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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null Pay Range: $27.73 - $54.06 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
Summary GENERAL SUMMARY: Conducts day-to-day activities for the clinical, financial and utilization coordination of the patient’s hospital experience. Proactively consults with the interdisciplinary team which includes, but is not limited to, hospital patient care staff, physicians, patient support and family to ensure the patient’s hospital stay meets medical necessity and insurance authorizations are obtained in order to facilitate the patient’s and hospitals financial well-being. PRINCIPAL JOB FUNCTIONS: 1. *Commits to the mission, vision, beliefs and consistently demonstrates our core values. 2. *Performs utilization review activities, including concurrent and retrospective reviews as required. 3. *Determines the medical necessity of request by performing first level reviews, using approved evidence based guidelines/criteria. 4. *Collaborates with the patient’s provider and other healthcare team members in managing the patient’s length of stay and determining the continuing medical necessity of continued stays. 5. *Refers cases to reviewing physician when the treatment request does not meet criteria per appropriate algorithm. 6. *Participates in concurrent and retrospective denials and appeals process by researching issues surrounding the denial, participating in all levels of the appeal and process follow-up. 7. *Serves as an internal and external resource regarding appropriate level of care; admission status/classification; Medicare/Medicaid rules, regulations, and policies; 3rd party and managed care contracts; discharge planning; and length of stay. 8. Ensures appropriate resource utilization relevant to the financial, regulatory and clinical aspects of care; proposes alternative treatment to ensure a cost effective and efficient plan of care. 9. *Maintains awareness of financial reimbursement methodology, utilization management, payer/reimbursement practices and regulations and participates in resource stewardship. 10. *Promotes quality improvement initiatives and health care outcomes based on currently accepted clinical practice guidelines and total quality improvement initiatives. 11. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise. 12. Participates in meetings, committees and department projects as assigned. 13. Performs other related projects and duties as assigned. (Essential Job functions are marked with an asterisk “*”. Refer to the Job Description Guide for the definition of essential and non-essential job functions.) Attach Addendum for positions with slightly different roles or work-specific differences as needed. REQUIRED KNOWLEDGE, SKILLS AND ABILITIES: 1. Maintains clinical competency as required for the unit including but not limited to age-specific competencies relative to patient’s growth and developmental needs, annual skill competency verification and mandatory education and competencies. 2. Knowledge of governmental and third party payer regulations and requirements related to patient hospitalization and acute rehabilitation admission, stay and discharge activities, i.e., CMS, CARF, FIM (TM). 3. Knowledge of computer hardware equipment and software applications relevant to work functions. 4. Skill in conflict diffusion and resolution. 5. Ability to communicate effectively both verbally and in writing. 6. Ability to perform crucial conversations with desired outcomes. 7. Ability to establish and maintain effective working relationships with all levels of personnel and medical staff. 8. Ability to problem solve and engage independent critical thinking skills. 9. Ability to maintain confidentiality relevant to sensitive information. 10. Ability to prioritize work demands and work with minimal supervision. 11. Ability to perform crucial conversations with desired outcomes. 12. Ability to maintain regular and punctual attendance. EDUCATION AND EXPERIENCE: Current Registered Nurse licensure from the State of Nebraska or approved compact state of residence as defined by the Nebraska Nurse Practice Act. Minimum of two (2) years recent clinical experience required. Prior care coordination and/or utilization management experience preferred. OTHER CREDENTIALS / CERTIFICATIONS: Basic Life Support (CPR) certification required. Bryan Health recognizes American Heart Association (for healthcare professionals), American Red Cross (for healthcare professionals) and the Military Training Network. PHYSICAL REQUIREMENTS: (Physical Requirements are based on federal criteria and assigned by Human Resources upon review of the Principal Job Functions.) (DOT) – Characterized as sedentary work requiring exertion up to 10 pounds of force occasionally and/or a negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects, including the human body.
Job Description Located in the metropolitan area of Sacramento, the Adventist Health corporate headquarters have been based in Roseville, California, for more than 40 years. In 2019, we unveiled our WELL-certified campus - a rejuvenating place for associates systemwide to collaborate, innovate and connect. Whether virtual or on campus, Adventist Health Roseville and shared service teams have access to enjoy a welcoming space designed to promote well-being and inspire your best work. Preferred candidate will be based in Roseville, CA, Glendale, CA or Portland, OR Job Summary Plays a critical role in ensuring that patients receive high-quality care while efficiently utilizing medical resources. Reviews patient medical records, assessing the appropriateness and necessity of proposed treatments, and collaborating with healthcare providers and insurance companies to ensure a seamless care experience and the practicing of financial stewardship and denial prevention. Focuses on maximizing patient outcomes and optimizing resource allocation. Utilizes exceptional clinical knowledge, excellent communication skills, and the ability to thrive in a fast-paced and ever-changing healthcare environment. Job Requirements Education and Work Experience: Associate’s Degree in nursing or equivalent combination of education/related experience: Required Bachelor's Degree in Nursing (BSN): Preferred Five years' acute hospital experience required with preferred experience in critical care areas: Required Two years' utilization review experience using the Optum/Inter Qual product within the last 12 months: Required Licenses/Certifications Registered Nurse (RN) licensure in the state of practice: Required Essential Functions Completes clinical reviews of acute medical patients using the Optum/Inter Qual tool to determine if the patient is in the right acute setting, receiving the right acute services, during the appropriate length of stay. Participates in annual Optum/Inter Qual training required. Takes the required annual Optum/Inter Qual Interrater Reliability (IRR) test with a minimum passing score as defined in the yearly departmental goals. Meets weekly productivity metrics within 90 days of completing orientation and maintains on a weekly basis as defined in the yearly departmental goals. Meets quality audit metrics within 90 days of completing orientation and maintained on the audit cadence set within the department as defined in the yearly departmental goals. Completes all required departmental education assigned with timeliness and accuracy. Follows all departmental workflows in communication variances to the on-site care management teams when appropriate. Reviews and analyzes medical records to assess the necessity and appropriateness of treatments and interventions. Collaborates with healthcare professionals to develop and implement comprehensive patient care plans. Facilitates communication between the patient, healthcare team, insurance providers, and other stakeholders to ensure a coordinated and efficient care process. Stays up to date with the latest healthcare regulations, insurance guidelines, and evidence-based practices to ensure the delivery of optimal healthcare services. Performs other job-related duties as assigned. Organizational Requirements Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations as a condition of employment and annually thereafter, where applicable. Medical and religious exemptions may apply. Adventist Health participates in E-Verify. Visit https://adventisthealth.org/careers/everify/ for more information about E-Verify. By choosing to apply, you acknowledge that you have accessed and read the E-Verify Participation and Right to Work notices and understand the contents therein. About Us Adventist Health is a faith-based, nonprofit, integrated health system serving more than 100 communities on the West Coast and Hawaii with over 440 sites of care, including 27 acute care facilities. Founded on Adventist heritage and values, Adventist Health provides care in hospitals, clinics, home care, and hospice agencies in both rural and urban communities. Our compassionate and talented team of more than 38,000 includes employees, physicians, Medical Staff, and volunteers driven in pursuit of one mission: living God's love by inspiring health, wholeness and hope.
