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.
Ready to Find Utilization Review Nurse Jobs?
Check out all the positions available right now. Want additional options? IntelyCare can match you with even more nursing jobs that interest you.
Medical Director - Utilization Management Department: HS - UM Employment Type: Full Time Location: 1600 Corporate Center Dr., Monterey Park, CA 91754 Reporting To: Dr. Dinesh Kumar Compensation: $275,000 - $325,000 / year Description As Medical Director - Utilization (UM) at Astrana Health, you will provide clinical oversight and strategic leadership through our utilization review operations to ensure members receive high-quality, medically appropriate, and cost-effective care. This is a critical, cross-functional role that bridges clinical expertise with operational execution across value-based care, capitated models, and delegated risk structures. You’ll work closely with teams in Care Management, Quality Improvement, Pharmacy, Behavioral Health, and Compliance to drive aligned decision-making that supports both optimal patient outcomes and efficient healthcare resource use. In this role, you’ll apply evidence-based criteria to utilization decisions, mentor clinical review teams, and support compliance with all applicable regulatory and contractual obligations. This position is ideal for a clinically grounded physician who thrives in a data-informed, team-based environment and is passionate about transforming how care is delivered in a risk-bearing, population health-focused ecosystem. Our Values: Put Patients First Empower Entrepreneurial Provider and Care Teams Operate with Integrity & Excellence Be Innovative Work As One Team What You'll Do Prior Authorization Management Review and issue timely determinations for prior authorization requests, ensuring medical necessity, regulatory compliance, and alignment with evidence-based clinical guidelines. Collaborate with care management and operational teams to streamline and enhance prior authorization workflows for efficiency and provider satisfaction. Provide clinical leadership in the development, implementation, and regular updating of authorization criteria and policies based on the latest medical standards. Promote transparency by clearly documenting and communicating authorization decisions to providers and members, including rationale and guidance for alternative treatment options when applicable. Utilization Management Provide oversight for the daily activities of the UM program, ensuring services are delivered appropriately and in accordance with clinical best practices. Analyze utilization data to identify trends, high-cost drivers, and opportunities for care optimization and cost containment. Participate in the clinical review of complex or high-cost cases, offering recommendations rooted in medical necessity and member-centered care. Collaborate with interdisciplinary clinical teams to ensure the appropriate use of healthcare resources without compromising quality. Quality Assurance and Improvement Ensure all UM activities meet applicable federal, state, and accreditation standards (e.g., CMS, NCQA). Lead and contribute to quality improvement initiatives focused on enhancing the effectiveness, accuracy, and consistency of the prior authorization and UM processes. Conduct audits and peer reviews to validate adherence to guidelines and evaluate the quality of medical decision-making. Provider and Member Communication Serve as the primary clinical contact for complex medical necessity determinations and escalated provider appeals. Build strong working relationships with providers by offering education and clarity around the prior authorization process and criteria. Support member care continuity by suggesting medically appropriate alternatives when requested services are denied. Regulatory Compliance and Accreditation Ensure full compliance with all applicable UM regulatory and accreditation standards, including NCQA and CMS requirements. Maintain up-to-date knowledge of evolving healthcare laws, policies, and industry standards affecting prior authorization and UM processes. Lead internal efforts to prepare for and maintain UM-related accreditation, including audits, documentation, and process improvement. Data Analysis and Reporting Monitor and analyze prior authorization and UM metrics (e.g., denial rates, turnaround times, appeal volumes) to identify performance gaps and track progress. Use data-driven insights to inform strategic decisions, improve process efficiency, and support cost management goals. Provide regular updates and reporting to senior leadership on program performance, cost impact, compliance status, and quality indicators. Qualifications Medical Degree (MD or DO) from an accredited institution; active and unrestricted medical license in CA. Board certification (preferred) in a relevant specialty (e.g., Internal Medicine, Family Medicine, or equivalent). Minimum 5+ years of clinical practice experience. At least 3 years of experience in utilization management or medical management within a health plan, IPA/MSO, or risk-bearing organization. Deep knowledge of managed care, value-based care, capitation, and CMS/Medi-Cal guidelines. Proficient in applying MCG, InterQual, or equivalent criteria. Strong understanding of state and federal regulations (e.g., CMS, DMHC, NCQA). Excellent communication skills, including the ability to engage providers in meaningful, respectful clinical dialogue. Highly collaborative mindset with a commitment to improving healthcare equity, quality, and cost-effectiveness. Environmental Job Requirements and Working Conditions This position operates on a hybrid schedule out of our Monterey Park office, located at 1600 Corporate Center Drive. We are seeking candidate who reside in Southern California who are able to go in-office for orientation, meetings, etc. The national target base salary range for this role is: $275,000 - $325,000. Actual compensation will be determined based on geographic location (current or future), experience, or other job-related factors. Astrana Health is proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based on race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. All employment is decided based on qualifications, merit, and business need. If you require assistance in applying for open positions due to a disability, please email us at humanresourcesdept@astranahealth.com to request an accommodation. Additional Information: The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.
