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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Utilizing InterQual and other appropriate criteria, responsible for reviewing all admissions and continued stay of patients in conformance with the established criteria set forth in the hospital's utilization management and quality assurance plan. Will determine the medical necessity for admission and continued stays for patients within department's scope of service and to meet the hospital's objectives for assuring a high quality of patient care as well as assuring the effective and efficient utilization of available health services. Identifies appropriate level of care for inpatients and outpatients requiring overnight care. Education Other Graduate Of An Accredited School Of Nursing Required Bachelor's Degree BSN Required Experience 1 year experience of recent Utilization Review in acute care or in insurance company setting. Required 1 Year Experience In Medical-surgical Setting. Required 1 year experience in working with competency utilizing InterQual criteria. Required General Experience In Working With Utilization Review Standards Required Licenses PA Registered Nurse License Required Certified Case Manager Preferred Multi State Compact RN License Required Or
Utilizing InterQual and other appropriate criteria, responsible for reviewing all admissions and continued stay of patients in conformance with the established criteria set forth in the hospital's utilization management and quality assurance plan. Will determine the medical necessity for admission and continued stays for patients within department's scope of service and to meet the hospital's objectives for assuring a high quality of patient care as well as assuring the effective and efficient utilization of available health services. Identifies appropriate level of care for inpatients and outpatients requiring overnight care. Education Other Graduate Of An Accredited School Of Nursing Required Bachelor's Degree BSN Required Experience 1 year experience of recent Utilization Review in acute care or in insurance company setting. Required 1 Year Experience In Medical-surgical Setting. Required 1 year experience in working with competency utilizing InterQual criteria. Required General Experience In Working With Utilization Review Standards Required Licenses PA Registered Nurse License Required Certified Case Manager Preferred Multi State Compact RN License Required Or
ABOUT OLYMPIC MEDICAL CENTER: Imagine working on Washington State’s beautiful North Olympic Peninsula where recreational opportunities abound. Whether you enjoy hiking, camping, fishing, kayaking or cycling, the Olympic Peninsula is home to numerous adventures for outdoor enthusiasts. It's a great place to live, work, play and raise a family. Bordered by the scenic Olympic National Park, the Strait of Juan de Fuca and the Pacific Coast - with Seattle and Victoria, BC just a ferry ride away - you won’t find a better location. You’ll receive a competitive salary, excellent benefits, relocation assistance plus an amazing PNW lifestyle – a perfect combination! FTE: 100% WORK SHIFT Days PAY RANGE: $39.76 - $68.19 UNION: SEIU 1199-RN and LPN SHIFT DIFFERENTIALS/PREMIUMS: Weekend & Holiday Shifts: Yes On-Call Shifts: No Shift Differentials: Evening $3.00/hour Night $5.00/hour Premiums: Weekend Premium $4.50/hour Standby Premium $4.00/hour Charge Premium $3.25/hour Float/PM Premium $2.50/hour Per Diem Premium 15% (on rate of pay, in lieu of benefits) Certification Premium $2.00/hour JOB DESCRIPTION: Under general direction using established level of care criteria/guidelines, the Utilization Management RN I monitors the appropriateness of hospital admissions and stays. Monitoring includes review of admission status, medical necessity (severity of illness and intensity of service), and continued stay to comply with government and insurance company reimbursement policies. The Utilization Management RN I consults with physician/supervisor as necessary to resolve deviations from established criteria, and obtains documentation needed for continued hospitalization. This position assists with claims resolution issues and appeals, develops and maintains community relations, and collaborates with interdisciplinary team to achieve maximum internal and external customer satisfaction, as well as resource stewardship. EDUCATION Graduate from an accredited school of nursing, required. BSN preferred. EXPERIENCE At least three years of professional nursing experience required. Preference is for nursing experience to have occurred in a clinical/acute setting. Experience in Utilization Management/In-Patient Case Management preferred. LICENSURE/CREDENTIALS Current Washington State RN license required. Basic Life Support (BLS) certification required within 30 days of hire. BENEFITS INFORMATION: Click here for information about our benefits . Equal Employment Opportunity (EEO) Statement: Olympic Medical Center is an Equal Opportunity Employer that values workplace diversity. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, or protected veteran status and will not be discriminated against on the basis of disability. For more information, please visit www.eeoc.gov .
Job Summary: Clinical Care Reviewer II is responsible for processing medical necessity reviews for appropriateness of authorization for health care services, assisting with discharge planning activities (i.e. DME, home health services) and care coordination for members, as well as monitoring the delivery of healthcare services. Essential Functions: Complete prospective, concurrent and retrospective review such as acute inpatient admissions, post-acute admissions, elective inpatient admissions, outpatient procedures, homecare services and durable medical equipment Identify, document, communicate, and coordinate care, engaging collaborative care partners to facilitate transitions to an appropriate level of care Engage with medical director when additional clinical expertise if needed Maintain knowledge of state and federal regulations governing CareSource, State Contracts and Provider Agreements, benefits, and accreditation standards Identify and refer quality issues to Quality Improvement Identify and refer appropriate members for Care Management Provide guidance to non-clinical staff Provide guidance and support to LPN clinical staff as appropriate Attend medical advisement and State Hearing meetings, as requested Assist Team Leader with special projects or research, as requested Perform any other job related duties as requested. Education and Experience: Associates of Science (A.S) Completion of an accredited registered nursing (RN) degree program required Three (3) years clinical experience required Med/surgical, emergency acute clinical care or home health experience preferred Utilization Management/Utilization Review experience preferred Medicaid/Medicare/Commercial experience preferred Competencies, Knowledge and Skills: Proficient data entry skills and ability to navigate clinical platforms successfully Working knowledge of Microsoft Outlook, Word, and Excel Effective oral and written communication skills Ability to work independently and within a team environment Attention to detail Proper grammar usage and phone etiquette Time management and prioritization skills Customer service oriented Decision making/problem solving skills Strong organizational skills Change resiliency Licensure and Certification: Current, unrestricted Registered Nurse (RN) Licensure in state(s) of practice required MCG Certification or must be obtained within six (6) months of hire required Working Conditions: General office environment; may be required to sit or stand for extended periods of time Travel is not typically required Compensation Range: $62,700.00 - $100,400.00 CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package. Compensation Type (hourly/salary): Hourly Organization Level Competencies Fostering a Collaborative Workplace Culture Cultivate Partnerships Develop Self and Others Drive Execution Influence Others Pursue Personal Excellence Understand the Business This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.
Please note- Candidates must have COS-C, HCS-O or COQS and HCS-D or BCHH-C in order to be considered, there is no flexibility around this requirement. BAYADA Home Health Care has an immediate opening for a Full Time, OASIS and Coding Review Manager with OASIS and Coding certification to work remotely. RN, PT, OT, and SLP's with certifications will be considered for this role. BAYADA believes that our clients and their families deserve home health care delivered with compassion, excellence, and reliability. Apply your skills and knowledge of OASIS and ICD-10 coding to help clients receive the home health care services they need. BAYADA Perks: This is a fully remote position. Base Salary: $77,000 - $81,000 / year BAYADA offers a comprehensive benefits plan that includes the following: Paid holidays, vacation and sick leave, vision, dental and medical health plans, employer paid life insurance, 401k with company match, direct deposit, and employee assistance program Responsibilities: Review clinical information for appropriateness, congruency, and accuracy as it relates to the OASIS and ICD 10 coding while using the Medicare PDGM billing model and CMS guidelines. Review and communicate OASIS edit recommendations to each clinician to promote OASIS accuracy. Perform final review and lock OASIS. Timely review and coding of OASIS documents with productivity maintained at the quarterly target set by the Director of MCM. Prevent or decrease the occasion of Medicare denials by assuring proper coding on the plan of care and accurate OASIS documentation. Provide support and communication to all disciplines within the service. Provide customer service/education and act as a resource to Medicare Certified Offices with regards to CMS guidelines, Home Care Coding, PDGM guidelines and billing related issues. Provide ongoing communication with service offices via e-mail, zoom, or telephone (specific to the service office needs). Communication with service offices monthly and as appropriate with a focus on documentation trends, star ratings and potential revenue impact. Perform related duties, or as required or requested by Manager/Director. Qualifications: Competency in PC skills required to perform job function Active State RN Nursing License, Physical (PT), Occupational (OT) or Speech (SLP) Therapists with required certifications with a minimum of 2 years clinical experience. Please note, while this is a clinical opening, BAYADA does have non-clinical openings available COS-C or HCS-O or COQS OASIS Certification and experience required BCHH-C or HCS-D Home Health Care Coding Certification and experience required HCHB, SHP, and Coding Center experience, a plus! Be part of a caring, professional team that is instrumental in providing the highest quality care while developing your career with an industry leader. Apply now for immediate consideration. OASIS Review, Utilization Review, Quality Assurance, Remote, Home Health Coding, Coder, Medicare As an accredited, regulated, certified, and licensed home health care provider, BAYADA complies with all state/local mandates. BAYADA is celebrating 50 years of compassion, excellence, and reliability. Learn more about our 50th anniversary celebration and how you can join in here. BAYADA Home Health Care, Inc., and its associated entities and joint venture partners, are Equal Opportunity Employers. All employment decisions are made on a non-discriminatory basis without regard to sex, race, color, age, disability, pregnancy or maternity, sexual orientation, gender identity, citizenship status, military status, or any other similarly protected status in accordance with federal, state and local laws. Hence, we strongly encourage applications from people with these identities or who are members of other marginalized communities.
