review and/or coding experience, or equivalent combination of relevant education and experience. Registered Nurse (RN). License must be active and unrestricted in state of practice. Experience demonstrating knowledge of ICD-10, Current Procedural Technology (CPT) coding and Healthcare Common Procedure Coding (HCPC). Experience working within applicable state, federal, and third-party regulations. Analytic, problem-solving, and decision-making skills. Organizational and time-management skills. Attention to detail. Critical-thinking and active listening skills. Common look proficiency. Effective verbal and written communication skills. Microsoft Office suite and applicable software program(s) proficiency. PREFERRED QUALIFICATIONS: Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ), or other health care certifications. Nursing experience in critical care, emergency medicine, medical/surgical or pediatrics. Billing and coding experience. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $29.05 - $67.97 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
Newport News, Virginia This is not a remote position, this position is located on site at Riverside Regional Medical Center in the Emergency Department working 12 hour shifts. Available Shift: 7am-7pm Responsible for the judicious management of health system resources through advocacy for both the patient and the organization. Provides initial medical necessity reviews for all patients hospitalized within the organization in accordance with national guidelines and standards of excellence, in accordance with the UM Plan established by the organization, facility goals, and strategic plans. What you will do Recognizes and demonstrates shared accountability, both at the patient and the team level. Contributes to decision-making and decision support as a member of the interdisciplinary team. Provides level of care determination to physicians (Emergency and Attending) based upon thorough medical record review and knowledge of federal and evidence-based guidelines, including CMS Conditions of Participation. Aligns practice with organization's mission and vision. Advances the application of research and evidence-based practices through the expert use of MCG national guidelines when assigning levels of care to admitted patients. Communicates effectively and professionally regarding modality. Provides education regarding utilization management to patients, families, and other members of the care team as needed. Maintains current knowledge of health care economics, trends, and reimbursement methodologies, and applies this knowledge to daily practice. Remains current via continuing education, MCG Interrater Reliability, and ACMA Compass modules. Respects and incorporates patients' goals of care and treatment preferences while respecting available resources. Builds and maintains relationships that foster trust and confidence. Engages with physician leaders to provide education and promote optimal patient care. Routinely collaborates with members of the interdisciplinary team, physician advisors, and facility leadership. Advocates on behalf of patients/families/caregivers for service access or creation and for protection of the patient's health, well-being, safety, and rights. Promotes and engages in culturally competent care. Partners with providers and payers to ensure the patient can access their full benefits. Balances resources with patient preferences. Advocates for the organization regarding compliance with the administration of required notices when medical necessity does not exist and ensures the patient/family is in complete understanding. Manages cost of care with the benefits of patient safety, clinical quality, risk, and patient satisfaction to provide recommendations and decisions that ensure optimal outcomes. Informs the interdisciplinary team of the economic impact of treatment options. Facilitates care delivery for the setting and duration that is appropriate to the clinical need. Applies knowledge of contractual arrangements and payment models to daily practice. Embraces and incorporates innovation and technology to improve collaboration and patient outcomes. Ensures compliance with organizational policy and regulatory requirements to securely transmit patient information and protect their health information. Utilizes established processes for secondary review when warranted. Qualifications Education Program Graduate, Professional Nursing (Required) Bachelors Degree, Nursing (Preferred) Experience 3-4 years Clinical nursing experience (Required) Skills and Abilities Excellent verbal and written communication skills Excellent interpersonal skills Excellent organizational skills and attention to detail Ability to act with integrity, professionalism, and confidentiality Proficiency with computer systems required to perform job Licenses and Certifications Registered Nurse (RN) - Virginia Department of Health Professions (VDHP) (Required) Certified Case Manager (CCM) - Commission for Case Manager Certification (Preferred) or Accredited Case Manager (ACM) - American Case Management Association (ACMA) (Preferred) Other Requirements Weekend Shifts Irregular Shifts To learn more about being a team member with Riverside Health System visit us at https://www.riversideonline.com/careers .