Interested in working for the Golden Isles’ healthcare provider and employer of choice? Throughout the many locations that make up the Southeast Georgia Health System network, there is a common thread that pulls everything together: A team of committed professionals like you. These individuals appreciate the value of every person who walks through our doors and are the key to our culture of Service Excellence. Summary: Manages the Medical Staff Peer Review Process for the Health System by identifying records, review, and analysis of information obtained, summarizing findings, and coordination of provider review. Maintains the integrity, confidentiality, and privilege of the safety event reporting system and Peer Review Professional Practice Evaluation Process. Conducts thorough research, interviews, and retrospective chart reviews on reported safety events and patient/family complaints with provider involvement contributing to the event and/or complaint as appropriate. Coordinates Peer Review meetings to include documentation and follow-up recommendations. Drafts and submits educational and informative decision letters to providers as required and oversees management of Peer Review files. Attends medical staff meetings to integrate medical staff into Performance Improvement Program and advise medical staff on policies and procedures as needed. Adheres to credentialing and peer review deadlines. Processes Peer Review issues in a timely manner. Assists in identifying and coordinating resolution of system process issues that may adversely affect the quality and safety of care being provided to patients. Collaborates with the Risk Analyst on event management through use of the event reporting software, assigning event investigations to appropriate leadership for review and follow-up, ensuring follow-up is timely and complete. Closes the event submission upon completion. Follow up with team members and/or complainants when appropriate. Prepares Risk Reviews as directed. Other job duties pertaining to the functions of the Medical Staff Services Department and Risk Management Department. Minimum Qualifications: Graduate of a Diploma, Associate’s Degree or Bachelor’s Degree Nursing Program Current RN license to practice in the State of Georgia Knowledge of basic nursing theory and practice, medical terminology, and familiarity with Health System policies and procedures. Familiarity with hospital regulatory requirements. Possesses knowledge of Microsoft and Cerner applications. Possess excellent written, oral, and interpersonal communication skills; Strong analytical, problem solving, decision making, and organizational skills Able to establish and maintain effective rapport with members of the medical staff. Able to work in a high volume, complex environment while maintaining confidentiality Able to work independently and able to be a part of a collaborative team. Able to multi-task, create and present data as needed. Why Choose Southeast Georgia Health System? We are mission-focused to provide safe, quality, accessible, and cost-effective care to meet the health needs of the people and communities it serves. Our workplace is as pleasant and rewarding as the setting we enjoy outside of work -- imagine stepping out of your workspace and into a world of scenic beauty, outdoor recreational activities, mild winters, natural beaches, fine dining, and a full array of cultural and colonial historic attractions. The chance to work within a culture that is collegial yet professional, has exceptional career-advancement potential, and work/life balance that is practically unparalleled. Our facility will allow you to use, sharpen, and add to your skills without having to commute to a large city environment. We offer competitive salaries and a comprehensive benefits package which includes generous Paid Time Off, tuition reimbursement, and wellness programs. The ability to be a part of the prestigious Coastal Community Health, a regional affiliation between Baptist Health and Southeast Georgia Health System. This collaboration forms a highly integrated hospital network focused on significant initiatives designed to enhance the quality and value of care provided to our contiguous communities.