Coordinates Essential Functions Consults with physician services Utilizes clinical diagnostics, physician documentation and non-physician clinical guidelines to facilitate status determination of inpatient, outpatient or outpatient observation. Coordinates final status with admitting and attending physicians Performs initial and concurrent clinical reviews as indicated by payer and patient clinical needs Inpatient and/or outpatient notification and precertification of services to payers Facilitates peer to peer, written reconsiderations or appeals throughout all denial cycle as appropriate Facilitates appropriate observation utilization Consults with patient financial services Educations: Provides education and literature to physician services regarding IPPS and OPPS Educates physicians and other care team member on level of care criteria and other third party payer requirements Reporting/Recordkeeping: Updates patient’s medical records as required Shares medical necessity documentation with payers to facilitate reimbursement Regulation : Adheres to NMHS/NMMC Policies/Procedures/Guidelines Complies with applicable Local/State/Federal policies/procedures/guideline/regulations/laws/statues Requirements: Associates Degree in Nursing, required; Bachelor’s Degree preferred Licensed as a Registered Nurse by the Mississippi Board of Nursing; required Minimum of 5 years clinical and/or healthcare experience; required Excellent organizational and communication (written and verbal) skills; required Knowledge of various payer sources, federal/state laws/regulations, and cost containment; required Certified as an Accredited Case Manager (ACM); desirable Excellent interpersonal skills; required Demonstrates ability to care for a patient population from pediatric to geriatric; required
Job Summary: Works collaboratively with an MD to coordinate and screen for the appropriateness of admissions and Continued stays. Makes recommendations to the physicians for alternate levels of care when the patient does not meet the medical necessity for Inpatient hospitalization. Interacts with the family, patient and other disciplines to coordinate a safe and acceptable discharge plan. Functions as an indirect caregiver, patient advocate and manages patients in the most cost effective way without compromising quality. Transfers stable non-members to planned Health care facilities. Responsible for complying with AB 1203, Post Stabilization notification. Complies with other duties as described. Must be able to work collaboratively with the Multidisciplinary team, multitask and in a fast pace environment. Essential Responsibilities: Plans, develops, assesses and evaluates care provided to members. Collaborates with physicians, other members of the multidisciplinary health care team and patient/family in the development, implementation and documentation of appropriate, individualized plans of care to ensure continuity, quality and appropriate resource use. Recommends alternative levels of care and ensures compliance with federal, state and local requirements. Assesses high risk patients in need of post-hospital care planning. Develops and coordinates the implementation of a discharge plan to meet patients identified needs; communicates the plan to physicians, patient, family/caregivers, staff and appropriate community agencies. Reviews, monitors, evaluates and coordinates the patients hospital stay to assure that all appropriate and essential services are delivered timely and efficiently. Participates in the Bed Huddles and carries out recommendations congruent with the patients needs. Coordinates the interdisciplinary approach to providing continuity of care, including Utilization management, Transfer coordination, Discharge planning, and obtaining all authorizations/approvals as needed for outside services for patients/families. Conducts daily clinical reviews for utilization/quality management activities based on guidelines/standards for patients in a variety of settings, including outpatient, emergency room, inpatient and non-KFH facilities. Acts as a liaison between in-patient facility and referral facilities/agencies and provides case management to patients referred. Refers patients to community resources to meet post hospital needs. Coordinates transfer of patients to appropriate facilities; maintains and provides required documentation. Adheres to internal and external regulatory and accreditation requirements and compliance guidelines including but not limited to: TJC, DHS, HCFA, CMS, DMHC, NCQA and DOL. Educates members of the healthcare team concerning their roles and responsibilities in the discharge planning process and appropriate use of resources. Provides patients with education to assist with their discharge and help them cope with psychological problems related to acute and chronic illness. Per established protocols, reports any incidence of unusual occurrences related to quality, risk and/or patient safety which are identified during case review or other activities. Reviews, analyses and identifies utilization patterns and trends, problems or inappropriate utilization of resources and participates in the collection and analysis of data for special studies, projects, planning, or for routine utilization monitoring activities. Coordinates, participates and or facilitates care planning rounds and patient family conferences as needed. Participates in committees, teams or other work projects/duties as assigned.
JOB DESCRIPTION Job SummaryProvides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines. • Analyzes clinical service requests from members or providers against evidence based clinical guidelines. • Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. • Conducts reviews to determine prior authorization/financial responsibility for Molina and its members. • Processes requests within required timelines. • Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner. • Requests additional information from members or providers as needed. • Makes appropriate referrals to other clinical programs. • Collaborates with multidisciplinary teams to promote the Molina care model. • Adheres to utilization management (UM) policies and procedures. Required Qualifications • At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience. • Registered Nurse (RN). License must be active and unrestricted in state of practice. • Ability to prioritize and manage multiple deadlines. • Excellent organizational, problem-solving and critical-thinking skills. • Strong written and verbal communication skills. • Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications • Certified Professional in Healthcare Management (CPHM). • Recent hospital experience in an intensive care unit (ICU) or emergency room. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $25.08 - $51.49 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
Job Title: Utilization Review Educator - Registered Nurse Department: Physician Advisor Program -Utilization Review Location: Rochester General Hospital Hours Per Week: 40 Full Time Schedule: Days - M-F SUMMARY: Comprehensively plans with the health care team to ensure patient needs are met and care delivery is coordinated across the continuum. Identifies and works to eliminate/minimize system variation and service delivery barriers that prevent achievement of optimal patient outcomes in the expected time frame and with most efficient utilization of resources. Carries out activities related to utilization review. Performs as an integral part of the interdisciplinary team promoting interdisciplinary collaboration and champions service excellence. Facilitates assignment of level of care, considers payer requirements and responds accordingly to avoid adverse financial consequence to patient and hospital. Provide superior customer service by modeling the Brand Promise and Core Values. RESPONSIBILITIES : Conducts clinical reviews utilizing nationally recognized standards of care guidelines to evaluate hospital admissions and assigns patient to the appropriate level of care; identifies clinical resources required to achieve optimal patient outcomes and appropriate reimbursement for the hospital. Documents level of care and medical necessity concurrently in the patient’s chart to support the clinical review process. Concurrently monitors resources utilization, performing continued stay reviews and assists with managing the length of stay of patients across the continuum. Appropriately identifies and refers cases to the Physician Advisor to validate level of care based on medical necessity to support timely progress of patients along the continuum. Concurrently communicates clinical information to payors; severity of illness, intensity of service and plan of care. Functions as a resource to members of the health care team for payor requirements, ensuring optimal use of patient health care benefits. Maintains current and accurate knowledge regarding commercial and government payors and facilitates communication between hospital and payors as appropriate. Proactively participates in process improvement initiatives with the use of data, trends and reports, working with a variety of departments and multi-disciplinary staff. Works with Utilization Leadership to identify potential problems, recommend solutions and work toward resolution. Collaborates with nursing, physicians, admissions, verification team, care management, compliance, coding, and billing staff to answer clinical questions related to medical necessity and patient status Assists in identifying and providing orientation, training, and competency development for Utilization Review RNs on an ongoing basis REQUIRED QUALIFICATIONS: Required Degree: Diploma or Associate’s Degree in Nursing Required Certification/Licensure: Licensed in New York State as a Registered Nurse PREFERRED QUALIFICATIONS: Minimum five (5) to eight (8) years clinical experience; utilization management/review experience Bachelor’s Degree in Nursing from an accredited school Ability to easily navigate Epic EMR EDUCATION: LICENSES / CERTIFICATIONS: PHYSICAL REQUIREMENTS: M - Medium Work - Exerting 20 to 50 pounds of force occasionally, and/or 10 to 25 pounds of force frequently, and/or greater than negligible up to 10 pounds of force constantly to move objects; Requires frequent walking, standing or squatting. For disease specific care programs refer to the program specific requirements of the department for further specifications on experience and educational expectations, including continuing education requirements. Any physical requirements reported by a prospective employee and/or employee’s physician or delegate will be considered for accommodations. PAY RANGE: $86,528.00 - $118,976.00 CITY: Rochester POSTAL CODE: 14621-3038 The listed base pay range is a good faith representation of current potential base pay for a successful full time applicant. It may be modified in the future and eligible for additional pay components. Pay is determined by factors including experience, relevant qualifications, specialty, internal equity, location, and contracts. Rochester Regional Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, sex (including pregnancy, childbirth, and related medical conditions), sexual orientation, gender identity or expression, national origin, age, disability, predisposing genetic characteristics, marital or familial status, military or veteran status, citizenship or immigration status, or any other characteristic protected by federal, state, or local law.