Department: Utilization Management Shift: Days Daily Work Times: 8am - 4:30pm Scheduled Hours per Pay: 40 Position Summary: Responsible for determining the appropriate patient status based on the regulatory and reimbursement requirements of various commercial and government payers in collaboration with the admitting/attending physician. Partners with the health care team to ensure hospital admissions are based on medical necessity and documentation is sufficient to support the level of care being billed. Conducts concurrent reviews to ensure criteria for patient status and continued stay are met and documented. Along with other health care team members, monitors the use of hospital resources and identifies delays. Reports delays to leadership for resolution. Essential Functions and Responsibilities as Assigned: Performs a variety of concurrent and retrospective utilization management-related reviews and functions to ensure that appropriate data are tracked, evaluated, and reported. Collaborates with the health care team to determine the appropriate hospital setting (inpatient vs. outpatient) based on medical necessity. Actively seeks additional clinical documentation from the physician to optimize hospital reimbursement when appropriate. Works collaboratively with ICM service lines to expedite patient discharge. Screens physician documentation or order entry for timeliness, appropriateness and completeness as pertains to the utilization management process including level of care, medical necessity, and third-party payer requirement. Documents in the electronic medical record (EMR): clinical reviews (medical necessity), payer authorizations, avoidable days, readmission risks, continued stay reviews and potential discharge date. Utilizes other application tools to document including Veracity, Optum, InterQual, Milliman, etc. Facilitates peer to peer reviews with payer/providers. Actively participates in clinical case review/rounds with the interdisciplinary team regarding continued stays review/LOS outliers, Collaborate with providers/physician advisor when medical necessity and/or appropriateness of care is questioned, in accordance with established SOP procedures. Maintains current knowledge of hospital utilization review processes and participates in the resolution of retrospective reimbursement issues including appeals, PACER authorization, third party payer certification, and denied cases. Assists with monitoring the effectiveness/outcomes of the utilization management program, identifying and applying appropriate metrics, evaluating the data, reporting results to various audiences, and designing and implementing process improvement projects as needed. Assists with orientation, training, and competency development for appropriate staff and colleagues on an ongoing basis. Performs other related duties as required and directed. Qualifications: Required State licensure as a registered nurse (RN) Bachelor’s degree in nursing from accredited educational institution, or actively pursuing degree and to be obtained within five years of accepting position. Three years of recent nursing or utilization management experience with an acute care hospital Preferred: Experience in utilization management/case management, critical care, clinical documentation, or patient outcomes/quality management. Certification in Case Management Certification (ACM or CCM) Basic Life Support (BLS) certification as a Healthcare Provider by the American Heart Association, American Red Cross or equivalent through the Military Training Network (MTN) Additional Information Schedule: Part-time Requisition ID: 25006780 Daily Work Times: 8am - 4:30pm Hours Per Pay Period: 40 On Call: No Weekends: Yes
Description Pen Bay Hospital Nursing Req #: 56867 For a limited time MaineHealth is offering a $10,000 Sign on bonus for all eligible Registered Nurses with 0-2 years of RN experience and $20,000 for Registered Nurses with greater than 2 years of RN work experience! Eligible candidates are hired (offer accepted) into a Full or Part time RN position. Bonus amount prorated for Part time hires, per diem hires are ineligible. Current MaineHealth member employees are ineligible; former MaineHealth Members are ineligible until greater than 6 months separation from employment. Summary This is a day shift position, with rotating weekends. The Registered Nurse – UR Case Management role provides clinically based care coordination and utilization review management, supporting the delivery of safe patient/family centered care and has accountability for individual patients from admission through discharge. Required Minimum Knowledge, Skills, And Abilities (KSAs) Education: Graduate of an accredited School of Nursing required; Bachelor’s Degree in Nursing preferred. License/Certifications: Current applicable state(s) license as a Registered Professional Nurse required. Current BLS Certification required or must obtain within 30 days of start date. Experience: Three years of acute care clinical setting nursing experience preferred. Knowledge and experience in discharge planning, case management and utilization review preferred. Additional Skills/Requirements Required: N/A Additional Skills/Requirements Preferred: N/A Additional Information With a career at any of the MaineHealth locations across Maine and New Hampshire, you’ll be working with health care professionals that truly value the people around them – both within the walls of the organization and the communities that surround it. We offer benefits that support an individual's needs for today and flexibility to plan for tomorrow – programs such as paid parental leave, a flexible work policy, student loan assistance, training and education, along with well-being resources for you and your family. MaineHealth remains focused on investing in our care team and developing an inclusive environment where you can thrive and feel supported to realize your full potential. If you’re looking to build a career in a place where people help one another deliver best-in-class care, apply today. If you have questions about this role, please contact lisa.bickford@mainehealth.org
Overview Summary The Utilization Review Nurse is responsible for evaluating the medical necessity and appropriateness of healthcare services and treatment as prescribed by utilization review standards. The UR Nurse works with providers, insurance companies and patients to ensure cost-effective and appropriate care. Areas of work include status management, medical necessity reviews, verification of authorization, resource utilization, and denial prevention. Responsibilities Completes and enters inpatient and observation admission review against standard criteria per payer guidelines Prioritizes observation case review Assists with level of care in collaboration with attending provider Enters working diagnosis-related groups (DRGs) in the electronic medical record Submits clinical information to payer per payer requirements Completes continued stay reviews every 3 days or more often if required Communicates with care coordinators for authorized days, level of care, medical necessity or other areas when indicated Communicates with physician advisors related to status concerns or denials Updates auth/cert screen in the electronic medical record Works assigned queues in the electronic medical record Communicates with authorization coordinator Communicates in-house high dollar case information Completes assigned goals Requirements, Preferences and Experience Experience Minimum: RN with 3 years of clinical experience Experience Preferred: RN with 3 years of clinical experience Education Minimum: Diploma or Associate Degree in Nursing Education Preferred: BSN or MSN Special Skills Minimum: Critical thinking skills, clinical knowledge, attention to detail communication, organization, interpersonal, time management and computer skills. Problem solving; and knowledge of governmental regulations. Licensure Minimum: RN Licensure Preferred: CCM;ACM About Baptist Memorial Health Care At Baptist, we owe our success to our colleagues, who have both technical expertise and a compassionate attitude. Every day they carry out Christ's three-fold ministry—healing, preaching and teaching. And, we reward their efforts with compensation and benefits packages that are highly competitive in the Mid-South health care community. For two consecutive years, Baptist has won a Best in Benefits award for offering the best benefit plans compared with their peer groups. Winners are chosen based on plan designs, premiums and the results of a Benefits Benchmarking Survey. At Baptist, We Offer: Competitive salaries Paid vacation/time off Continuing education opportunities Generous retirement plan Health insurance, including dental and vision Sick leave Service awards Free parking Short-term disability Life insurance Health care and dependent care spending accounts Education assistance/continuing education Employee referral program Job Summary: Position: 19737 - RN-Utilization Review Facility: BMHCC Corporate Office Department: HS Case Mgmt Administration Corporate Category: Nurse RN Type: Clinical Work Type: PRN Work Schedule: Days Location: US:TN:Memphis Located in the Memphis metro area
Responsibilities Highlands Behavioral Health System is an 86 bed, acute care psychiatric hospital located in Littleton, CO. Highlands features individual units for adolescents, adults, and seniors, and offers inpatient acute care, partial hospitalization, and intensive outpatient programs. Website: https://highlandsbhs.com The Utilization Review Coordinator possesses knowledge of psychiatric clinical diagnosis and the ability to articulate those indicators professionally. The UM Coordinator manages medical necessity by evaluating the patient medical records to determine severity of patient’s illness and determining the appropriateness of level of care. Serves as liaison for patients and hospital with insurance companies. Negotiates and advocates for patient length of stay and level of care. Oversees utilization review activities with other departments to ensure reimbursement for services provided by the hospital. The UM Coordinator leads physician daily treatment team meetings, manages authorizations and reviews for outpatient programming and at time of admission is responsible for obtaining the precertification. The UM coordinator must be able to work with the business office and admissions departments to complete preliminary verification of benefits. The UM Coordinator has a working knowledge of all levels of care offered and appropriately manages patient benefits. This role will also act as the Outpatient RN and will assist with clinical screening of admissions, collaborating on treatment plans, interfacing with the treatment team, external case managers, and managed care organizations, and assisting the provider with provider visits and medication management as needed. Benefit Highlights: Tuition and Educational Reimbursement Program. Student Loan Repayment Program. Challenging and rewarding work environment Career development opportunities within UHS and its Subsidiaries Competitive Compensation & Generous Paid Time Off Excellent Medical, Dental, Vision and Prescription Drug Plans Discounts on pet insurance, automotive insurance & homeowners insurance 401(K) with company match and discounted stock plan Career development opportunities within UHS and its Subsidiaries SoFi Student Loan Refinancing Program More information is available on our Benefits Guest Website: benefits.uhsguest.com Questions or concerns? Contact the Human Resources department at HIGHLANDSBHSHumanResourceContact@uhsinc.com. Screening of applications begins immediately and continues until the position is filled. Qualifications Requirements: Current license to practice nursing in Colorado (or eligible to receive or renew). Graduate of an accredited School of Nursing or baccalaureate program. Clinical experience in psychiatric setting preferred. About Universal Health Services One of the nation’s largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (NYSE: UHS) has built an impressive record of achievement and performance, growing since its inception into a Fortune 500 corporation. Headquartered in King of Prussia, PA, UHS has 99,000 employees. Through its subsidiaries, UHS operates 28 acute care hospitals, 331 behavioral health facilities, 60 outpatient and other facilities in 39 U.S. States, Washington, D.C., Puerto Rico and the United Kingdom. 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
null Pay Range: $27.73 - $54.06 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
Health and Hospital Corporation is an organization that celebrates diversity, and seeks to employ a diverse workforce. We actively encourage all individuals to apply for employment and to seek advancement opportunities. Health and Hospital Corporation also provides reasonable accommodations to qualified individuals with disabilities as required by law. For additional questions please contact us at: hrmail@hhcorp.org. Job Role Summary Assists the Long Term Care department in the review and analysis of care and services provided by HHC owned nursing homes and licensed residential facilities. Performs on site, overnight as needed, and office review of various clinical resident care services and management operations at HHC affiliated long term care facilities and participates in the preparation of related reports for the long term care department, individual facilities and the contract management company. Assists in the analysis of various aspects of nursing home operations using professional standards of practice and industry benchmarks. This position is responsible for promoting health and wellbeing of long term care residents of Health & Hospital Corporation Marion County nursing facilities by promoting preventive, therapeutic, and supportive care based on standards of practice and in compliance with all applicable regulatory requirements with an emphasis on resident behavior health needs including dementia, addiction and current DSM manual (DSM-5-TR). Essential Duties Responsibility 1: 70% • Performs quality review oversight, including overnight as directed, visits to HHC owned nursing homes and retirement communities as assigned. May serve as a member of a quality review team or at times may visit assigned facilities as the sole representative from the HHC Long Term Care Department. Maintains a professional and supportive role when interacting with the nursing home and licensed residential facility staff providing helpful observations and suggestions. • Performs various auditing/review activities during the site visits including but not limited to: meal service observations, resident care observations, resident and family interviews, staff interviews, clinical record reviews and review of facility management records. At times may assist the other members of the quality review team to complete their assigned tasks. • Performs various auditing/review activities during the site visits including but not limited to: observations of resident behavioral interaction/intervention, medication administration, wound care, personal care services, meal service, clinical record reviews and review of nursing management records. • Participates in the exit conferences held with facility management and the quality reviewers and provides summary information regarding significant observations during the facility visit including specific resident and employee identification when possible. • Prepares a written site visit report following each facility visit in cooperation with other quality review team members who participated in the facility visit. Reviews report for accuracy, and clarity. Distributes reports in a confidential manner to all parties and maintains HHC records. • Assures the retention and confidentiality of all data materials from facility visits and forwards to the department Executive Assistant for proper storage/retention. Responsibility 2: 30% • Participates in the compilation and completion of quarterly and other reports prepared for the HHC Board of Trustees’. • Accepts phone calls from residents, family members and interested parties in the absence of other Long Term Care Department staff or as assigned. Receives concerns or information in a manner that reflects good customer service practices and prepares detailed written information for the Vice President’s review and processing. • Attends community and professional association functions and meetings representing HHC Long Term Care division, as requested. • Follows departmental travel policy for travel arrangements/reservations for out of town facility site visits. Qualifications • Registered nurse with four or more years experience including two or more years of behavioral health background. Licenses/Certifications Required Registered Nurse (RN) Knowledge, Skills & Abilities • Good judgment and discretion in communication (written, verbal and non-verbal).Must be able to prioritize work, meet deadlines, and work well under pressure. • Flexibility to adjust to changing program/department needs and activities. • Excellent verbal and written skills. • Must be proficient with Microsoft Office, Word, Internet Explorer, and all usual and customary office equipment. • Must possess the ability to work independently, and as part of a team. Working Environment Unconfined sitting 75% Confined sitting 15% Standing or walking 10% (50% - on site visit days) Steady use of hands or fingers – Typing and filing 85% Lift, carry, etc. with arms and legs – 15% Ability to perform driving functions in normal course of workday with confined sitting for several hours at times All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.