Position: Clinical Review Nurse, Appeals Location: Any Job Id: 684 # of Openings: 1 Position Summary: Enhances continuity of patient care by providing liaison between assigned populations, providers, hospitals, and physicians through the processing of medical determinations. To review, coordinate and facilitate all necessary information required from the payer or provider in order to render an informed determination on medically reasonable, necessary and appropriate clinical care. Roles and Responsibilities: • Primary role as an appeal or claim reviewer. Perform pre-service appeals, post service appeals, and post service claim reviews, and provide documented recommendations based on the use of appropriate clinical guidelines. • Review initial evaluation and all additional clinical documentation against clinical standards, applicable state regulations and relevant treatment guidelines. • Review and comply with treatment guidelines and clinical review criteria to assist in determining the appropriateness of services. • Clinical nurse reviewers cannot render a recommendation or a determination for an appeal, however, may assist with providing appeals and claims recommendations to the payer, and in the notification process for delegated appeals. • Assist manager and clinical staff in quality improvement projects to provide instructive feedback to clients and providers within scope of practice. • Resolves patient care issues by working one-to-one with clients, community providers and staff to resolve issues in determination process. • Support non-clinical staff with clinically related questions or issues that arise within scope of practice. • Meets medical operational standards by contributing information to strategic plans and reviews, implementing production, productivity, quality, and customer-service standards; resolving problems; identifying system improvements. • Educates clients and community provider’s team by attending nursing team meetings; providing input relating to clinical concerns for individual patient requests. • Provides information by responding to queries of payers, physicians, and their practice staffs; sorting and distributing messages and documents; answering questions and requests; preparing information for recommendations and determinations; maintaining databases. • Improves quality results by studying, evaluating procedures and processes, recommending changes to services if needed. JOB DESCRIPTION • Serves and protects the company by adhering to URAC and NCQA standards, professional standards, policies and procedures, federal, state, and local requirements, and professional and licensing standards. • Contributes to company effectiveness by identifying short-term and long-range issues that must be addressed; providing information and commentary pertinent to deliberations; recommending options and courses of action; implementing directives. • Attend meetings and training. • Updates job knowledge by participating in educational opportunities; reading professional publications; maintaining personal networks; participating in professional organizations. • Enhances company reputation by accepting ownership for accomplishing new and different requests; exploring opportunities to add value to job accomplishments. • Follows company policies and procedures and conducts annual performance reviews in a timely manner. • Acts as a liaison for interdepartmental communication. • Respects and maintains HIPAA confidentiality guidelines. • Other duties as directed. Education, Experience and Licensure: Internal candidates must have at least 6 months in current role or prior claims and/or appeals experience No corrective action or attendance issues on file • Active and unrestricted Registered Nurse or License Practical Nurse licensure in any State in the United States. Some states may require an active and unrestricted nursing license. • Diploma of nursing from an accredited school required. • Bachelor’s Degree in a health related field preferred. • Minimum of 5 years’ experience in healthcare operations preferred. • Excellent verbal and written communication skills. Ability to foster a cohesive working environment. Preferred Professional Competency: • RN: National Certification in specialty area (i.e. Orthopedics, Cardiology, etc.) • LPN: Experienced in area of UM focus and working within a managed care environment. Preferred Skills: Creating a Safe, Effective Environment, Health Promotion and Maintenance, Nursing Skills, Verbal Communication, Listening, Confidentiality, Dependability, Emotional Control, Medical Teamwork. Strong organizational skills; commitment to customer service; ability to problem solve; strong presentation skills throughout all levels of the organization. Must be able to foster a positive and productive work environment with ability to lead, build teams and motivate staff. Proficient in Microsoft Word, Excel and Outlook. Apply for this Position
Are you looking to take your career to new heights with a leader in healthcare? SUNY Downstate Health Sciences University is one of the nation's leading metropolitan medical centers. As the only academic medical center in Brooklyn, we serve a large population that is among the most diverse in the world. We are also highly-ranked by Castle Connolly Medical, a healthcare rating company for consumers, among the top 5 leading U.S. medical schools for training doctors. Bargaining Unit UUP Job Summary The Department of Case Management at SUNY Downstate Health Sciences University is seeking a full-time TH Utilization Review & Quality Assurance Senior Coordinator / Utilization Review Nurse. The successful candidate will: Report directly to the RN Case Management Manager. Review patient records for chief complaints, signs and symptoms of disease to justify medical necessity for admission to acute inpatient rehabilitation facility (IRF) per Milliman Care Guidelines (MCGs). Provide critical feedback per established MCGs. Collaborate with social workers, referring case