Utilizing InterQual and other appropriate criteria, responsible for reviewing all admissions and continued stay of patients in conformance with the established criteria set forth in the hospital's utilization management and quality assurance plan. Will determine the medical necessity for admission and continued stays for patients within department's scope of service and to meet the hospital's objectives for assuring a high quality of patient care as well as assuring the effective and efficient utilization of available health services. Identifies appropriate level of care for inpatients and outpatients requiring overnight care. Education Other Graduate Of An Accredited School Of Nursing Required Bachelor's Degree BSN Required Experience 1 year experience of recent Utilization Review in acute care or in insurance company setting. Required 1 Year Experience In Medical-surgical Setting. Required 1 year experience in working with competency utilizing InterQual criteria. Required General Experience In Working With Utilization Review Standards Required Licenses PA Registered Nurse License Required Certified Case Manager Preferred Multi State Compact RN License Required Or Schedule: Monday–Friday, 8:00 AM–4:30 PM
GRADE 20 LOCATION OF POSITION MDH - Division of Children's Services 201 W. Preston Street Baltimore, MD 21201 Main Purpose of Job The main purpose of this Medical Services Reviewing Nurse II position is to perform quality improvement activities within the Rare and Expensive Case Management (REM) program. This position works directly with the REM case management contractor to assure that the REM enrollees are receiving appropriate case management and medical services per the REM contract requirements. The review nurse communicates with the REM case management contractors, and/or the REM case managers regarding potential obstacles to care (reportable events). Minimum Qualifications Education: A Bachelor’s degree in Nursing or a related field from an accredited college or university. Experience: One year of experience reviewing medical services claims to ensure that the nature and quality of services are in accordance with State and federal regulations. Notes Candidates may substitute two years of experience as a Registered Nurse for the required education. Candidates may substitute U.S. Armed Forces military service experience as a commissioned officer in Nursing classifications or Nursing specialty codes in the Nursing field of work on a year-for-year basis for the required education. Desired Or Preferred Qualifications The desired candidate should possess the following: Previous experience in case management services and quality assurance review and reporting. Experience with Maryland Medicaid Information System Subsystems (MMIS) and/or LTSS. Experience with applicable state and federal laws, regulations and requirements. Experience with Microsoft Office and Google applications. Experience with Institutional Billing and Medicaid Waiver programs. LICENSES, REGISTRATIONS AND CERTIFICATIONS Candidates for positions in this classification must possess a current license as a Registered Nurse from the Maryland State Board of Nursing, 4140 Patterson Avenue, Baltimore, Maryland 21215 or possess a current multi-state license in party states that candidates have declared as primary states of residence. Employees in this classification may be assigned duties which require the operation of a motor vehicle. Employees assigned such duties will be required to possess a motor vehicle operator’s license valid in the State of Maryland. SELECTION PROCESS Applicants who meet the minimum (and selective) qualifications will be included in further evaluation. The evaluation may be a rating of your application based on your education, training and experience as they relate to the requirements of the position. Therefore, it is essential that you provide complete and accurate information on your application. Please report all related education, experience, dates and hours of work. Clearly indicate your college degree and major on your application, if applicable. For education obtained outside the U.S., any job offer will be contingent on the candidate providing an evaluation for equivalency by a foreign credential evaluation service prior to starting employment (and may be requested prior to interview). Complete applications must be submitted by the closing date. Information submitted after this date will not be added. Incorrect application forms will not be accepted. Resumes will not be accepted in lieu of a completed application. Candidates may remain on the certified eligible list for a period of at least one year. The resulting certified eligible list for this recruitment may be used for similar positions in this or other State agencies. Benefits STATE OF MARYLAND BENEFITS FURTHER INSTRUCTIONS Online applications are highly recommended. However, if you are unable to apply online, the paper application (and supplemental questionnaire) may be submitted to MDH, Recruitment and Selection Division, 201 W. Preston St., Room 114-B, Baltimore, MD 21201. Paper application materials must be received by 5 pm, close of business, on the closing date for the recruitment, no postmarks will be accepted. If additional information is required, the preferred method is to upload. If you are unable to upload, please fax the requested information to 410-333-5689. Only additional materials that are required will be accepted for this recruitment. All additional information must be received by the closing date and time. For questions regarding this recruitment, please contact the MDH Recruitment and Selection Division at 410-767-1251. If you are having difficulty with your user account or have general questions about the online application system, please contact the MD Department of Budget and Management, Recruitment and Examination Division at 410-767-4850 or Application.Help@maryland.gov . Appropriate accommodations for individuals with disabilities are available upon request by calling: 410-767-1251 or MD TTY Relay Service 1-800-735-2258. We thank our Veterans for their service to our country. People with disabilities and bilingual candidates are encouraged to apply. As an equal opportunity employer, Maryland is committed to recruitment, retaining and promoting employees who are reflective of the State's diversity. MDHMedCare
JOB DESCRIPTION Job SummaryProvides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines. • Analyzes clinical service requests from members or providers against evidence based clinical guidelines. • Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. • Conducts reviews to determine prior authorization/financial responsibility for Molina and its members. • Processes requests within required timelines. • Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner. • Requests additional information from members or providers as needed. • Makes appropriate referrals to other clinical programs. • Collaborates with multidisciplinary teams to promote the Molina care model. • Adheres to utilization management (UM) policies and procedures. Required Qualifications • At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience. • Registered Nurse (RN). License must be active and unrestricted in state of practice. • Ability to prioritize and manage multiple deadlines. • Excellent organizational, problem-solving and critical-thinking skills. • Strong written and verbal communication skills. • Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications • Certified Professional in Healthcare Management (CPHM). • Recent hospital experience in an intensive care unit (ICU) or emergency room. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $23.76 - $51.49 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