Penn State Health - Hershey Medical Center Location: US:PA: Hershey Work Type: Full Time FTE: 0.90 Shift: Evening Evening Shift Differential: $2.50/hour Hours: 3:00p - 11:00p Recruiter Contact: Corey Cunningham at ccunningham3@pennstatehealth.psu.edu SUMMARY OF POSITION: Responsible for the review of clinical documentation in the Electronic Medical Record (EMR), comparing it to the nationally accepted and evidence-based criteria to certify an admission to the facility, and for concurrent/continued stay review as appropriate. Also responsible for maintaining compliance with the CMS Conditions of Participation for Utilization Management. MINIMUM QUALIFICATION(S): Bachelors Degree in Nursing or Masters Degree in Nursing required. 3 years advanced clinical experience in a hospital setting required. Currently licensed to practice as a Registered Nurse by state of employment or holds a multistate RN license through the interstate Nurse Licensure Compact. WHY PENN STATE HEALTH? Penn State Health offers exceptional opportunities to learn and grow, exposure to a wide patient population, and the ability to provide individualized, innovative, and specialized care to patients in the community. Penn State Health offers an exceptional benefits package including medical, dental and vision with no waiting period as well as a Total Rewards Program that highlights a few of the many additional offerings below: Be Well with Employee Wellness Programs, and Fitness Discounts (University Fitness Center, Peloton). Be Balanced with Generous Paid Time Off, Personal Time, and Paid Parental Leave. Be Secured with Retirement, Extended Illness Bank, Life Insurance, and Identity Theft Protection. Be Rewarded with Competitive Pay, Tuition Reimbursement, and PAWS UP employee recognition program. Be Supported by the HR Solution Center, Learning and Organizational Development and Virtual Benefits Orientation, Employee Exclusive Concierge Service for scheduling. WHY PENN STATE HEALTH MILTON HERSHEY MEDICAL CENTER? Penn State Hershey Medical Center is Central Pennsylvania’s only Academic Medical Center, Level 1 Regional Adult and Pediatric Trauma Center, and Tertiary Care Provider. As a four-time Magnet-designated hospital, Hershey Medical Center values the hard work and dedication that our employees exhibit every day. Through our core values of Respect, Integrity, Teamwork, and Excellence, our employees are a team committed to compassionate care for our diverse patient population, our community and each other. As a valued team member, we promote continued professional development, specialty certification, continuing education, and career growth. YOU TAKE CARE OF THEM. WE’LL TAKE CARE OF YOU. State-of-the-art equipment, endless learning, and a culture of excellence – that’s Penn State Health. But what makes our healthcare award-winning? That’s all you. This job posting is a general outline of duties performed and is not to be misconstrued as encompassing all duties performed within the position. Eligibility for shift differential pay based on the terms outlined in company policy or union contract. All individuals (including current employees) selected for a position will undergo a background check appropriate for the position's responsibilities. Penn State Health is an Equal Opportunity Employer and does not discriminate on the basis of any protected class including disability or veteran status. Penn State Health’s policies and objectives are in direct compliance with all federal and state constitutional provisions, laws, regulations, guidelines, and executive orders that prohibit or outlaw discrimination. Union: SEIU Healthcare Pennsylvania
The Utilization Management (UM) RN performs utilization review activities, including, but not limited to, precertification, ensures appropriate level of care and status (Inpatient, Outpatient, and Observation) throughout admission and performs concurrent reviews/retrospective reviews according to guidelines. Determines the medical necessity of requests by performing first level reviews. The UM nurse ensures a process that is efficient for providing care, ensuring timely and appropriate levels of care for the incoming patients. UM RN is responsible for preparing cases for Physician Advisor for 2 nd level review. PIH Health is a nonprofit, regional healthcare network that serves approximately 3 million residents in the Los Angeles County, Orange County and San Gabriel Valley region. The fully integrated network is comprised of PIH Health Downey Hospital, PIH Health Good Samaritan Hospital, PIH Health Whittier Hospital, 37 outpatient medical office buildings, a multispecialty medical (physician) group, home healthcare services and hospice care, as well as heart, cancer, digestive health, orthopedics, women’s health, urgent care and emergency services. The organization is nationally recognized for excellence in patient care and patient experience, and the College of Healthcare Information Management Executives (CHIME) has identified PIH Health as one of the nation’s top hospital systems for best practices, cutting-edge advancements, quality of care and healthcare technology. For more information, visit PIHHealth.org or follow us on Facebook , Twitter , or Instagram . Required Skills Excellent verbal and written communication skills Ability to follow chain of command. Highly developed ability to multi-task and maintain focus Proactive, can-do approach and desire to build positive working relationships through collaborative problem-solving Self-motivated and results oriented. Must be able to demonstrate sound decision making, flexibility and prioritization skills with minimal supervision. Strong organizational skills Basic computer skills: Word, Excel, PowerPoint, Outlook. Able to utilize multiple electronic systems. Type 50 WPM. Ability to apply appropriate UM criteria. Required Experience Required: Maintain an active California RN license. LA City Fire Card within 6 months of employment BLS from American Heart Association Minimum of 2 years’ acute hospital experience. Knowledge of payer requirements. Preferred: Certified Case Manager or Accredited Case Manager BSN preferred. Experience with Milliman Care Guidelines (MCG) Address 1225 Wilshire Boulevard Salary 53.08-79.85 Shift Days Zip Code 90017
Description Become part of an inclusive organization with over 40,000 teammates, whose mission is to improve the health and well-being of the unique communities we serve. Summary: Works in collaboration with the patient/family, and interdisciplinary team (including physicians, other care providers, and payors), and assesses the patient care progression from acute care episode through post discharge for quality, efficiency, and effectiveness. The Utilization Manager works collaboratively with other Clinical Care Management staff to ensure patient needs are met and care delivery is coordinated across the continuum. The Utilization Manager completes admission, continued stay, and discharge reviews in accordance with federal regulations & the Hospitals? Utilization Management Plan. In addition, the Utilization Manager is responsible for revenue protection by reconciling physician orders, bed billing type, and medical necessity. This may include delivering notifications to patients directly. Interface is completed verbally, via email, data base tasks, or other electronic communication and via telephone. Responsibilities: 1. Clinical Review Process - Uses approved criteria and conducts admission review/status change review within 24 hours of patient admission to the hospital to ensure appropriateness of the setting and timely implementation of the plan of care. Identifies and obtains observation status as appropriate. Partners with physicians, nursing, and other care providers to help ensure timely and accurate documentation of patient data and treatments. Communicates daily with the Case Manager to manage level of care transitions & appropriate utilization of services. Coordinates with the support center to assure third party payor pre-certification and/or re-certifications when required. Utilizes high risk screening criteria to make appropriate referrals to Manager. 2. Discharge Facilitation - Identifies patient/families with the complex psychosocial, on-going medical discharge planning issues, continuing care needs by initiating appropriate case management referrals. Initiates appropriate social work referrals. 