managers, and physicians for alternative care sites when appropriate. Validate admission and continuing stay criteria with third party payers as well as primary care and attending physicians. Complete clinical reviews and forward to MCOs. Use clinical knowledge and knowledge of anticipated response to treatment to assess patient progression toward anticipated outcomes. Assess patients and care support for continuing care needs to develop, implement and evaluate an effective discharge plan in collaboration with the multidisciplinary team. Use knowledge of usual length of stay to initiate a plan for discharge. Determine medical necessity, appropriateness of admission, continuing stay and level of care using a combination of clinical information, clinical criteria, and third-party information. Intervene when determinations are not in alignment with clinical information, clinical criteria, IT systems or third-party information to resolve the situation. Communicate and coordinate with patients/care teams to intervene when progression is stalled or diverted. Collaborate and communicate with patients/care teams related to reimbursement issues and to create a discharge plan. Support the process of patient choice in establishing a discharge plan. Actively contribute to and participate in all IRF AM huddles, Rehab Unite team meetings, rehab unit related length of stay meetings, discharge planning rounds, unit daily reports, clinical practice team and department meetings. PRN participate in med-surg unit interdisciplinary team rounds. Complete IRF discharge calls, perform utilization reviews, and facilitate peer-to-peer reviews in care management module. Complete PRls and forward to SAR/SNF after patient/care team selection. Assist in Joint Reconstruction surgery QAPI and optimization. Work in dynamic work environment across multiple settings, while frequently communicating with team members as necessary and appropriate. Be a team player and a role model for other staff members and students. Model the organization's WE CARE values. Demonstrate flexibility and perform other job related duties as business need demands, as the position is not limited to the above description. Required Qualifications New York State Registered Nurse Licensure. Current Patient Review Instrument (PRI) Certification. 2+ years of recent acute care clinical nursing experience (Critical Care preferred). Working knowledge of Utilization Review processes. Use of CareGuidelines (MCG/Interqual). Computer proficiency in Microsoft Word, Excel, PowerPoint. Strong interpersonal, communication, administrative, and organizational skills. Or, a satisfactory equivalent combination of experience, education and training to the above. Preferred Qualifications Bachelor of Science Degree preferred. Competency/experience with Careport, Allscripts EHR. Work Schedule Monday to Friday; 9:00am to 5:00pm (Full-Time) Salary Grade/Rank SL-4 Salary Range Commensurate with experience and qualifications Executive Order Pursuant to Executive Order 161, no State entity, as defined by the Executive Order, is permitted to ask, or mandate, in any form, that an applicant for employment provide his or her current compensation, or any prior compensation history, until such time as the applicant is extended a conditional offer of employment with compensation. If such information has been requested from you before such time, please contact the Governor’s Office of Employee Relations at (518) 474-6988 or via email at info@goer.ny.gov. Equal Employment Opportunity Statement SUNY Downstate Health Sciences University is an affirmative action, equal opportunity employer and does not discriminate on the basis of race, color, national origin, religion, creed, age, disability, sex, gender identity or expression, sexual orientation, familial status, pregnancy, predisposing genetic characteristics, military status, domestic violence victim status, criminal conviction, and all other protected classes under federal or state laws. Women, minorities, veterans, individuals with disabilities and members of underrepresented groups are encouraged to apply. If you are an individual with a disability and need a reasonable accommodation for any part of the application process, or in order to perform the essential functions of a position, please contact Human Resources at ada@downstate.edu
Current Emanate Health Employees - Please log into your Workday account to apply Everyone at Emanate Health plays a vital role in the care we deliver. No matter what department you belong to, the work you do at Emanate Health affects lives. When you join Emanate Health, you become part of a team that works together to strengthen our communities and grow as individuals. On Glassdoor's list of "Best Places to Work" in 2021, Emanate Health was named the #1 ranked health care system in the United States, and the #19 ranked company in the country. Job Summary Provides expertise to the organization in the form of quality management review and performance improvement knowledge. Supports the hospital and medical staff in Performance Improvement activities and works within the organization's Performance Improvement plan. Job Requirements a. Minimum Education Requirement : BSN preferred. b. Minimum Experience Requirement : All (1) newly graduated nurses, (2) re-entry nurses, and (3) nurses new to the U.S. healthcare system must satisfactorily complete the Emanate Health R.N. Residency Program within the first 6 months of employment. Minimum of three years of acute care experience. Experience in quality- related job preferred. Computer proficiency is required. Excellent customer service skills required. c. Minimum License Requirement : Current California RN license. CPHQ preferred. Delivering world-class health care one patient at a time. Pay Range: $54.63 - $84.67