$20,000 BONUS, PLUS RELOCATION ASSISTANCE!! Facility Cape Fear Valley Medical Center Location Fayetteville, North Carolina Department Coordination of Care Job Family Nursing Work Shift Days (United States of America) Summary Responsible for performing the initial and concurrent Utilization Review determination on all patients admitted or placed in observation (Outpatient with Observation Services). Direct discussion with the physicians and advanced practice providers to determine medical necessity for admission and establish appropriate status and level of care requirements. Facilitates clinical guidelines and achievement of desired treatment outcomes in the most appropriate setting and the most cost-effective manner. Analyzes patient records to determine appropriateness of admission, treatment, and length of stay in a health care facility to comply with regulatory and payor reimbursement policies. Maintain compliance with regulatory changes affecting utilization management and performs utilization review in accordance with all state and federally mandated regulations. Works collaboratively with the Utilization Management Manager and payors to ensure that denials and appeals are tracked and responded to in a timely and appropriate manner. Major Job Functions The following is a summary of the major essential functions of this job. The incumbent may perform other duties, both major and minor, that are not mentioned below. In addition, specific functions may change from time to time: Performs initial admission reviews on all patients within one day of bedding, using the appropriate InterQual guidelines or in accordance with CMS rules and regulations for admission and medical necessity Reviews physician orders for level of care status against patient status in the hospital registration system to ensure accuracy Ensures the chart coincides with the review or CMS rules and regulations for appropriate level of care and status on all patients Adheres to Medicare Condition Code 44 process Issues Medicare Outpatient Observation Notice (MOON) promptly to ensure timely notification to patients Coordinates with registration/bed placement departments and physician’s office to assure pre-certification authorizations and supporting documents are obtained when required Reviews patient medical records for third party payors and provides clinical information to support admission and continued stay review Send billing communication to the designated PFS and HIM team members to ensure accurate billing designation Assesses and evaluates the medical necessity and appropriateness of ancillary testing, medications, treatment, and plan of care, discussing concerns with the involved case manager Representative and point of contact for the Medicare Appeal process Adheres to mandates, standards and policies and procedures as determined at the federal, state, health system and department level Promotes positive customer service and service orientation in the performance of position duties and responsibilities and interactions with patients, hospital staff and visitors Participate in quality improvement activities in the direction of the Leadership Team to improve processes and promote evidence-based practice Other duties as assigned Minimum Qualifications The following qualifications, or equivalents, are the minimum requirements necessary to perform the essential functions of this job: Education and Formal Training : Associate’s degree in nursing required Bachelor’s degree in nursing preferred Registered Nurse with active North Carolina License or Compact State Licensure preferred Professional certification in Case Management or Utilization Management preferred Work Experience : 3 years’ experience in Acute Care Setting preferred Medical/Surgical and/or ICU experience preferred Case Management experience preferred Additional one year in managed care claims/reimbursement or other healthcare field preferred Knowledge, Skills, and Abilities Required : Critical thinking and clinical competence demonstrated at an above average level Excellent interpersonal communication and negotiation skills Self-motivated, proven written, telephonic, and electronic communication skills, assertive and persuasive in interactions with customers, peers, management, and core staff served Ability to discuss a patient’s clinical, socio-economic, and financial issues with physicians and patient and/or patient representatives Strong organizational and time management skills Proficiency with various computer programs, including Microsoft Office, Allscripts, InterQual, Valley Link, eHIM, Teletracking, Form Fast and SMS Ability to transition to EPIC system, for Utilization Management processes. Ability to be flexible, open-minded, and adaptable to change Ability to analyze related information, plan effective actions and follow through reliably Ability to work collaboratively with department staff, physicians, and healthcare professionals at all levels to achieve established goals Physical Requirements : Some light carrying and lifting may be required Occasional walking may be required to access all areas of the Medical Center Near visual acuity to proofread hand and typewritten materials Manual ability to use telephones and computer keyboards Position involves sitting for extended periods of time performing data entry into the computer Must be able to lift 35 pounds Required Licenses and Certifications RN - Board Of Nursing Cape Fear Valley Health System is an Equal Opportunity Employer M/F/Disability/Veteran/Sexual Orientation/Gender Identity
Please note- Candidates must have COS-C, HCS-O or COQS and HCS-D or BCHH-C in order to be considered, there is no flexibility around this requirement. BAYADA Home Health Care has an immediate opening for a Full Time, OASIS and Coding Review Manager with OASIS and Coding certification to work remotely. RN, PT, OT, and SLP's with certifications will be considered for this role. BAYADA believes that our clients and their families deserve home health care delivered with compassion, excellence, and reliability. Apply your skills and knowledge of OASIS and ICD-10 coding to help clients receive the home health care services they need. BAYADA Perks: This is a fully remote position. Base Salary: $77,000 - $81,000 / year BAYADA offers a comprehensive benefits plan that includes the following: Paid holidays, vacation and sick leave, vision, dental and medical health plans, employer paid life insurance, 401k with company match, direct deposit, and employee assistance program Responsibilities: Review clinical information for appropriateness, congruency, and accuracy as it relates to the OASIS and ICD 10 coding while using the Medicare PDGM billing model and CMS guidelines. Review and communicate OASIS edit recommendations to each clinician to promote OASIS accuracy. Perform final review and lock OASIS. Timely review and coding of OASIS documents with productivity maintained at the quarterly target set by the Director of MCM. Prevent or decrease the occasion of Medicare denials by assuring proper coding on the plan of care and accurate OASIS documentation. Provide support and communication to all disciplines within the service. Provide customer service/education and act as a resource to Medicare Certified Offices with regards to CMS guidelines, Home Care Coding, PDGM guidelines and billing related issues. Provide ongoing communication with service offices via e-mail, zoom, or telephone (specific to the service office needs). Communication with service offices monthly and as appropriate with a focus on documentation trends, star ratings and potential revenue impact. Perform related duties, or as required or requested by Manager/Director. Qualifications: Competency in PC skills required to perform job function Active State RN Nursing License, Physical (PT), Occupational (OT) or Speech (SLP) Therapists with required certifications with a minimum of 2 years clinical experience. Please note, while this is a clinical opening, BAYADA does have non-clinical openings available COS-C or HCS-O or COQS OASIS Certification and experience required BCHH-C or HCS-D Home Health Care Coding Certification and experience required HCHB, SHP, and Coding Center experience, a plus! Be part of a caring, professional team that is instrumental in providing the highest quality care while developing your career with an industry leader. Apply now for immediate consideration. OASIS Review, Utilization Review, Quality Assurance, Remote, Home Health Coding, Coder, Medicare As an accredited, regulated, certified, and licensed home health care provider, BAYADA complies with all state/local mandates. BAYADA is celebrating 50 years of compassion, excellence, and reliability. Learn more about our 50th anniversary celebration and how you can join in here. BAYADA Home Health Care, Inc., and its associated entities and joint venture partners, are Equal Opportunity Employers. All employment decisions are made on a non-discriminatory basis without regard to sex, race, color, age, disability, pregnancy or maternity, sexual orientation, gender identity, citizenship status, military status, or any other similarly protected status in accordance with federal, state and local laws. Hence, we strongly encourage applications from people with these identities or who are members of other marginalized communities.