Job Details Description Position Summary : The Utilization Review Case Manager validates the patient’s placement to be at the most appropriate level of care based on nationally accepted admission criteria. The UR Case Manager uses medical necessity screening tools, such as InterQual or MCG criteria, to complete initial and continued stay reviews in determining appropriate level of patient care, appropriateness of tests/procedures and an estimation of the patient’s expected length of stay. The UR Case Manager secures authorization for the patient’s clinical services through timely collaboration and communication with payers as required. The UR Case Manager follows the UR process as defined in the Utilization Review Plan in accordance with the CMS Conditions of Participation for Utilization Review Experience Required: 3 to 5 years acute care nursing experience Preferred: Experience in case management Education Required: Graduate of accredited diploma, associate degree or baccalaureate degree nursing program Preferred: BSN preferred License and Credentials Required: NJ RN licensure Preferred: Certification in case management Skills Required: Current sound clinical knowledge; knowledge of medical literature, research methodology, financial/ reimbursement issues. Strong collaboration, communication and interpersonal skills. Excellent organizational and time management skills. Knowledge of computers, Electronic Health Records, data base systems and utilization review/case management documentation systems. Desire to work collaboratively and proactively with healthcare teams and other hospital-based interdisciplinary teams. Current knowledge of discharge planning, resource management, and care coordination in an acute care setting. Knowledge of CMS, commercial payer requirements and hospital financial/reimbursement processes. Excellent written/verbal communication skills, critical thinking skills, creative problem solving skills, good organizational and planning skills. Must be self-directed, have the ability to tolerate frequent interruption and work in a fast-paced work environment. Knowledge of funding, resources, services, clinical standards, care coordination processes and outcomes is preferred. Weekend, Holiday and on call may be required. Bi-Weekly Hours: Per-Diem, Day Shift, Weekends The rate for this position is $53.00 When determining a team members base rate, several factors may be considered as applicable (e.g., years of recent relevant experience, education, credentials, and internal equity). At Deborah, healthcare is still about caring...for patients and team members. That is why we offer an outstanding benefits package, which includes healthcare coverage for team members in regularly budgeted positions of at least 30 hours per week. The benefits package also includes generous paid time-off, 401K matching contribution, tuition assistance, short and long term disability benefits, life insurance, meal discount, dependent care subsidy, adoption assistance and free parking. Qualifications Skills Behaviors : Motivations : Education Preferred Bachelor Science Nursing or better in Nursing. Experience Licenses & Certifications Required Registered Prof. Nurse Equal Opportunity Employer This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.
Job Description Utilization review nurse is responsible for the day to day coordination of admission criteria as it relates to healthcare needs of the patient and organization. Including knowledge of regulatory and compliance with Medicare, Medicaid and other insurance payors. This team member will communicate with a variety of clinical discipline, commercial payers, patient access, patient financial services, physician advisor and other staff members. Responsibilities Provides, initial, concurrent and retrospective reviews if assigned patients for severity of illness and intensity of service Demonstrates the ability to interpret InterQual and Milliman and Roberts criteria to ensure the patients meet admission and continued stay criteria Provides accurate and complete account authorization and details in plan notes Performs admission review on the following business day of patient's admission Involves the Physician Advisor as needed when physician-to-physician interaction is required to achieve appropriate clinical utilization for the patient Collaboratively works with the Physician Advisor to facilitate all aspects of the utilization management plan Serve as a liaison to patient accounting, patients access as it relates to authorizations and claims Demonstrates ability to communicate effectively with internal and external customers Demonstrates commitment toward customer satisfaction and patient advocacy Maintains confidentiality of patient/physician/and other team members as well as maintaining compliance with all federal/state guidelines and regulations Achieves budget length of stay (LOS) goal May perform other duties as assigned or requested and job specification can be modified or updated at any time Qualifications Required Education: Graduate of an accredited Nursing Program Preferred Education: Bachelors of Science Degree in Nursing (BSN) Required Experience: Three (3) years of experience in acute care nursing. Computers skills a must as well as excellent communication and the ability to work collaboratively with other disciplines Required Certifications and Licensures: Hold a current, active license as a registered nurse in Virginia or hold a current multistate/compact license. Hold a current, active American Heart Association Basic Life Support (AHA BLS) course completion card. Preferred Certifications and Licensures: ACMA Certification