3. Utilization Management Process - Performs utilization management assessments and interventions, using collaboration with interdisciplinary team approach, on assigned patients as appropriate to ensure optimal patient outcomes. Using approved criteria, conducts continued stay and quality reviews to monitor the patient's progress along the continuum of care and intervenes as necessary to ensure appropriateness of setting and that the services provided are quality-driven, efficient, and effective. Enters all pertinent review data into the correct computer system in a timely manner. Consults with Physician Advisor as necessary to resolve barriers through appropriate administrative and medical channels. 4. Utilization Outcomes Management - Monitors and guides to trend interdisciplinary documentation and guides medical staff in documentation that will assist in coding accuracy, enhance quality of care, reflect accurate severity of illness and appropriate reimbursement. Facilitates patient movement to appropriate (acuity) level of care including observation status issues through collaboration with patient/family, multidisciplinary team, third party payors and resource center. Provides information regarding denials and approvals to designated entities. Assists in coordination of practice parameter development with the assigned departments/sections/specialties of Medical Staff. Oversees collection and analysis of patient care and financial data relevant to the target case types. Directs delivery of notifications to patients (includes traveling to hospital(s) to deliver notifications. Other Information Other information: Education Requirements: ● Graduation from a state-accredited school of professional nursing ● If hired after October 1, 2015, must be enrolled in an accredited program within four years of employment, and obtain a Bachelor's degree with a major in Nursing or a Master's degree with a major in Nursing within seven years of employment date. Licensure/Certification Requirements: ● Licensed to practice as a Registered Nurse in the state of North Carolina. Professional Experience Requirements: ● Two (2) years of clinical experience in a medical facility and/or comparable Utilization Management experience. Knowledge/Skills/and Abilities Requirements: Job Details Legal Employer: NCHEALTH Entity: Johnston Health Organization Unit: Care Management - Work Type: Per Diem Standard Hours Per Week: 4.00 Salary Range: $35.52 - $51.05 per hour (Hiring Range) Pay offers are determined by experience and internal equity Work Assignment Type: Onsite Work Schedule: Day Job Location of Job: US:NC:Smithfield Exempt From Overtime: Exempt: Yes This position is employed by NC Health (Rex Healthcare, Inc., d/b/a NC Health), a private, fully-owned subsidiary of UNC Heath Care System. This is not a State employed position. Qualified applicants will be considered without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, status as a protected veteran or political affiliation. UNC Health makes reasonable accommodations for applicants' and employees' religious practices and beliefs, as well as applicants and employees with disabilities. All interested applicants are invited to apply for career opportunities. Please email applicant.accommodations@unchealth.unc.edu if you need a reasonable accommodation to search and/or to apply for a career opportunity.
Description Become part of an inclusive organization with over 40,000 teammates, whose mission is to improve the health and well-being of the unique communities we serve. Summary: Works in collaboration with the patient/family, and interdisciplinary team (including physicians, other care providers, and payors), and assesses the patient care progression from acute care episode through post discharge for quality, efficiency, and effectiveness. The Utilization Manager works collaboratively with other Clinical Care Management staff to ensure patient needs are met and care delivery is coordinated across the continuum. The Utilization Manager completes admission, continued stay, and discharge reviews in accordance with federal regulations & the Hospitals? Utilization Management Plan. In addition, the Utilization Manager is responsible for revenue protection by reconciling physician orders, bed billing type, and medical necessity. This may include delivering notifications to patients directly. Interface is completed verbally, via email, data base tasks, or other electronic communication and via telephone. Responsibilities: 1. Clinical Review Process - Uses approved criteria and conducts admission review/status change review within 24 hours of patient admission to the hospital to ensure appropriateness of the setting and timely implementation of the plan of care. Identifies and obtains observation status as appropriate. Partners with physicians, nursing, and other care providers to help ensure timely and accurate documentation of patient data and treatments. Communicates daily with the Case Manager to manage level of care transitions & appropriate utilization of services. Coordinates with the support center to assure third party payor pre-certification and/or re-certifications when required. Utilizes high risk screening criteria to make appropriate referrals to Manager. 2. Discharge Facilitation - Identifies patient/families with the complex psychosocial, on-going medical discharge planning issues, continuing care needs by initiating appropriate case management referrals. Initiates appropriate social work referrals. 3. Utilization Management Process - Performs utilization management assessments and interventions, using collaboration with interdisciplinary team approach, on assigned patients as appropriate to ensure optimal patient outcomes. Using approved criteria, conducts continued stay and quality reviews to monitor the patient's progress along the continuum of care and intervenes as necessary to ensure appropriateness of setting and that the services provided are quality-driven, efficient, and effective. Enters all pertinent review data into the correct computer system in a timely manner. Consults with Physician Advisor as necessary to resolve barriers through appropriate administrative and medical channels. 4. Utilization Outcomes Management - Monitors and guides to trend interdisciplinary documentation and guides medical staff in documentation that will assist in coding accuracy, enhance quality of care, reflect accurate severity of illness and appropriate reimbursement. Facilitates patient movement to appropriate (acuity) level of care including observation status issues through collaboration with patient/family, multidisciplinary team, third party payors and resource center. Provides information regarding denials and approvals to designated entities. Assists in coordination of practice parameter development with the assigned departments/sections/specialties of Medical Staff. Oversees collection and analysis of patient care and financial data relevant to the target case types. Directs delivery of notifications to patients (includes traveling to hospital(s) to deliver notifications. Other Information Other information: Education Requirements: ● Graduation from a state-accredited school of professional nursing ● If hired after October 1, 2015, must be enrolled in an accredited program within four years of employment, and obtain a Bachelor's degree with a major in Nursing or a Master's degree with a major in Nursing within seven years of employment date. Licensure/Certification Requirements: ● Licensed to practice as a Registered Nurse in the state of North Carolina. Professional Experience Requirements: ● Two (2) years of clinical experience in a medical facility and/or comparable Utilization Management experience. Knowledge/Skills/and Abilities Requirements: Job Details Legal Employer: NCHEALTH Entity: Johnston Health Organization Unit: Care Management - Work Type: Full Time Standard Hours Per Week: 40.00 Salary Range: $35.52 - $51.05 per hour (Hiring Range) Pay offers are determined by experience and internal equity Work Assignment Type: Onsite Work Schedule: Day Job Location of Job: US:NC:Smithfield Exempt From Overtime: Exempt: Yes This position is employed by NC Health (Rex Healthcare, Inc., d/b/a NC Health), a private, fully-owned subsidiary of UNC Heath Care System. This is not a State employed position. Qualified applicants will be considered without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, status as a protected veteran or political affiliation. UNC Health makes reasonable accommodations for applicants' and employees' religious practices and beliefs, as well as applicants and employees with disabilities. All interested applicants are invited to apply for career opportunities. Please email applicant.accommodations@unchealth.unc.edu if you need a reasonable accommodation to search and/or to apply for a career opportunity.