Facility Name: Jackson Health System - Central UR Facility Address: 1611 NW 12 Ave., Miami, FL 33136 Shift details: Full Time, Days, 8:00 am - 4:30 pm Mon.-Fri. (Will work one weekend month) -Remote, but will need to visit JHS facilities as needed Why Jackson: Jackson Health System is a nationally and internationally recognized academic medical system offering world-class care to any person who walks through our doors. For more than 100 years, Jackson has evolved into one of the world's top medical providers for all levels of care, no matter if it's for a routine patient visit or for a lifesaving procedure. With more than 2,000 licensed beds, we are also proud of our role as the primary teaching hospital for the University of Miami Miller School of Medicine. Here, the best people come together to deliver Jackson's mission for our diverse communities. Our employees are committed to providing the best CARE by demonstrating compassion, accountability, respect, and expertise in everything we do. Summary The Clinical Resource Coordinator is a professional member of the health care team who has 24hour/7day accountability for the coordination, monitoring and management of patient care resources to promote cost effective delivery of patient care services at the appropriate level while maintaining a standard of quality patient care for all patient populations. The Clinical Resource Coordinator acts as a resource to all levels of staff in defining / implementing and evaluating patient care and nursing practice standards utilizing clinical expertise, the nursing process, current concepts/principles of case management/utilization management/disease management, quality improvement, clinical practice and health care trends. This professional member of the healthcare team maintains compliance with current regulatory standards and new regulatory regulations, clinical and financial, and promotes such compliance as part of daily operations amongst all team members. The Clinical Resource Coordinator performs specific job criteria/performance standards according to prevailing applicable Jackson Health System, professional and regulatory standards. Responsibilities Leads the assessment, planning, implementation, and evaluation for new department models and initiatives. Identifies practice issues, systems issues, and trends utilizing medical criteria, clinical data systems, and protocols. Performs problem-resolution activities to maintain quality patient care. Presents at administrative meetings. Manages Case Management and Social Work metrics and productivity, including but not limited to length of stay (LOS), case mix index (CMI), discharge barriers, resource utilization, discharge planning, and level of care. Provides management oversight of patient throughput, including assessment and evaluation to determine appropriate level of care and admission status (inpatient, observation, outpatient procedure) from point of entry through discharge. Follows up in the outpatient setting for patients enrolled in the CRM Placement EDP program. In the absence of the Manager for Clinical Resource Management, visits facilities to evaluate and determine patient appropriateness for the current level of care as needed. Works in collaboration with the Manager for Clinical Resource Management to transition CRM Placement EDP program patients to the appropriate level of care as needed. Provides management oversight of the Clinical Care Coordinator's performance regarding level of care along the continuum (e.g., medication effectiveness, treatments, pain status, discharge plans) and individualizing the plan of care, including reinforcement of teaching and discharge planning. Maintains leadership visibility, supports service-excellence initiatives, and focuses on improving employee satisfaction. Rounds on patient units to identify barriers to staff performance and discharge barriers. Creates and implements Corrective Action Plans (CAP) for problem resolution and escalation of issues preventing efficient performance. Coordinates day-to-day CRM operations for designated areas, including program development, implementation, outcomes, staffing, liaison with PROS/MCOS/regulatory/community agencies, revenue cycle department, length-of-stay initiatives, Physician Adviser activities, and evidence-based practices. Provides management oversight for referral and problem resolution of complicated discharges. May provide management oversight for referral and problem resolution of complex discharges. Collaborates with family, Attending Physician, Chief Utilization Officer, Utilization Management Committee, and discharge-services providers to ensure a safe discharge plan. Conducts concurrent review of employee schedules to ensure appropriate staffing coverage based on patient census. Collaborates with the Chief Utilization Officer regarding the Utilization Management Committee, case-consultation activities, negotiation of patient placement at the appropriate level of care, and evaluation of the patient's medical plan of care. Demonstrates behaviors of service excellence and CARE values (Compassion, Accountability, Respect, and Expertise). Performs all other related job duties as assigned. Experience Generally requires 3 to 5 years of related experience. Preferred Experience Current experience as utilization review registered nurse. Education BSN or Bachelor's degree in related field is required. Master's degree is preferred. Credentials Must meet and maintain valid and current all unit specific and organizational skills/competencies, certifications/licensures, as required by regulatory and/or nursing standard of practice for the specialty. Jackson Health System is an equal opportunity employer and makes employment decisions without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, disability status, age, or any other status protected by law.
The Utilization Review RN performs admission and continued stay utilization reviews and discharge screening to assure the medical necessity of hospital admission, appropriate level of care, continued stay and supportive services, and to examine delays in the provision of services. Collaborates with attending physicians, advanced practice providers, and/or Department Medical Directors concerning status and/or medical necessity issues. Follows departmental policy to escalate cases to second level review when criteria is in question. The UR RN consistently interacts with physicians, nurses, revenue cycle services, other patient caregivers, and coding professionals to ensure that medical record documentation accurately reflects the level of services rendered to patient and the clinical information utilized in profiling and reporting outcomes is completed. Monitors and evaluates care to ensure care is medically necessary, provided in the appropriate setting, and generated according to governmental and regulatory agency standards. Essential Job Function Conducts initial case reviews within 24 hours of admission and continues reviews as long as the patient is hospitalized, following all relevant regulations. Reviews are documented in EPIC, and clinical information is securely transmitted to carriers, with outcomes communicated to relevant medical and hospital staff. Refers appropriate cases to the Physician Advisor promptly and communicates effectively with peers to ensure patient needs are met. Acts as a liaison between physician and payor regarding non-coverage of benefits or denials. Oversees resource utilization, identifies and addresses issues promptly with the healthcare team, and educates them on payer requirements, denials, and regulatory compliance. Monitors patient status authorizations, documents code 44 processes, and documents avoidable days before discharge. Documents UR processes and supports the healthcare team by providing comprehensive documentation in the EMR/Epic. Maintains clinical/authorization documentation to minimize denials and coordinates with the denials team on appeals. Monitors readmissions, reporting trends and possibilities to the transition of care nurse. Performs other duties as assigned. Education Required: Bachelor’s Degree in Nursing or healthcare-related field Experience Required: 3 years as a Registered Nurse Licensure/Certification/Listing Required:Registered Nurse license in North Carolina or a Compact state
As a community, the University of Rochester is defined by a deep commitment to Meliora - Ever Better. Embedded in that ideal are the values we share: equity, leadership, integrity, openness, respect, and accountability. Together, we will set the highest standards for how we treat each other to ensure our community is welcoming to all and is a place where all can thrive. Job Location (Full Address): 601 Elmwood Ave, Rochester, New York, United States of America, 14642 Opening: Worker Subtype: Regular Time Type: Full time Scheduled Weekly Hours: 40 Department: 500009 Utilization Management Work Shift: UR - Day (United States of America) Range: UR URCD 215 Compensation Range: $80,923.00 - $105,208.00 The referenced pay range represents the minimum and maximum compensation for this job. Individual annual salaries/hourly rates will be set within the job's compensation range, and will be determined by considering factors including, but not limited to, market data, education, experience, qualifications, expertise of the individual, and internal equity considerations. Responsibilities: Works collaboratively with various departments across the entire health care system to review clinical documentation, utilizing evidence based criteria to support medical necessity and appropriate level of patient care for services provided. Reviews outcome trends and patterns to identify educational opportunities and performance improvement processes across the health care continuum. Responsible for auditing the quality of clinical documentation and providing education based on findings. ESSENTIAL FUNCTIONS Determines level of care per regulatory requirements. Provides level of care notifications to patients and families as needed. Works collaboratively with payers to ensure authorization for dates of service. Collaborates with HIM, providers, Financial Counseling and Patient Financial Services. Monitors all UM hold bills and unplanned readmission reports. Conducts initial and concurrent reviews, utilizing evidence based criteria through Interqual. Supports discharge appeal process. Responsible for departmental denials and appeal activity. Documents according to regulatory guidelines and UM RN workflow protocols. Conducts clinical documentation improvement efforts through query process. Meets productivity expectations established by UM department. Provides and supports ongoing educational needs for all UM customers. Other duties as assigned. MINIMUM EDUCATION & EXPERIENCE Associate's degree in Nursing and 3 years of acute hospital experience required Bachelor's degree preferred Or equivalent combination of education and experience Utilization Management experience preferred KNOWLEDGE, SKILLS AND ABILITIES Database experience including: Interqual, Sharepoint, eRecord, ePARC, Cobius preferred LICENSES AND CERTIFICATIONS RN - Registered Nurse - State Licensure and/or Compact State Licensure NYS Registered Nurse license upon hire required The University of Rochester is committed to fostering, cultivating, and preserving an inclusive and welcoming culture to advance the University’s Mission to Learn, Discover, Heal, Create – and Make the World Ever Better. In support of our values and those of our society, the University is committed to not discriminating on the basis of age, color, disability, ethnicity, gender identity or expression, genetic information, marital status, military/veteran status, national origin, race, religion, creed, sex, sexual orientation, citizenship status, or any other characteristic protected by federal, state, or local law (Protected Characteristics). This commitment extends to non-discrimination in the administration of our policies, admissions, employment, access, and recruitment of candidates, for all persons consistent with our values and based on applicable law.