Job Description Job Summary Provides support for medical claim and internal appeals review activities - ensuring alignment with applicable state and federal regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Contributes to overarching strategy to provide quality and cost-effective member care. Job Duties Facilitates clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases in which an appeal has been made, or is likely to be made, to ensure medical necessity and appropriate/accurate billing and claims processing. Reevaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of relevant and applicable state and federal regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of services provided, length of stay, level of care, and inpatient readmissions. Validates member medical records and claims submitted/correct coding, to ensure appropriate reimbursement to providers. Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) issues. Identifies and reports quality of care issues. Assists with complex claim review including diagnosis-related group (DRG) validation, itemized bill review, appropriate level of care, inpatient readmission, and any opportunities identified by the payment integrity analytical team; makes decisions and recommendations pertinent to clinical experience. Prepares and presents cases representing Molina, along with the chief medical officer (CMO), for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings. Reviews medically appropriate clinical guidelines and other appropriate criteria with medical directors on denial decisions. Supplies criteria supporting all recommendations for denial or modification of payment decisions. Serves as a clinical resource for utilization management, CMOs, physicians and member/provider inquiries/appeals. Provides training and support to clinical peers. Identifies and refers members with special needs to the appropriate Molina program per applicable policies/protocols. Job Qualifications REQUIRED QUALIFICATIONS: At least 2 years clinical nursing experience, including at least 1 year of utilization review, medical claims review, long-term services and supports (LTSS), claims auditing, medical necessity review and/or coding experience, or equivalent combination of relevant education and experience. Registered Nurse (RN). License must be active and unrestricted in state of practice. Experience demonstrating knowledge of ICD-10, Current Procedural Technology (CPT) coding and Healthcare Common Procedure Coding (HCPC). Experience working within applicable state, federal, and third-party regulations. Analytic, problem-solving, and decision-making skills. Organizational and time-management skills. Attention to detail. Critical-thinking and active listening skills. Common look proficiency. Effective verbal and written communication skills. Microsoft Office suite and applicable software program(s) proficiency. PREFERRED QUALIFICATIONS: Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ), or other health care certifications. Nursing experience in critical care, emergency medicine, medical/surgical or pediatrics. Billing and coding experience. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $29.05 - $67.97 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
Registered Nurse Looking for Utilization Management AND Education experience. Medical Management Educator within Utilization Management This is a hybrid position. The role includes being an Epic Credentialed Trainer from March - October 2026, returning to the Utilization Management team upon Epic implementation. Scope of work: In conjunction with Medical Management leadership, coordinates the educational plan for the Behavioral Health, Care Management, and Utilization Management departments. Stakeholders include staff, physicians, department leadership, and third-party vendors. Uses specific age and culture-related physical, intellectual, psychological, and development attributes in the educational plans for staff. Reports to either a Director of Behavioral Health, Care Management, or Utilization Management with matrix reporting to other areas in Medical Management. Develops/implements the educational plan for Behavioral Health, Care Management, and Utilization Management. ·Develops/implements orientation of new staff which is comprehensive and individualized with one-on-one training for three or more weeks. ·Rounding and telephonic support of staff education needs and problem solving. ·Ongoing education based on analysis of outcomes from external audits. ·Education and support for implementation and ongoing use of new electronic medical record system and supplemental ancillary computer systems. ·Collaborate with educators to Provide education and support as needed. Conducts department-specific assessment for educational needs related to Compliance Monitoring and Education. ·Monthly auditing of Compliance Risk areas and identification of staff education and documentation needs to ensure compliance ·Annual education on InterQual ® criteria changes with annual Interrater Reliability Assessment. ·Analyze and evaluate the effectiveness of all educational activities. Conducts educational workshops to medical management and related audiences as requested. ·Education of changes and payor requirements to targeted Physician groups. Develops informational materials and/or other media to be distributed to internal/external customers. · Internal/external orientation material. · Maintains and updates repositories of educational content needed for staff orientation, day-to-day operations, and continuing education on Sharepoint sites. · Develops annual education plan to ensure Care and Utilization management staff have access to current best practice and relevant updates. · Monthly auditing for specific areas of focus as directed by leadership, to ensure adherence to clinical best practice. Department Liaison for external audits. ·Coordinates and facilitates with other departments to ensure readiness for audits ·Analyze audit recommendations ·Reporting outcomes and development/implementation of staff education as needed. ·Assists with project and program improvement efforts Qualifications Required Bachelor's Degree