Capital Health is the region's leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advanced technology. Capital Health is a five-time Magnet-Recognized health system for nursing excellence and is comprised of 2 hospitals. Capital Health Medical Group is made up of more than 250 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region. Capital Health recognizes that attracting the best talent is key to our strategy and success as an organization. As a result, we aim for flexibility in structuring competitive compensation offers to ensure we can attract the best candidates. Pay Range: $39.40 - $59.19 Scheduled Weekly Hours: 40 Position Overview Performs chart review of identified patients to identify quality, timeliness and appropriateness of patient care. Conducts admission reviews for Medicare, Medicaid beneficiaries, as well as private insurers and self pay patients, based on appropriate guidelines. Uses these criteria guidelines to screen for appropriateness for inpatient level of care or observation services based on physician certification (physicians H&P, treatment plan, potential risks and basis for expectation of a 2 midnight stay). Refers cases as appropriate, to the UR physician advisor for review and determination. Gathers clinical information to conduct continued stay utilization review activities with payers on a daily basis. Performs concurrent and retrospective clinical reviews with various payers, utilizing the appropriate guidelines as demonstrated by compliance with all applicable regulations, policies and timelines. Adheres to CMS guidelines for utilization reviews as evidenced by utilization of the relevant guidelines and appropriate referrals to the physician advisor and the UR Committee. Identifies, develops and implements strategies to reduce length of stay and resource consumption. . Confers proactively with admitting physician to provide coaching on accurate level of care determinations at point of hospital entry. Keeps current on all regulatory changes that affect delivery or reimbursement of acute care services. Uses knowledge of national and local coverage determinations to appropriately advise physicians. Understands and applies federal law regarding the use of Hospital Initiated Notice of Non-Coverage (HINN) and Lifetime Reserve Days letters. Identifies and records consistently any information on any progression of care or patient flow barriers using the Avoidable Days tool in the Utilization software program. Consults with medical staff, care team and case managers as necessary to resolve immediate progression of care barriers through appropriate administrative and medical channels. Engages care team colleagues in collaborative problem solving regarding appropriate utilization of resources. Recognizes and responds appropriately to patient safety and risk factors. Represents Utilization Management at various committees, professional organizations an physician groups as needed. Promotes the use of evidence based protocols and or order sets to influence high quality and cost effective care. Identifies, develops and implements strategies to reduce lengths of stay and resource consumption in the patient population. Participates in performance improvement activities. Promotes medical documentation that accurately reflects findings and interventions, presence of complication or comorbidities, and patient's need for continued stay. Identifies and records episodes of preventable delays or avoidable days due to failure of progression of care processes. Maintains appropriate documentation in the Utilization software system on each patient to include specific information of all resource utilization activities. Participates actively in daily huddles, patient care conferences, and hospitalist or nurse handoff reports to maintain knowledge about intensity of services and the progression of care. Identifies potentially wasteful or misused resources and recommends alternatives if appropriate by analyzing clinical protocols. Maintains related continuing education credits = 15 per calendar year. MINIMUM REQUIREMENTS Education: Minimum of Associate's degree in Nursing. Graduate of an accredited school of nursing. CPHQ, CCM or CPUR preferred. Experience: Three years of clinical nursing or two years quality management, utilization review or discharge planning experience. Other Credentials: Registered Nurse - NJ Knowledge and Skills: Three years of clinical nursing or two years quality management, utilization review or discharge planning experience. CPHQ, CCM or CPUR preferred. Special Training: Basic computer skills including the working knowledge of Microsoft Office, UR software and EMR. Possesses familiarity with MCG guidelines. Mental, Behavioral and Emotional Abilities: Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form. Usual Work Day: 8 Hours PHYSICAL DEMANDS AND WORK ENVIRONMENT Frequent physical demands include: Sitting , Standing , Walking Occasional physical demands include: Climbing (e.g., stairs or ladders) , Carry objects , Push/Pull , Twisting , Bending , Reaching forward , Reaching overhead , Keyboard use/repetitive motion , Talk or Hear Continuous physical demands include: Lifting Floor to Waist 10 lbs. Lifting Waist Level and Above 5 lbs. Sensory Requirements include: Accurate Near Vision, Accurate Far Vision, Accurate Color Discrimination, Accurate Depth Perception, Accurate Hearing Anticipated Occupational Exposure Risks Include the following: N/A This position is eligible for the following benefits: Medical Plan Prescription drug coverage & In-House Employee Pharmacy Dental Plan Vision Plan Flexible Spending Account (FSA) - Healthcare FSA - Dependent Care FSA Retirement Savings and Investment Plan Basic Group Term Life and Accidental Death & Dismemberment (AD&D) Insurance Supplemental Group Term Life & Accidental Death & Dismemberment Insurance Disability Benefits – Long Term Disability (LTD) Disability Benefits – Short Term Disability (STD) Employee Assistance Program Commuter Transit Commuter Parking Supplemental Life Insurance - Voluntary Life Spouse - Voluntary Life Employee - Voluntary Life Child Voluntary Legal Services Voluntary Accident, Critical Illness and Hospital Indemnity Insurance Voluntary Identity Theft Insurance Voluntary Pet Insurance Paid Time-Off Program The pay range listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future. When determining base salary and/or rate, several factors may be considered including, but not limited to location, years of relevant experience, education, credentials, negotiated contracts, budget, market data, and internal equity. Bonus and/or incentive eligibility are determined by role and level. The salary applies specifically to the position being advertised and does not include potential bonuses, incentive compensation, differential pay or other forms of compensation, compensation allowance, or benefits health or welfare. Actual total compensation may vary based on factors such as experience, skills, qualifications, and other relevant criteria.
Under general supervision, provides consultative support to the admitting teams concerning patient status determinations and utilization of resources for patients requiring hospital services. Works collaboratively with interdisciplinary teams facilitating appropriate status determinations through the utilization review process supporting quality, cost-effective patient outcomes. Responsible for analyzing clinical information and performing timely initial and concurrent reviews using InterQual screening software. Education Bachelor of Science in Nursing (BSN) OR Associate of Science in Nursing and currently enrolled in a BSN program with an expected graduation date within three (3) years. Experience Five (5) years diversified, progressive experience in acute care and/or other settings within the continuum required. Two (2) years of Utilization Management experience which includes utilization review processes and discharge planning preferred. Knowledge, Skills and Abilities Advanced knowledge of InterQual and/or MCG admission criteria Knowledge of healthcare regulatory standards Advanced skill in using computer software Advanced skill in oral and written communication Advanced skill in critical thinking Ability to work independently and resolve complex problems Ability to remain calm under pressure and intense time constraints Strong analytical and problem solving skills Strong interpersonal communication skills Strong organizational and time management skills Proficiency in electronic medical record review Licensures, Certifications Current state of Maryland Registered Nurse license Bachelor of Science in Nursing (BSN) OR documentation of current enrollment in BSN program with expected graduation within three years of hire Certification in Utilization Management and/or Care Management highly desired. Physical Requirements Ability to sit, stand, stoop, and bend. Working Conditions Primarily in an office environment, evaluating electronic medical records and performing electronic documentation and communication 70% of time. Remainder of time working with interdisciplinary staff Conditions of Employment Maintain current licensure Principal Duties and Responsibilities Reviews available electronic medical records during the pre-admission process to determine appropriate patient status, optimizing correct patient classification and corresponding payer notifications. Develops initial admission reviews for patients requiring hospital services and provides timely status recommendations to admitting providers in accordance with departmental and clinical guidelines. Maintains a working knowledge of contractual and clinical criteria guidelines. Assures timely utilization compliance with all payers who require authorizations and clinical submission. Demonstrates knowledge of reimbursement mechanisms. Considers patient’s financial resources for meeting healthcare needs (insurance reimbursement, managed care plans, entitlement programs, and personal resources). Participates as an active partner with physicians and interdisciplinary teams, providing education regarding admission decisions including status determinations, financial and clinical outcomes, and documentation requirements and standards. Maintains current knowledge on all regulatory changes that affect care delivery or reimbursement of acute care services. Uses knowledge of national and local coverage determinations to appropriately advise physicians. Identifies system obstacles that affect patient outcomes and consults with interdisciplinary team members to problem solve. Demonstrates mastery in InterQual level of care guidelines. Possesses proficiency in utilization review systems, clinical support systems, and business support applications. Promotes use of evidence-based protocols to influence high quality and cost-effective care. Escalates clinically and financially complex cases to leadership, offering possible solutions through discussion and feedback. Engages regularly in formal and informal dialogue about quality; directly addressing concerns and promoting continuous improvement. Performs concurrent reviews and additional duties as assigned. All roles must demonstrate GBMC Values: Respect I will treat everyone with courtesy. I will foster a healing environment. Treats others with fairness, kindness, and respect for personal dignity and privacy Listens and responds appropriately to others’ needs, feelings, and capabilities Excellence I will strive for superior performance in every aspect of my work. I will recognize and celebrate the accomplishments of others. Meets and/or exceeds customer expectations Actively pursues learning and self-development Pays attention to detail; follows through Accountability I will be professional in the way I act, look and speak. I will take ownership to solve problems. Sets a positive, professional example for others Takes ownership of problems and does what is needed to solve them Appropriately plans and utilizes required resources for various job duties Reports to work regularly and on time Teamwork I will be engaged and collaborative. I will keep people informed. Works cooperatively and collaboratively with others for the success of the team Addresses and resolves conflict in a positive way Seeks out the ideas of others to reach the best solutions Acknowledges and celebrates the contribution of others Ethical Behavior I will always act with honesty and integrity. I will protect the patient. Demonstrates honesty, integrity and good judgment Respects the cultural, psychosocial, and spiritual needs of patients/families/coworkers Results I will set goals and measure outcomes that support organizational goals. I will give and accept help to achieve goals. Embraces change and improvement in the work environment Continuously seeks to improve the quality of products/services Displays flexibility in dealing with new situations or obstacles Achieves results on time by focusing on priorities and manages time efficiently Pay Range $66,292.41 - $107,062.33 Final salary offer will be based on the candidate's qualifications, education, experience and alignment with our organizational needs. Equal Employment Opportunity GBMC HealthCare and its affiliates are Equal Opportunity employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity and expression, age, national origin, mental or physical disability, genetic information, veteran status, or any other status protected by federal, state, or local law.