** Highly Prefer Utilization Management, Case Management, Medical Necessity Review, Preauthorization Work Experience ** Must Live in Washington State or Idaho Job Summary: Reviews coverage requests using established timelines and all relevant clinical information for appropriate coding, medical necessity, care coordination, place of service, and care rendered. Summarizes findings and facilitates appropriate authorization or payment. Prepares information for review by the physician reviewer according to established procedures. Determine if new services are experimental or investigational and whether the service requires a new medical technology assessment by Kaiser Foundation Health Plan of Washington. Identifies potential fraud, waste and abuse and evaluates claims to validate. Essential Responsibilities: Conducts clinical review of coverage request based on the application of medical necessity criteria, understanding of individual coverage contracts and ability to meet Kaiser Foundation Health Plan of Washington, coding rules and other regulatory standards. Uses clinical information available in medical records and treatment summaries as a foundation to complete these reviews. Documents the above review process and decisions for determination of coverage and submits questions or potential denials to the physician review staff. Conducts these reviews while meeting regulatory standards for review timeliness. Conducts audits of claims that are suspended because of potential coding issues or high cost against established coding and billing principles. Provides consultation to requesting providers related to medical review, review criteria and coordination of care. Assures consistency and equity in access to medical benefits. Collects data to ensure appropriate reporting occurs related regulatory guidelines and decision consistency. Participates in the development and maintenance of performance and work force planning data. Supports the development and implementation of new criteria or changes in existing criteria through identification (research on the web) and reporting occurrences. Researches and supports the medical determination for experimental and investigational service requests. Works closely with the referral staff regarding medical necessity; provider relations staff regarding contract terms; and coverage and benefits staff regarding clarity and interpretation of contract language. Contacts the requesting physician by phone when required to provide notification of determination outcomes. Coordinates patient care working with treating providers and Kaiser Foundation Health Plan of Washington Case Managers. Understands and complies with medical protocols, referral processes and claims submission processes.
PST applicants preferred. Job Summary Provides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines. • Analyzes clinical service requests from members or providers against evidence based clinical guidelines. • Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. • Conducts reviews to determine prior authorization/financial responsibility for Molina and its members. • Processes requests within required timelines. • Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner. • Requests additional information from members or providers as needed. • Makes appropriate referrals to other clinical programs. • Collaborates with multidisciplinary teams to promote the Molina care model. • Adheres to utilization management (UM) policies and procedures. Required Qualifications • At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience. • Registered Nurse (RN). License must be active and unrestricted in state of practice. • Ability to prioritize and manage multiple deadlines. • Excellent organizational, problem-solving and critical-thinking skills. • Strong written and verbal communication skills. • Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications • Certified Professional in Healthcare Management (CPHM). • Recent hospital experience in an intensive care unit (ICU) or emergency room. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $26.41 - $59.21 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Information Schedule: Monday-Friday 11:30am-8:00pm EST Location: 100% Remote (U.S. only) About Us American Health Holding, Inc. (AHH), a division of Aetna/CVS Health, is a URAC-accredited medical management organization founded in 1993. We provide flexible, cost-effective care management solutions that promote high-quality healthcare for members. Position Summary Join a team that’s making a difference in the lives of patients facing complex medical journeys. As a Utilization Management (UM) Nurse Consultant specializing in Oncology and Transplant, you’ll play a vital role in ensuring members receive timely, medically necessary care through thoughtful clinical review and collaboration with providers. This fully remote position offers the opportunity to apply your clinical expertise in a fast-paced, desk-based environment where precision, communication, and compassion intersect. Key Responsibilities Conduct medical necessity reviews for oncology and transplant-related services, both inpatient and outpatient. Collaborate with healthcare providers to gather and assess clinical documentation via phone and electronic systems. Apply evidence-based clinical criteria and guidelines to authorize services or refer cases to Medical Directors when needed. Navigate multiple computer systems efficiently while maintaining accurate and timely documentation. Work primarily in a sedentary setting involving extended periods of sitting, talking, listening, and computer use. Participate in occasional on-call rotations, including some weekends and holidays, per URAC and client requirements. Remote Work Expectations This is a 100% remote role; candidates must have a dedicated workspace free of interruptions. Dependents must have separate care arrangements during work hours, as continuous care responsibilities during shift times are not permitted. Required Qualifications Active, unrestricted RN license in your state of residence with multistate/compact licensure privileges. Ability to obtain licensure in non-compact states as needed. Minimum of 1 year of experience in Oncology and Transplant either in UM, concurrent review, or prior authorization 3+ years of experience in Acute clinical Oncology or Oncology/Transplant. Strong decision-making skills and clinical judgment in independent scenarios. Proficient with phone systems, clinical documentation tools, and navigating multiple digital platforms. Commitment to attend a mandatory 3-week training (Monday–Friday, 8:30am–5:00pm EST) with 100% participation. Preferred Qualifications 1+ years of Managed Care (MCO) preferred. 1+ years of experience working in a high-volume clinical call center environment. NCCN (National Comprehensive Cancer Network) guideline experience/exposure. Remote work experience. Education Associate's degree in nursing (RN) required, BSN preferred. Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $29.10 - $62.32 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan . No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 03/11/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
Job Requisition ID: 53540 Opening Date: 02/20/2026 Closing Date: 03/05/2026 Agency: Department of Human Services Class Title: REGISTERED NURSE II - 38132 Skill Option: None Bilingual Option: None Salary: Anticipated Salary: $7,172 - $9,896 per month ($86,064 - $118,752 per year) Job Type: Salaried Category: Full Time County: Randolph Number of Vacancies: 1 Bargaining Unit Code: RC023 Registered Nurses, INA Merit Comp Code: This position is a union position; therefore, provisions of the relevant collective bargaining agreement/labor contract apply to the filling of this position. While not required, a Resume/Curriculum Vitae (CV) is recommended. When applicable, titles that require specific coursework, professional license or certification will include a notation requesting the appropriate document(s) be uploaded in the Additional Documents section of your application. Failure to upload requested transcripts, license and/or proof of certification when specified may result in ineligibility. Please note that the Department of Human Services must verify proof of higher education for any degree earned (if applicable) regardless of vacancy title before any offer can be extended. All applicants who want to be considered for this position MUST apply electronically through the illinois.jobs2web.com website. State of Illinois employees should click the link near the top left to apply through the SuccessFactors employee career portal. Applications submitted via email or any paper manner (mail, fax, hand delivery) will not be considered. Why Work for Illinois? Working with the State of Illinois is a testament to the values of compassion, equity, and dedication that define our state. Whether you’re helping to improve schools, protect our natural resources, or support families in need, you’re part of something bigger—something that touches the lives of every person who calls Illinois home. No matter what state career you’re looking for, we offer jobs that fit your life and your schedule—flexible jobs that provide the gold standard of benefits. Our employees can take advantage of various avenues to advance their careers and realize their dreams. Our top-tier benefits and great retirement packages can help you build a rewarding career and lasting future with the State of Illinois. Position Overview The Division of Behavioral Health and Recovery is seeking to hire a Registered Nurse II for the Chester Mental Health Center located in Chester, Illinois to serve as Utilization Review Coordinator for the facility-wide Utilization Review Program. Verifies patients receive the appropriate medical care per the Utilization Review Plan. Confirms all on-site and off-site medical appointments/referrals ordered are reviewed for appropriateness and medical necessity. Identifies problems in services provided according to criteria in the Utilization Review Plan by conducting current and retrospective chart reviews. Chairs the Utilization Review Committee and provides required reports. Coordinates satisfaction surveys from all off-grounds medical appointments. Essential Functions Serves as Utilization Review Coordinator for the facility-wide Utilization Review Program. Oversees the arrangement and scheduling all off-site medical appointments for patients with contractual providers. Utilizing the nursing process, provides professional nursing care to mentally ill patients on a living unit on an assigned shift. Oversees the scheduling of all dental and podiatric appointments for patients on-site. Chairs the Utilization Review Committee and provides required reports. Assists patients in identifying situations related to medical procedures that cause maladaptive behavior. Performs other duties as required or assigned which are reasonably within the scope of the duties enumerated above. Minimum Qualifications Requires (a) graduation from an approved nursing education program resulting in an associate or diploma degree in nursing and two years of progressively responsible professional nursing experience OR (b) a bachelor’s degree in nursing and one year of professional experience OR (c) a master’s degree in nursing. Requires licensure as a Registered Nurse in the State of Illinois. Conditions of Employment Requires the ability to work after business hours, weekends and holidays on a rotation basis. Requires the ability to walk and stand for a significant period of time, including stooping, bending, lifting or exerting up to 20 pounds of force occasionally. Requires the ability to serve on an on-call basis. Requires the ability to lift up to 50 pounds unassisted. Requires the ability to acquire and maintain Cardiopulmonary Resuscitation (CPR) certificate. Requires the ability to travel in the performance of job duties. Requires the ability to physically restrain patients as necessary to prevent injury to patients or others. Requires ability to pass the IDHS background check. Requires ability to pass a drug screen for drugs prohibited from recreational use under