RN Quality Review Manager- Registered Nurse Brooklyn, NY This a full time , in-person position based out of Brooklyn, NY . RN new grads are welcome . Pay: $90, 000- $105, 000/ annually About Us : With over 50 years of dedicated service to our communities, Personal Touch has been a trusted provider of home care. Our priority lies in ensuring exemplary patient care while fostering a supportive and empowering workplace culture for all team members. We are currently seeking compassionate and skilled nurses to join our team and continue our legacy of providing personalized and attentive care to patients in the comfort of their own home. Why Choose Us: At Personal-Touch Home Care, we are committed to creating a rewarding and fulfilling experience for our team members. Our established history and reputation provide a stable and trusted foundation for your career. Join us in positively impacting the lives of our patients and their families. As a member of our team, you will enjoy a wide range of benefits that enhance your overall well-being and support your career growth. They include: Employee Recognition Programs: We acknowledge and celebrate your contributions. Comprehensive Health Benefits: We offer an inclusive package with Medical, Dental, Vision, Accident, and Long-Term Disability Coverage to ensure access to quality medical care while promoting overall wellness. Generous Paid Time Off: We provide generous paid time off to ensure you can recharge and return to work refreshed, leading to greater productivity and job satisfaction. We support a healthy work-life balance. Retirement Benefits: We offer a 401k plan to secure your financial future and help you save for retirement. Life Insurance: We offer company paid life insurance providing peace of mind and financial protection for you and your loved ones. Mileage Reimbursement: We make sure you're compensated for your business travel. Opportunities for Professional Growth and Development: Empowering you to thrive and grow. Employee Assistance Program: Supporting the well-being of you and your family. Perks Program: Exclusive deals and offers on products, services, and experiences you need and love Job Details Overview: As a RN Clinical Manager/ Quality Review Manager , you will play a pivotal role in coordinating and managing patient care to ensure the highest standards are met. This position involves supervising clinical personnel and ensuring the delivery of quality home care services. Responsibilities: Receive case referrals and assess patient needs to assign appropriate clinicians. Review and evaluate each case, providing guidance to clinicians for effective performance. Instruct and guide clinicians to promote quality care delivery, being available to assist as needed. Review patient clinical information, including diagnosis, medications, and procedures. Assist in establishing therapeutic goals and developing care plans. Attend case conference meetings to facilitate care coordination. Conduct concurrent chart and record reviews and communicate findings to appropriate personnel. Assist in screening, interviewing, and orienting new personnel. Assist in planning and implementing in-service and continuing education programs. Contribute to the formulation, revision, and implementation of policies and procedures. Perform direct patient care duties as needed. Maintain compliance with professional standards and principles. Performs all other duties as assigned. Qualifications: Registered Nurse (RN) with current licensure to practice professional nursing in the State. Graduate of an accredited nursing school; BSN degree preferred. Two (2) years of prior home health care experience. At least one (1) year of management or supervisory experience in a health care setting, preferably home care. Demonstrates excellent observation, verbal and written communication skills. Verbal and written communication skills in English. Job type: Full-time Pay: $90, 000- $105, 000/ annually We are excited to welcome passionate and dedicated individuals to join our team at Personal Touch Home Care . We’re more than just a company, we’re a close-knit family dedicated to supporting each other’s success and well-being. Apply now and join us in making a positive impact on the communities we serve.
Overview Job Summary Manages the care for a specific population; facilitates the safe transition of patients throughout the continuum of care for appropriate utilization of resources, service delivery and compliance with federal and other payer requirements. Provides early assessment of transitional needs identified during their hospitalization, illness, and/or life situation. Performs other duties as assigned. Responsibilities Utilization Review Discharge planning Readmission Reduction Participation Payer Communication and denial reduction Completes assigned goals. Specifications Experience Minimum Required RN with at least one (1) year of clinical experience Preferred/Desired RN with 3 years of clinical experience with Case Management experience in a hospital or payer setting Education Minimum Required Diploma or Associate Degree in Nursing Preferred/Desired BSN or MSN Training Minimum Required Preferred/Desired Certified Case Manager Special Skills . Minimum Required Critical thinking skills, communication, organization, interpersonal and computer skills. Problem solving; and governmental regulations. Preferred/Desired Critical thinking skills, communication, organization, interpersonal and computer skills. Knowledge of payer requirements; problem solving; and governmental regulations. Licensure RN Minimum Required RN Preferred/Desired RN;CCM;ACM
Overview Job Summary Manages the care for a specific population; facilitates the safe transition of patients throughout the continuum of care for appropriate utilization of resources, service delivery and compliance with federal and other payer requirements. Provides early assessment of transitional needs identified during their hospitalization, illness, and/or life situation. Performs other duties as assigned. Responsibilities Utilization Review Discharge planning Readmission Reduction Participation Payer Communication and denial reduction Completes assigned goals. Specifications Experience Minimum Required RN with at least one (1) year of clinical experience Preferred/Desired RN with 3 years of clinical experience with Case Management experience in a hospital or payer setting Education Minimum Required Diploma or Associate Degree in Nursing Preferred/Desired BSN or MSN Training Minimum Required Preferred/Desired Certified Case Manager Special Skills . Minimum Required Critical thinking skills, communication, organization, interpersonal and computer skills. Problem solving; and governmental regulations. Preferred/Desired Critical thinking skills, communication, organization, interpersonal and computer skills. Knowledge of payer requirements; problem solving; and governmental regulations. Licensure RN Minimum Required RN Preferred/Desired RN;CCM;ACM