Preferred Master's Degree Utilization Management experience highly preferred. Education and/or training experience highly preferred 3 years of relevant experience Must have 3 to 5 years' experience in Care Management, or Utilization Management. Required Registered Nurse (RN) - State of Michigan Upon Hire required How Corewell Health cares for you Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here . On-demand pay program powered by Payactiv Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more! Optional identity theft protection, home and auto insurance, pet insurance Traditional and Roth retirement options with service contribution and match savings Eligibility for benefits is determined by employment type and status Primary Location SITE - Priority Health - 1231 E Beltline Ave NE - Grand Rapids Department Name Utilization Management Operations - PH Managed Benefits Employment Type Full time Shift Day (United States of America) Weekly Scheduled Hours 40 Hours of Work 8 a.m. to 5 p.m. Days Worked Monday to Friday Weekend Frequency N/A CURRENT COREWELL HEALTH TEAM MEMBERS – Please apply through Find Jobs from your Workday team member account. This career site is for Non-Corewell Health team members only. Corewell Health is committed to providing a safe environment for our team members, patients, visitors, and community. We require a drug-free workplace and require team members to comply with the MMR, Varicella, Tdap, and Influenza vaccine requirement if in an on-site or hybrid workplace category. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process, to perform the essential functions of a job, or to enjoy equal benefits and privileges of employment due to a disability, pregnancy, or sincerely held religious belief. Corewell Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category. An interconnected, collaborative culture where all are encouraged to bring their whole selves to work, is vital to the health of our organization. As a health system, we advocate for equity as we care for our patients, our communities, and each other. From workshops that develop cultural intelligence, to our inclusion resource groups for people to find community and empowerment at work, we are dedicated to ongoing resources that advance our values of diversity, equity, and inclusion in all that we do. We invite those that share in our commitment to join our team. You may request assistance in completing the application process by calling 616.486.7447.
Job Description Job Summary Provides support for medical claim and internal appeals review activities - ensuring alignment with applicable state and federal regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Contributes to overarching strategy to provide quality and cost-effective member care. Job Duties Facilitates clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases in which an appeal has been made, or is likely to be made, to ensure medical necessity and appropriate/accurate billing and claims processing. Reevaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of relevant and applicable state and federal regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of services provided, length of stay, level of care, and inpatient readmissions. Validates member medical records and claims submitted/correct coding, to ensure appropriate reimbursement to providers. Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) issues. Identifies and reports quality of care issues. Assists with complex claim review including diagnosis-related group (DRG) validation, itemized bill review, appropriate level of care, inpatient readmission, and any opportunities identified by the payment integrity analytical team; makes decisions and recommendations pertinent to clinical experience. Prepares and presents cases representing Molina, along with the chief medical officer (CMO), for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings. Reviews medically appropriate clinical guidelines and other appropriate criteria with medical directors on denial decisions. Supplies criteria supporting all recommendations for denial or modification of payment decisions. Serves as a clinical resource for utilization management, CMOs, physicians and member/provider inquiries/appeals. Provides training and support to clinical peers. Identifies and refers members with special needs to the appropriate Molina program per applicable policies/protocols. Job Qualifications REQUIRED QUALIFICATIONS: At least 2 years clinical nursing experience, including at least 1 year of utilization review, medical claims review, long-term services and supports (LTSS), claims auditing, medical necessity review and/or coding experience, or equivalent combination of relevant education and experience. Registered Nurse (RN). License must be active and unrestricted in state of practice. Experience demonstrating knowledge of ICD-10, Current Procedural Technology (CPT) coding and Healthcare Common Procedure Coding (HCPC). Experience working within applicable state, federal, and third-party regulations. Analytic, problem-solving, and decision-making skills. Organizational and time-management skills. Attention to detail. Critical-thinking and active listening skills. Common look proficiency. Effective verbal and written communication skills. Microsoft Office suite and applicable software program(s) proficiency. PREFERRED QUALIFICATIONS: Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ), or other health care certifications. Nursing experience in critical care, emergency medicine, medical/surgical or pediatrics. Billing and coding experience. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $29.05 - $56.64 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