Responsibilities Join the Southwest Healthcare Team! About Us: Creating Health and Harmony, Southwest Healthcare is a comprehensive network of care with convenient hospital and ambulatory care/outpatient locations here to serve the Southern California community. With over 6,000 passionate providers and healthcare employees, our shared goal is to provide convenient access to a wide range of healthcare services in a way that benefits you, your family, and the entire community. Southwest Healthcare is comprised of five acute care hospitals and several non-hospital access points, including: Corona Regional Medical Center, Palmdale Regional Medical Center, Southwest Healthcare Rancho Springs Hospital, Southwest Healthcare Inland Valley Hospital and Temecula Valley Hospital, Temecula Valley Day Surgery, A+ Urgent Care Centers, and Riverside Medical Clinics. For more information on how to join our dynamic team, please visit our website at www.swhealthcaresystem.com . Job Summary: The Southwest Healthcare Regional office in Temecula, CA is seeking a Full-Time Central Utilization Review Nurse who will be responsible for carrying out utilization management functions by planning, coordinating, and managing patient needs during hospitalization and throughout the continuum of care. Duties include but not limited to: Conducts admission and continued stay reviews per guidelines to ensure medical necessity of level of care and hospitalization for multiple entities. Reviews medical record for presence of accurate placement orders reconciles variances with patient providers. Works collaboratively with attending providers, specialty providers, and physician advisors to ensure application of evidence-based guidelines for determining appropriate status. Collaborates with Patient Access team to ensure correct payer source for hospitalization and communication. Ensures compliance of utilization review practices as required by payers, external regulatory agencies, and organization. Hybrid schedule may be considered after 90 days of employment. Must be available to work weekends and holidays. Qualifications Experience/Training/Experience: Associates degree in Nursing or Graduate of a Vocational Nursing school required. Two (2) years of clinical experience in an acute care hospital setting with (1) year in of inpatient Care Management and/or Utilization Review experience required. Certifications/Licenses: Current license as a RN in the State of California required. Other Skills and Abilities: Demonstrates knowledge and ensures compliance with the Nurse Practice Act, The Joint Commission and Title 22 standards and guidelines. Demonstrates compliance with hospital policies and procedures at all times. Demonstrates strong leadership, organization, communication and interpersonal skills. Demonstrates ability to relate to clinical personnel and medical staff, as well as ability to interact well with the public. Must have knowledge of PC and applications. Capable of resolving escalated issues arising from operations and requiring coordination with other Knowledgeable in Interqual guidelines. Benefit Highlights: Challenging and rewarding work environment. Competitive Compensation & Generous Paid Time Off. Excellent Medical, Dental, Vision and Prescription Drug Plans. 401(K) with company match and discounted stock plan. SoFi Student Loan Refinancing Program. Tuition, CEU, Certification, Licenses Reimbursement program. Career development opportunities within UHS and its 300+ Subsidiaries! More information is available on our Benefits Guest Website: UHS Guest Benefits Southwest Healthcare is owned and operated by subsidiaries of Universal Health Services, Inc. (UHS) , a King of Prussia, PA-based company, one of the nation’s largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (NYSE: UHS) has built an impressive record of achievement and performance, growing since its inception into a Fortune 500 corporation. Headquartered in King of Prussia, PA, UHS has 99,000 employees. Through its subsidiaries, UHS operates 28 acute care hospitals, 331 behavioral health facilities, 60 outpatient and other facilities in 39 U.S. States, Washington, D.C., Puerto Rico and the United Kingdom. EEO Statement: All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws. We believe that diversity and inclusion among our teammates is critical to our success. 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.
Wisconsin RN license required 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 #PJHS Pay Range: $26.41 - $51.49 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
Department: Utilization Review Daily Work Times: 8:00am-4:30pm Hours Per Pay Period: 40 Position Summary: Responsible for determining the appropriate patient status based on the regulatory and reimbursement requirements of various commercial and government payers in collaboration with the admitting/attending physician. Partners with the health care team to ensure hospital admissions are based on medical necessity and documentation is sufficient to support the level of care being billed. Conducts concurrent reviews to ensure criteria for patient status and continued stay are met and documented. Along with other health care team members, monitors the use of hospital resources and identifies delays. Reports delays to leadership for resolution. Essential Functions and Responsibilities as Assigned: Performs a variety of concurrent and retrospective utilization management-related reviews and functions to ensure that appropriate data are tracked, evaluated, and reported. Collaborates with the health care team to determine the appropriate hospital setting (inpatient vs. outpatient) based on medical necessity. Actively seeks additional clinical documentation from the physician to optimize hospital reimbursement when appropriate. Works collaboratively with ICM service lines to expedite patient discharge. Screens physician documentation or order entry for timeliness, appropriateness and completeness as pertains to the utilization management process including level of care, medical necessity, and third-party payer requirement. Documents in the electronic medical record (EMR): clinical reviews (medical necessity), payer authorizations, avoidable days, readmission risks, continued stay reviews and potential discharge date. Utilizes other application tools to document including Veracity, Optum, InterQual, Milliman, etc. Facilitates peer to peer reviews with payer/providers. Actively participates in clinical case review/rounds with the interdisciplinary team regarding continued stays review/LOS outliers, Collaborate with providers/physician advisor when medical necessity and/or appropriateness of care is questioned, in accordance with established SOP procedures. Maintains current knowledge of hospital utilization review processes and participates in the resolution of retrospective reimbursement issues including appeals, PACER authorization, third party payer certification, and denied cases. Assists with monitoring the effectiveness/outcomes of the utilization management program, identifying and applying appropriate metrics, evaluating the data, reporting results to various audiences, and designing and implementing process improvement projects as needed. Assists with orientation, training, and competency development for appropriate staff and colleagues on an ongoing basis. Performs other related duties as required and directed. Qualifications: Required State licensure as a registered nurse (RN) Bachelor’s degree in nursing from accredited educational institution, or actively pursuing degree and to be obtained within five years of accepting position. Three years of recent nursing or utilization management experience with an acute care hospital Preferred: Experience in utilization management/case management, critical care, clinical documentation, or patient outcomes/quality management. Certification in Case Management Certification (ACM or CCM) Basic Life Support (BLS) certification as a Healthcare Provider by the American Heart Association, American Red Cross or equivalent through the Military Training Network (MTN) Additional Information Schedule: Part-time Requisition ID: 25006554 Daily Work Times: 8a-430p Hours Per Pay Period: 40 On Call: No Weekends: Yes Show more Show less
Salary Range: $102,183.00 (Min.) - $132,838.00 (Mid.) - $163,492.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job Summary The Supervisor of Utilization Management (UM) RN is responsible for executing the day-to-day operations of the UM department, and monitoring the Care Management (CM) staff’s responsibilities and activities. This includes, but not limited to, ensuring proper staffing and coverage; monitoring and evaluating departmental operations to ensure optimal efficiency, productivity, and effectiveness; documenting and appropriately addressing excellence or deviations in work, departmental, and organizational expectations; and conducting intermittent and annual performance evaluations. This role assists in triaging identified issues/problems and forming resolution within the scope of work/licensure. The Supervisor is a subject matter expert (SME) in Care/Case/Utilization Management and supporting regulations, policies, protocols, and procedures. This position serves as a formal and informal instructor, and escalates issues/concerns to the appropriate person when outside of their scope. This position is responsible in assisting with and development and maintenance of a successful and cohesive unit, with high level of productivity and accuracy to achieve the department's overall performance metrics. The Supervisor ensures all functions of the UM department are operating in accordance with the organization's mission, values and strategic goals, which are focused on quality care delivery and continuous improvement; and are provided in a manner that is responsive and sensitive to the needs of L.A. Care's culturally diverse membership. The position supports the UM Manager/Director. This role also assists UM Educator/Manager/Director in identification of training needs including, but not limited to, collaborating in development of programs, training materials, competency checklist, and orientation checklists necessary to meet education and training needs of UM staff. The position supervises all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports. Duties Ensures adequate/appropriate distributions of workforce, assignments and time off requests. Participates in the hiring and termination process providing recommendations with appropriate supporting documentation. Monitors of staff's performance including productivity and compliance with regulatory requirements, compliance with policies. Identifies, communicates and coaches to improve staff performance. Develops tools, job aids, and workflows to optimize the process flow, performance and productivity of the UM team. Completes intermittent and annual staff evaluations. Serves as the primary resource for all business-related questions/issues raised by staff; escalates to appropriate leader/team when necessary. Recommends and implements process improvement measures to achieve department's performance measures outcomes and goals. Plans and oversees UM activities according to model of care, program description and policy and procedures to provide timely, quality care and services to members. Maintains all assigned reporting responsibilities, conducts regular audits to ensure compliance with community, industry and organizational standards including regulatory requirements. Serves as a super-user on electronic programs and systems used by the department. Assists in the development of programs, workflows, tools, training materials, orientation checklists, and competency checklist necessary to meet educational needs. Trains new staff, remediation of seasoned staff and cross training as needed in specified business lines. Serves as a leader and role model as well as technical and informational resource for staff and peers. Duties Continued Fosters a culture that encourages employee contribution to ensure that the department maintains an environment in which quality flourishes. Services as member/resource/liaison to the Interdisciplinary Care Team. Recommends resources to improve performance standards in terms of Utilization Management. Collaborates with peers and colleagues within the organization to address process improvements, member's needs, department and organizational enhancements and communicate development as appropriate. Participates on internal and external committees as delegated or assigned. Serves as a consultant to other departments or organizations as needed. Responsible for the daily workflow and leading the work of assigned staff. This role will mentor, coach, act as a resource and provide feedback on performance of assigned staff. Performs other duties as assigned. Education Required Associate's Degree in Nursing Education Preferred Bachelor's Degree in Nursing Experience Required: Minimum of 7 years of acute/clinical care experience. Minimum of 2 years of experience in Case/Care/Utilization Management in an acute care or health plan setting. Minimum of 3 years leading process, program, or staff or supervisory experience. Equivalency: Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement. Skills Required: Knowledge of state, federal and regulatory requirements in Care/Case/Utilization Management. Strong verbal and written communication skills. Computer literacy with proficiency with Microsoft Word, Excel, etc. and ability to learn core departmental computer systems and software. Excellent organizational, time management, and interpersonal skills. Must be detailed-oriented, energetic, and an enthusiastic team player. Must be able to work independently. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California License Licenses/Certifications Preferred Required Training Physical Requirements Light Additional Information Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. L.A. Care offers a wide range of benefits including Paid Time Off (PTO) Tuition Reimbursement Retirement Plans Medical, Dental and Vision Wellness Program Volunteer Time Off (VTO)
HOURLY RANGE: $40.72 - $54.99 Area of coverage- BEHAVIOR HEALTH DISTINGUISHING FEATURES OF THE CLASS: The work involves performing professional and non- professional nursing duties in connection with the Utilization Review Process at the Erie County Medical Center Corporation. The incumbent assesses, monitors and facilitates healthcare services and needs throughout the patient experience to optimize outcomes. The work is performed under the general direction of the Utilization Management Coordinator or higher level Utilization Review Manager. Supervision is not a function of this position. Does related work as required. Typical Work Activities Facilitates a process of assessment, planning and advocacy for options and services to meet an individual’s health needs through communication and available resources to promote quality cost effective care; Validates appropriate level of care (severity of illness), efficient and effective care delivery (intensity of services) and safe discharge to the next appropriate level of care; Conducts admission and concurrent review using current evidence-based clinical decision support criteria; Completes full assessment of plan of care to determine if criteria are met to ensure third party reimbursement; Enters data into utilization data base; Conducts clinical chart reviews; gathers clinical information to assess and expedite care needs; Discusses cases with treating physician(s) and other healthcare professional to better understand plans-of-care; Identifies and evaluates delays in care; Initiates a discharge planning and readmission prevention plan when applicable; Approves bed days for inpatient cases when applicable; Arranges for alternative care services such as acute long-term care, acute rehabilitation or skilled nursing to move patients through the care continuum; Completes all requirements relative to new Alternant Level of Care orders, admissions and denials; Completes Patient Review Instrument (PRI) prior to admission as needed; Maintains appropriate documentation; Consults with the Medical Director and treating physician(s) as needed to troubleshoot difficult or complex cases; Contacts third party payers with initial and concurrent reviews to obtain authorization for hospital stay; Participates in staff meetings. FULL PERFORMANCE KNOWLEDGE, SKILLS, ABILITITES AND PERSONAL CHARACTERISTICS: Thorough knowledge of utilization review concepts, resource management and reimbursement methodologies; thorough knowledge of Federal and State regulations as they relate to hospital utilization review; good knowledge of medical terminology related to patient charts; good knowledge of Patient Review Instrument (PRI); good knowledge of clinical decision support criteria; good knowledge of billing procedures and hospital insurance procedures; ability to identify and resolve utilization issues; ability to prepare reports and statistics of hospital utilization; ability to establish and maintain effective working relationships; ability to communicate effectively both orally and in writing; sound professional judgment; initiative; proficient in the use of Microsoft applications;; physically capable of performing the essential functions of the position with or without reasonable accommodation. Minimum Qualifications Graduation from a regionally accredited or New York State registered college or university with a Bachelor’s Degree in Nursing, Health Administration, Human Service or a closely related field and two (2) years of behavioral health and/or medical/surgical registered nursing experience; or: Graduation from a regionally accredited or New York State registered college or university with an Associate’s Degree in Nursing, Health Administration, Human Services or a closely related field and four (4) years of behavioral health or medical/surgical registered nursing experience. An equivalent combination of training and experience as set by the limits of (A) and (B). Continued..... UTILIZATION REVIEW NURSE (continued....) Page 2 Special Requirements Possession of a license and current registration to practice as a Registered Professional Nurse in the State of New York at time of appointment; and: Possession of a Certification as a Patient Review Instrument (PRI) Assessor as issued by the New York State Department of Health at the time of permanent appointment.
Summary 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 Job Status: full time, 40 hours per week, eligible for benefits Shift: evenings 3pm - 11pm Monday through Friday 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 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.
Overview Shift: 12pm - 12am Performs clinical review of patient records to evaluate the utilization of acute care services. Communicates to third party payors to support the medical necessity of the hospital admission for services reimbursement. Ensures the patient care team is aware of general length of stay requirements for all patients. Facilitates physician documentation through concurrent interaction with physicians to support reimbursement and clinical severity is captured for the service rendered to patients receiving hospital care. Provides clinical knowledge and data collection for quality improvement initiatives. Optimizes reimbursement for acute care services. This is not a remote position. Responsibilities Qualifications Education: Associates Degree in Nursing. Bachelor’s Degree in Nursing preferred. Evidence of continuing professional development Licensure/Certification/Registry: Current RN licensure in the State of Illinois required Experience: Minimum of 3- 5 years of recent acute care and/or home health nursing or case management experience required. Previous utilization review experience strongly preferred. Other Knowledge/Skills/Abilities: Understanding of healthcare reimbursement mechanisms preferred. Strong oral and written communication skills. Demonstrated adaptability to changes in health care environment with proactive problem solving attitudes Understanding of the principles of performance improvement, team collaboration, and conflict resolution
Up To $25,000 Sign On Bonus For Qualified RNs! Summary The Registered Nurse (RN) Utilization Management (UM) in collaboration with Care Coordination, Guthrie Clinic offices, other physician offices, payers, and the Guthrie Clinic health system business office, is responsible for developing, coordinating, and maintenance of UM processes based on regulatory and reimbursement requirements of commercial and government payers. The UM RN responsibilities include performing a variety of concurrent and retrospective UM-related clinical reviews and revenue cycle functions ensuring appropriate status and corresponding reimbursement. The UM RN leads and/or actively participates in process improvement initiatives, working with a variety of departments and multi-disciplinary staff. The UM RN maintains current knowledge regarding commercial and government payers and Joint Commission regulations/guidelines/criteria related to UM. This role is responsible for ensuring that the UM program maintains documented, up-to-date policies and procedures and ensures that all UM key processes have valid outcome measures that are monitored for compliance and reported to a variety of audiences. The UM RN effectively and efficiently manages a diverse workload in a fast-paced, rapidly changing regulatory environment. The UM RN is a member of and provides support to the hospital’s UM Committee. He/she collaborates with multiple leaders at various levels throughout the Guthrie Clinic health system, including directors and vice presidents, for the purpose of supporting and improving the UM program. Experience BSN with a minimum of five years’ clinical experience in an acute health care setting preferred. RN with a minimum of five (5) years relevant acute care, clinical experience willing to pursue and complete a BSN may be considered. Must possess strong communication and organizational skills, be able to work independently and to complete work within specified time frames. Knowledge of health benefit plans and related UM requirements preferred. Experience with CPT/ICD coding, medical record or chart auditing, and experience in utilization management processes preferred. Knowledge of computer applications (such as Microsoft word processing and spreadsheets) desirable Education/License Current RN licensure required for the state in which the employee works. Essential Functions 1. Coordinate and facilitate correct identification of patient status.2. Collaborate and set standards with registered nurse (RN) case managers (CMs) and outcome managers to ensure that all hospitalized patients have the correct admission status (inpatient, outpatient short procedure, etc.). 3. Complete short stay work queue reviews and track and trend results for reporting and education purposes. 4. Collaborate with nursing, physicians, admissions, fiscal, legal, compliance, coding, and billing staff to answer clinical questions related to medical necessity and patient status. 5. Maintain status determination tools and other UM tools and distribute to staff as needed. - Coordinate and integrate UM functions.1. Prepare succinct, written clinical case summaries that include rationale for the recommended billing status. 2. Serve as a resource person for RN CMs and others to ensure consistent and accurate patient status determinations for appropriate claim submission. 3. Participate in UR Committee and UM activities. 4. Assist with preparation of discussion and appeal letters for Medicare/Medicaid medical necessity denials. 5. Assist with developing and maintaining efficient and effective documented policies and procedures for non-coverage notifications, including Notice of Non-coverage (HINN) and Advance Beneficiary Notice of Noncoverage (ABN), to include compliance monitoring. - Collaborate with all members of the healthcare team, both internal and external customers.1. Provide clinical consultation regarding UM to providers and other colleagues. 