Illinois Law. *All conditions of employment listed are incorporated and related to any of the job duties as listed in the job description. Work Hours: 7:00am-3:00pm; Sunday-Thursday; 30-minute unpaid lunch Facility Wide Headquarter Location: 1315 Lehmen Dr, Chester, Illinois, 62233-2542 Division of Behavioral Health and Recovery Chester Mental Health Center Medical Diagnostics Work County: Randolph Agency Contact: DHS.HiringUnit@illinois.gov Posting Group: Health Services; Social Services About the Agency: The Illinois Department of Human Services uplifts individuals and communities across Illinois. Our mission is to respond to the needs of all people in Illinois so they can lead healthy, safe, and enriched lives. Our vision is the future we are shaping with dignity and the well-being for everyone in Illinois. Our values are the principles that guide us as we work to remove systemic barriers and create lasting opportunities with Compassion, Accessibility, Responsibility, and Equity. As a State of Illinois Employee, you will receive a robust benefit package that includes the following: A Pension Program Competitive Group Insurance Benefits including Health, Life, Dental and Vision Insurance 3 Paid Personal Business Days annually 12 Paid Sick Days annually (Sick days carry over from year to year) 10-25 Days of Paid Vacation time annually - (10 days in year one of employment) Personal, Sick, & Vacation rates modified for 12-hour & part-time work schedules (as applicable) 13 Paid Holidays annually, 14 on even numbered years Flexible Work Schedules (when available dependent upon position) 12 Weeks Paid Parental Leave Deferred Compensation Program - A supplemental retirement plan Optional Pre-Tax Programs such as Medical Care Assistance Plan (MCAP), Dependent Care Assistance Plan (DCAP) Federal Public Service Loan Forgiveness Program eligibility GI Bill® Training/Apprenticeship Benefits eligibility for qualifying Veterans 5% Salary Differential for Bilingual Positions Commuter Savings Program (Chicago only) For more information about our benefits please follow this link: https://cms.illinois.gov/benefits/stateemployee.html APPLICATION INSTRUCTIONS Use the “Apply” button at the top right or bottom right of this posting to begin the application process. If you are not already signed in, you will be prompted to do so. State employees should sign in to the career portal for State of Illinois employees – a link is available at the top left of the Illinois.jobs2web.com homepage in the blue ribbon. Non-State employees should log in on the using the “View Profile” link in the top right of the Illinois.jobs2web.com homepage in the blue ribbon. If you have never before signed in, you will be prompted to create an account. If you have questions about how to apply, please see the following resources: State employees: Log in to the career portal for State employees and review the Internal Candidate Application Job Aid Non-State employees: on Illinois.jobs2web.com – click “Application Procedures” in the footer of every page of the website. State employees should include temporary assignment in the application profile. Temporary assignment verification forms can be uploaded to the Additional Documents section. The main form of communication will be through email. Please check your “junk mail”, “spam”, or “other” folder for communication(s) regarding any submitted application(s). You may receive emails from the following addresses: donotreply@SIL-P1.ns2cloud.com systems@SIL-P1.ns2cloud.com
Job Overview The Utilization Review RN participates as a member of a multidisciplinary team to support medical necessity reviews, ensure compliance, and actively participate in denial mitigation. It is a collaborative approach that uses pre-established guidelines and criteria to perform review activities to ensure the proper utilization of hospital services and payment of those services by Medicare, Medicaid, and other third-party payors. Department Name: Case Management - Utilization Review Job Status: full time, 40 hours per week, eligible for benefits Shift: Dayshift Monday through Friday 0800-1630 This position will be primarily remote but there may be occasions when you are expected to work onsite at one of the Children’s Hospital Colorado locations. The specific details will be discussed in the interview process, and subject to change at our discretion. Applicants must already reside in Colorado or be willing to relocate prior to starting. This position is eligible for relocation assistance, if relocating from 100 miles or greater. Duties & Responsibilities An employee in this position may be called upon to do any or all the following essential functions. These examples do not include all the functions which the employee may be expected to perform. Assesses all new inpatient admissions for identification of status and medical necessity for admission; communicates clinical review process with appropriate Payors. Assesses the continuity of care in conjunction with the Case Managers regarding the continued medical necessity of hospitalization and the status of the discharge plan; communicates this to the appropriate payors. Coordinates with other members of the healthcare team to help identify and control inappropriate resource utilization. Conducts concurrent admission and continued stay reviews based on appropriate utilization review criteria. Utilizes information provided by Patient Access regarding authorized length of stay and follows up with third-party payors on an ongoing basis, documents communications regarding continued authorizations. Follows up on denials communicated to the department and works with the revenue cycle staff to assist with appeals. Maintains and demonstrates appropriate clinical knowledge to assist physicians in providing documentation of severity of illness and intensity of service to assure that criteria for acute hospitalization are met. Employees are expected to comply with all regulatory requirements, including CMS and Joint Commission Standards. Minimum Qualifications Education: Bachelor of Science in Nursing (BSN) Experience: Three years of recent clinical or case management experience that includes recent UR experience in a hospital or with a Third-Party Payor Certification(s): BLS/CPR from the American Heart Association with at least 6 months left before expiration is required upon hire. Licensure(s): Registered Nurse License Salary Information Pay is dependent on applicant's relevant experience. Annual Salary Range (Based on 40 hours worked per week): $84,558.69 to $126,838.03 Benefits Information Here, you matter. As a Children’s Hospital Colorado team member, you will receive a competitive pay and benefits package designed to take care of your needs that includes base pay, incentives, paid time off, medical/dental/vision insurance, company provided life and disability insurance, paid parental leave, 403b employer match (retirement savings), a robust wellness program, and access to professional development tools, including an education benefit to help you advance your career. As part of our Total Rewards package, Children's Colorado offers an annual employee bonus program that rewards eligible team members based on organizational performance. If organizational goals are met for the year, the bonus is paid out the following April. Children’s Colorado delivers annual base pay increases to eligible team members based on their performance over the previous year. EEO Statement It is our intention that all qualified applicants be given equal opportunity and that selection decisions be based on job-related factors. We do not discriminate on the basis of race, color, religion, national origin, sex, age, disability, or any other status protected by law or regulation. Be aware that none of the questions are intended to imply illegal preferences or discrimination based on non-job-related information. The position is expected to stay open until the posted close date. Please submit your application as soon as possible as the posting is subject to close at any time once a sufficient pool of qualified applicants is obtained. Colorado Residents: In any materials you submit, you may redact or remove age-identifying information such as age, date of birth, or dates of attendance at or graduation from an educational institution. You will not be penalized for redacting or removing this information.
Responsibilities Lincoln Prairie Behavioral Health is looking for a Utilization Management Coordinator! Registered Nurse or LCPC required. If you have a desire to work in an engaging environment with a team of professionals dedicated to the healing and health of the patients we serve, we want to hear from you! Lincoln Prairie Behavioral Health Center is a 97-bed facility located in Springfield, Illinois. We are dedicated to providing youth with compassionate mental health treatment that encourages self-responsibility and personal growth. We are the only facility of our kind in Central Illinois! We provide psychiatric treatment to children and adolescents that present with a broad range of psychiatric and behavioral disorders. A clinically skilled multidisciplinary team works to partner with the youth and family to accomplish their goals in a supportive and therapeutic environment. POSITION SUMMARY The Utilization Management Coordinator performs all functions related to use of hospital resources and reimbursement. Utilization Review functions as a liaison between payers, the business office, and the treatment team, providing information and feedback to assist in optimum patient care and reimbursement. Qualifications QUALIFICATIONS Education: ADN or master's degree in psychology or social work or related field. Experience: Minimum of 2 years of direct clinical experience in an acute inpatient psychiatric or mental health care setting or a minimum of 2 years utilization management experience within a payer organization. RN Preferred. Additional Requirements : Completion of CPR Total Rewards for our UM Coordinator include: Career development opportunities across UHS and our 300+ locations! Competitive Compensation & Generous Paid Time Off Excellent Medical, Dental, Vision and Prescription Drug Plans 401(K) with company match and discounted stock plan Pet Insurance SoFi Student Loan Refinancing Program More information is available on our Benefits Guest Website: uhsguest.com About Universal Health Services One of the nation’s largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (UHS) has built an impressive record of achievement and performance. Growing steadily since its inception into an esteemed Fortune 500 corporation, annual revenues were $15.8 billion in 2024. UHS was again recognized as one of the World’s Most Admired Companies by Fortune; listed in Forbes ranking of America’s Largest Public Companies. Headquartered in King of Prussia, PA, UHS has approximately 99,000 employees and continues to grow through its subsidiaries. Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory care access points, an insurance offering, a physician network and various related services located all over the U.S. States, Washington, D.C., Puerto Rico and the United Kingdom. www.uhs.com EEO Statement All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws. Avoid and Report Recruitment Scams We are aware of a scam whereby imposters are posing as Recruiters from UHS, and our subsidiary hospitals and facilities. Beware of anyone requesting financial or personal information. At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skill set and experience with the best possible career path at UHS and our subsidiaries. During the recruitment process, no recruiter or employee will request financial or personal information (e.g., Social Security Number, credit card or bank information, etc.) from you via email. Our recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc. If you suspect a fraudulent job posting or job-related email mentioning UHS or its subsidiaries, we encourage you to report such concerns to appropriate law enforcement. We encourage you to refer to legitimate UHS and UHS subsidiary career websites to verify job opportunities and not rely on unsolicited calls from recruiters.