Job Description Job Summary Provides support for medical claim and internal appeals review activities - ensuring alignment with applicable state and federal regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Contributes to overarching strategy to provide quality and cost-effective member care. Job Duties Facilitates clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases in which an appeal has been made, or is likely to be made, to ensure medical necessity and appropriate/accurate billing and claims processing. Reevaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of relevant and applicable state and federal regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of services provided, length of stay, level of care, and inpatient readmissions. Validates member medical records and claims submitted/correct coding, to ensure appropriate reimbursement to providers. Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) issues. Identifies and reports quality of care issues. Assists with complex claim review including diagnosis-related group (DRG) validation, itemized bill review, appropriate level of care, inpatient readmission, and any opportunities identified by the payment integrity analytical team; makes decisions and recommendations pertinent to clinical experience. Prepares and presents cases representing Molina, along with the chief medical officer (CMO), for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings. Reviews medically appropriate clinical guidelines and other appropriate criteria with medical directors on denial decisions. Supplies criteria supporting all recommendations for denial or modification of payment decisions. Serves as a clinical resource for utilization management, CMOs, physicians and member/provider inquiries/appeals. Provides training and support to clinical peers. Identifies and refers members with special needs to the appropriate Molina program per applicable policies/protocols. Job Qualifications REQUIRED QUALIFICATIONS: At least 2 years clinical nursing experience, including at least 1 year of utilization review, medical claims review, long-term services and supports (LTSS), claims auditing, medical necessity review and/or coding experience, or equivalent combination of relevant education and experience. Registered Nurse (RN). License must be active and unrestricted in state of practice. Experience demonstrating knowledge of ICD-10, Current Procedural Technology (CPT) coding and Healthcare Common Procedure Coding (HCPC). Experience working within applicable state, federal, and third-party regulations. Analytic, problem-solving, and decision-making skills. Organizational and time-management skills. Attention to detail. Critical-thinking and active listening skills. Common look proficiency. Effective verbal and written communication skills. Microsoft Office suite and applicable software program(s) proficiency. PREFERRED QUALIFICATIONS: Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ), or other health care certifications. Nursing experience in critical care, emergency medicine, medical/surgical or pediatrics. Billing and coding experience. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $29.05 - $56.64 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
Description Introduction Do you want to join an organization that invests in you as a Clinical Nurse Reviewer? 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 Clinical Nurse Reviewer like you to be a part of our team. Job Summary and Qualifications The Clinical Nurse Reviewer WFH is responsible for performing retrospective medical reviews based on patient eligibility and contract requirements. Responsibilities: Perform a retrospective review of medical records using clinical expertise and Medicaid guidelines to determine medical necessity for emergent inpatient admissions and outpatient services. Perform clinical reviews and maintain clinical documentation in accordance with HCA policy, procedures, and job aids Submit authorization request based on state deadlines using various State portals Review deferred accounts and update according to payer request Review denied account to determine justification for Appeal requests Maintains clinical documentation according to HCA’S documentation policy Meet productivity requirement as established by leadership Assists in the orientation and training of new clinical staff Education: Successful completion of an accredited Licensed Practical/Vocational Nurse Program RN licensure is preferred Experience: A minimum of one-year experience reviewing medical records for medical necessity in a managed care, health plan, and/or hospital setting A minimum of one-year experience with denials and appeals in a clinical setting preferred A minimum of one-year experience in a patient care setting Experience working in a remote setting Work from home roles require employees must have high speed internet 60 MB download and 10 MB upload. Certificate/License: Currently licensed in applicable state Maintains an active LPN/LVN license in good standing " Parallon provides full-service revenue cycle management, or total patient account resolution, for HCA Healthcare. Our services include scheduling, registration, insurance verification, hospital billing, revenue integrity, collections, payment compliance, credentialing, health information management, customer service, payroll and physician billing. We also provide full-service revenue cycle management as well as targeted solutions, such as Medicaid Eligibility, for external clients across the country. Parallon has over 17,000 colleagues, and serves close to 1,000 hospitals and 3,000 physician practices, all making an impact on patients, providers and their communities. HCA Healthcare has been recognized as one of the World’s Most Ethical Companies® by the Ethisphere Institute more than ten times. In recent years, HCA Healthcare spent an estimated 3.7 billion in cost for the delivery of charitable care, uninsured discounts, and other uncompensated expenses. " "Good people beget good people." - Dr. Thomas Frist, Sr. HCA Healthcare Co-Founder We are a family 270,000 dedicated professionals! Our Talent Acquisition team is reviewing applications for our Clinical Reviewer LPN 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.