2. Respond to all payers, billing office, and business office requests appropriately, accurately, and timely. 3. Interact with providers, payers, nurses, and other hospital colleagues as indicated related to UM activities. - Participate in clinical performance improvement activities to achieve organizational goals.1. Use data to drive performance improvement strategies and action plans related to UM. 2. Create reports, displaying data and providing narrative analysis to a variety of audiences. 3. Participate in development, implementation, teaching, evaluation and revision of UM standards. - Demonstrate positive and professional written, verbal, and nonverbal communication skills.1. Effectively and efficiently create clinical case summaries from medical record documentation for internal and external audiences, including commercial payers and government payers/contractors. 2. Effectively promote conflict resolution with constructive solutions. 3. Reflect concise clinical pertinence in documentation for assigned patient population. 4. Respond to all inquiries related to UM within a professional manner. 5. Document and escalate UM quality and clinical care risks concerns (as identified during clinical reviews) and refer to the appropriate department for follow-up. - Apply advanced critical thinking and conflict resolution.1. Demonstrate a working knowledge of regulatory and survey standards (Medicare, Medicaid, Joint Commission) pertinent to UM. 2. Demonstrate a working knowledge of disease and age specific impact. 3. Demonstrate a working knowledge of approved status determination criteria and apply consistently according to inter-rater reliability techniques. 4. Demonstrate a working knowledge of Guthrie Health System process improvement. - Denials Adjudication1. Facilitate review of rejected medical claims using clinical evidenced based tools and peer-reviewed journals. 2. Provides clinical denial management assistance to Physician Advisor and denials team. 3. Ensure compliance with all federal, state, and local regulations governing rendered patient services and reimbursement. 4. Reviews and analyzes current audit information to facilitate UM process performance improvement and interdisciplinary healthcare and business/finance teams. 5. Responds to all internal and external requests for information, data, and /or education specific to clinical denials management. 6. Collaborates with revenue cycle team (business, billing, etc.) Admissions, coding, and the clinical team to answer clinical questions specific to denial management. 7. Seeks consultation from appropriate discipline/department as needed to expedite clinical review of potential and actual denials. - Education1. Provide ongoing education to providers, CM, billing, and business office teams as related to UM, medical necessity, patient status, InterQual, non-coverage notifications, and other UM areas as indicated. 2. Participate in new department staff orientation specific to UM and patient status. 3. Develop and provide individualized UM-related education as needed. Other Duties It is understood that this description is not intended to be all inclusive, and that other duties may be assigned as necessary in the performance of this position. Show more Show less
It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you’ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development. Summary We are seeking a skilled Utilization Review Nurse to conduct prior authorization, prospective, concurrent, and retrospective reviews for medical necessity and appropriateness of services, following clinical criteria, coverage policies, and contract guidelines. This involves reviewing medical documentation, accurately documenting findings, and ensuring policy compliance. Your role in our mission Review admissions, procedures, services, and supplies for medical necessity and appropriateness, meeting quality and production goals. Use clinical criteria for decision-making, referring complex cases to Medical Directors when needed. Engage with providers to gather clinical information, apply guidelines, and make determinations. Document findings and rationale in medical management systems. Assist in training new nurses, provide feedback, and stay updated on clinical guidelines. Maintain RN license and meet continuing education requirements. What we're looking for Active RN license. 3+ years of inpatient clinical experience. 1+ year in prior authorization reviews using InterQual or MCG. Strong written communication skills in a fast-paced setting. Proficient in Microsoft Office and other computer applications. What you should expect in this role Home-based position. High-speed internet and a distraction-free workspace required. Core hours: 8:00 AM - 6:00 PM ET, with potential for extended hours. Occasional travel (up to 10%) based on business needs. This position is for pipeline purposes, and we welcome applications on an ongoing basis. #LI-AC1 #LI-REMOTE The pay range for this position is $65,000.00 - $78,000.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits , and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities. We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings. Gainwell Technologies is an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics.
Description Introduction This Work from Home position requires that you live and will perform the duties of the position; within 60 miles of an HCA Healthcare Hospital (Our hospitals are located in the following states: FL, GA, ID, KS, KY, MO, NV, NH, NC, SC, TN, TX, UT, VA). Do you want to join an organization that invests in you as an Inpatient Authorization Review Services Registered Nurse or Licensed Practical Nurse -NICU (Code Pink)? At Parallon, you come first. HCA Healthcare has committed up to 300 million in programs to support our incredible team members over the course of three years. Benefits Parallon offers a total rewards package that supports the health, life, career and retirement of our colleagues. The available plans and programs include: Comprehensive medical coverage that covers many common services at no cost or for a low copay. Plans include prescription drug and behavioral health coverage as well as free telemedicine services and free AirMed medical transportation. Additional options for dental and vision benefits, life and disability coverage, flexible spending accounts, supplemental health protection plans (accident, critical illness, hospital indemnity), auto and home insurance, identity theft protection, legal counseling, long-term care coverage, moving assistance, pet insurance and more. Free counseling services and resources for emotional, physical and financial wellbeing 401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service) Employee Stock Purchase Plan with 10% off HCA Healthcare stock Family support through fertility and family building benefits with Progyny and adoption assistance. Referral services for child, elder and pet care, home and auto repair, event planning and more Consumer discounts through Abenity and Consumer Discounts Retirement readiness, rollover assistance services and preferred banking partnerships Education assistance (tuition, student loan, certification support, dependent scholarships) Colleague recognition program Time Away From Work Program (paid time off, paid family leave, long- and short-term disability coverage and leaves of absence) Employee Health Assistance Fund that offers free employee-only coverage to full-time and part-time colleagues based on income. Learn more about Employee Benefits Note: Eligibility for benefits may vary by location. You contribute to our success. Every role has an impact on our patients’ lives and you have the opportunity to make a difference. We are looking for a dedicated Inpatient Authorization Review Services Registered Nurse or Licensed Practical Nurse -NICU (Code Pink) like you to be a part of our team. Job Summary and Qualifications The Inpatient Authorization Review Services Registered Nurse or Licensed Practical Nurse NICU (Code Pink) will review post discharge, prebill accounts that do not have authorization on file, ALOS versus days authorized variances, and/or other account discrepancies identified that will result in the account being denied by the payor that require clinical expertise. Communicates with third party payors to resolve discrepancies prior to billing. Accurately and concisely documents all communications and action taken on the account in accordance with policies and procedures. Escalate medical review request and /or denial activities to management as needed. What you will do in this role: Work post discharge, prebill accounts efficiently and effectively daily to resolve accounts with “no auth numbers, ALOS vs. authorized days or other discrepancies. Evaluates clinical documentation on multiple patient accounts and escalates issues through the established channels. Perform accurate and timely documentation of all review activities based on policy and procedure. Demonstrates a working knowledge of managed care agreements based on available resources which may include and not be limited to payer UM Manual, policy and procedure, facility contract information. Escalates variations timely. Work assigned accounts in eRequest to resolve outstanding issues. Report insurance denial trends identified during daily operational assignments. Contact facilities, physicians’ offices and/or insurance companies to resolve denials/appeals if needed. Demonstrates knowledge of regulatory requirements, Ethics and Compliance policies, and quality initiatives; monitors self-compliance and implements process changes to ensure compliance to such regulations and quality initiatives. Assess CPT code(s) for outpatient accounts that require authorization when accounts have not been coded. Qualifications that you will need: Registered Nursing degree and current licensure or Vocational nursing degree required. Healthcare experience in an acute care hospital. Utilization Review, appeals, denials, managed care contracting, experienced preferred. Currently licensed as a registered nurse (RN) in the state(s) of practice and/or has an active compact license, in accordance with law and regulation or Licensed Practical Nurse -Currently licensed as a licensed practical nurse in the state in which he or she resides and practices, in accordance with law and regulation. Multi-state nursing licensure for compact states Parallon provides full-service revenue cycle management, or total patient account resolution, for HCA Healthcare. Our services include scheduling, registration, insurance verification, hospital billing, revenue integrity, collections, payment compliance, credentialing, health information management, customer service, payroll and physician billing. We also provide full-service revenue cycle management as well as targeted solutions, such as Medicaid Eligibility, for external clients across the country. Parallon has over 17,000 colleagues, and serves close to 1,000 hospitals and 3,000 physician practices, all making an impact on patients, providers and their communities. HCA Healthcare has been recognized as one of the World’s Most Ethical Companies® by the Ethisphere Institute more than ten times. In recent years, HCA Healthcare spent an estimated 3.7 billion in cost for the delivery of charitable care, uninsured discounts, and other uncompensated expenses. "Good people beget good people." - Dr. Thomas Frist, Sr. HCA Healthcare Co-Founder We are a family 270,000 dedicated professionals! Our Talent Acquisition team is reviewing applications for our Inpatient Auth Review Services RN or LPN -NICU opening. Qualified candidates will be contacted for interviews. Submit your resume today to join our community of caring! We are an equal opportunity employer. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.