Utilization Management Dept. Full Time Day Shift 8-4:30 Lexington Health is a comprehensive network of care that includes six community medical and urgent care centers, nearly 80 physician practices, more than 9,000 health care professionals and Lexington Medical Center, a 607-bed teaching hospital in West Columbia, South Carolina. It was selected by Modern Healthcare as one of the Best Places to Work in Healthcare and was first in the state to achieve Magnet with Distinction status for excellence in nursing care. Consistently ranked as best in the Columbia Metro area by U.S. News & World Report, Lexington Health delivers more than 4,000 babies each year, performs more than 34,000 surgeries annually and is the region's third largest employer. Lexington Health also includes an accredited Cancer Center of Excellence, the state’s first HeartCARE Center, the largest skilled nursing facility in the Carolinas, and an Alzheimer’s care center. Its postgraduate medical education programs include family medicine and transitional year residencies, as well as an informatics fellowship. Job Summary Performs admission and concurrent stay medical record review to determine appropriateness of admission, continued stay, and setting. Follows patient throughout hospitalization collaborating with attending physician and other health care providers. Communicates with third party payors to obtain authorization. Contributes to appropriate throughput and length of stay. Assists with denial management. Reviews physician medical record documentation and consults with physicians regarding completeness. Minimum Qualifications Minimum Education: ADN, Diploma Nursing Degree, or Bachelor of Science in Nursing Minimum Years of Experience: 3 Years of experience in an acute care hospital setting Substitutable Education & Experience: None. Required Certifications/Licensure: Registered Nurse currently licensed in the State of South Carolina Required Training: None. Essential Functions Works in a cooperative manner, which fosters favorable relations between employees and patients, patients' families, visitors, fellow employees, and the medical staff. Accepts chain of command, supervision, and constructive criticism. Exhibits commitment and pride through personal example by positively speaking about LMC, the department, employees and guests. Contributes to teamwork and creates harmonious, effective and positive working relationships with others. Respects, understands, and responds with sensitivity to employees and guests by treating others as one would wish to be treated. Resolves conflicts and problems-solves by remaining calm when confronted, attempting to identify solutions or referring person to appropriate authority and attempting to deliver more than is expected. Exhibits telephone courtesy by: Answering promptly with name and department. Speaking with pleasant tone while focusing on caller. Transferring calls correctly and promptly. Attending to calls on hold in a timely manner. Maintains confidentiality by: Discouraging gossip. Using discretion when discussing patient, work, or LMC-related information with others. Utilizes the service recovery process to resolve complaints (GIFT). Demonstrates competence in providing duties within role. Demonstrates competence to provide developmentally appropriate planning/review for patients of all age groups. Identifies need for professional growth and seeks appropriate professional development opportunities attaining a minimum of 15 hours of continuing education in topics related to the role annually. Serves as role model for other members of the health care team. Demonstrates receptiveness to change and flexibility in meeting department needs. Assists in orientation and training of staff. Performs admission and continued stay medical record review to gather information to support medical necessity of the admission and communicate with third party payors. Performs timely review of admissions utilizing InterQual criteria to assess for appropriate level of care assignment. Reviews both inpatient admissions and patients placed in Observation. Incorporates applicable governmental regulatory guidelines in effect for Medicare and/or Medicaid admissions. Submits clinical data to third party payors and documents authorization in electronic medical record system. Performs continued stay reviews based on intensity of service, clinical response to care, expected length of stay and readiness for discharge, or at intervals which correspond to authorized days. Refers Observation or Inpatient admissions that lack documented medical necessity for the stay to the Physician Advisor and completes any needed follow through to ensure correct level of care and billing based on the Physician Advisor’s determination. Documents pertinent clinical data on worksheets. Ensures regulatory compliance and revenue integrity utilizing appropriate billing policies. Certifies Medicare admission utilizing established admission screening criteria. Duties & Responsibilities Applies appropriate condition codes and modifiers in electronic medical record system to communicate accurate claims information for billing. Documents denial information in electronic medical record system including attempts at resolution/overturning of the denial. Provides all payor communication to be scanned into the system for use in appeals. Maintains good working relationships with other departments within the revenue cycle. Conveys and receives information efficiently to and from third party payors, physicians, patients/families, physician practices, other members of the health care team, and other external agencies. Respects patient confidentiality and uses discretion in all interactions regarding patient protected health information. Consults with attending physician when documentation in the medical record does not support admission or continued stay and seeks to ensure completeness of all clinical documentation. Functions as liaison between the Physician Advisor and the attending physician. Serves as a resource to physicians, patients, physician practices, and other members of the health care team regarding issues related to patient classification and reimbursement. Issues letters of non-coverage in cases where the admission or continued stay is not certified, as necessary. Ensures patient/family notification of Observation status and documents in electronic medical record. Communicates insurance authorization information to physician's office as requested. Communicates with case management triad regarding reimbursement issues. Uses appropriate channels for reporting progress or concerns. Participates in making appropriate and efficient discharge plans for patients on assigned areas. Consults with members of the health care team effectively and efficiently regarding patient discharge plans. Manages inpatient Medicare discharge expedited appeals process through the QIO. Notifies attending physician and other members of the health care team of inappropriate admissions, denials, end of authorized days, or other factors that have a reimbursement impact. Consults Physician Advisor in cases where patient demonstrates readiness for discharge, but there is no documented intent to discharge. Identifies and documents potentially avoidable days in electronic medical record system. Assist Social Work staff to coordinate/obtain authorization for post acute services as needed. Identifies opportunities for improvement and coordinates/participates in the development and implementation of action plans to make improvements. Participates in unit discharge planning activities and in interdisciplinary patient care conferences. Indentifies abnormal patterns of utilization and refers to Manager/Director. Recommends changes to system/processes to eliminate identified problems. Represents department on various committees/taskforces. Adapts to change in timely and positive manner. Strives to meet department and hospital goals. Performs all other duties as assigned by authorized personnel or as required in an emergency (e.g., fire or disaster). We are committed to offering quality, cost-effective benefits choices for our employees and their families: Day ONE medical, dental and life insurance benefits Health care and dependent care flexible spending accounts (FSAs) Employees are eligible for enrollment into the 403(b) match plan day one. LHI matches dollar for dollar up to 6%. Employer paid life insurance – equal to 1x salary Employee may elect supplemental life insurance with low cost premiums up to 3x salary Adoption assistance LHI provides its full-time employees employer paid short-term disability and long-term disability coverage after 90 days of eligible employment Tuition reimbursement Student loan forgiveness Equal Opportunity Employer It is the policy of Lexington Health to provide equal opportunity of employment for all individuals, and to remain compliant with applicable state and federal laws and regulations. Lexington Health strives to provide a discrimination-free environment, and to recruit, select, on-board, and employ all employees without regard to race, color, religion, sex, age, disability, national origin, veteran status, or pregnancy, childbirth, or related medical conditions, including but not limited to, lactation. Lexington Health endeavors to upgrade and promote employees from within the hospital where possible and consistent with the employee’s desires and abilities and the hospital’s needs.
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.