Description Introduction Do you want to join an organization that invests in you as a Clinical Nurse Reviewer? 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 Clinical Nurse Reviewer like you to be a part of our team. Job Summary and Qualifications The Clinical Nurse Reviewer WFH is responsible for performing retrospective medical reviews based on patient eligibility and contract requirements. Responsibilities: Perform a retrospective review of medical records using clinical expertise and Medicaid guidelines to determine medical necessity for emergent inpatient admissions and outpatient services. Perform clinical reviews and maintain clinical documentation in accordance with HCA policy, procedures, and job aids Submit authorization request based on state deadlines using various State portals Review deferred accounts and update according to payer request Review denied account to determine justification for Appeal requests Maintains clinical documentation according to HCA’S documentation policy Meet productivity requirement as established by leadership Assists in the orientation and training of new clinical staff Education: Successful completion of an accredited Licensed Practical/Vocational Nurse Program RN licensure is preferred Experience: A minimum of one-year experience reviewing medical records for medical necessity in a managed care, health plan, and/or hospital setting A minimum of one-year experience with denials and appeals in a clinical setting preferred A minimum of one-year experience in a patient care setting Experience working in a remote setting Work from home roles require employees must have high speed internet 60 MB download and 10 MB upload. Certificate/License: Currently licensed in applicable state Maintains an active LPN/LVN license in good standing " Parallon provides full-service revenue cycle management, or total patient account resolution, for HCA Healthcare. Our services include scheduling, registration, insurance verification, hospital billing, revenue integrity, collections, payment compliance, credentialing, health information management, customer service, payroll and physician billing. We also provide full-service revenue cycle management as well as targeted solutions, such as Medicaid Eligibility, for external clients across the country. Parallon has over 17,000 colleagues, and serves close to 1,000 hospitals and 3,000 physician practices, all making an impact on patients, providers and their communities. HCA Healthcare has been recognized as one of the World’s Most Ethical Companies® by the Ethisphere Institute more than ten times. In recent years, HCA Healthcare spent an estimated 3.7 billion in cost for the delivery of charitable care, uninsured discounts, and other uncompensated expenses. " "Good people beget good people." - Dr. Thomas Frist, Sr. HCA Healthcare Co-Founder We are a family 270,000 dedicated professionals! Our Talent Acquisition team is reviewing applications for our Clinical Reviewer LPN 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.
Description Introduction Do you want to join an organization that invests in you as a Clinical Nurse Reviewer? 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 Clinical Nurse Reviewer like you to be a part of our team. Job Summary and Qualifications The Clinical Nurse Reviewer WFH is responsible for performing retrospective medical reviews based on patient eligibility and contract requirements. Responsibilities: Perform a retrospective review of medical records using clinical expertise and Medicaid guidelines to determine medical necessity for emergent inpatient admissions and outpatient services. Perform clinical reviews and maintain clinical documentation in accordance with HCA policy, procedures, and job aids Submit authorization request based on state deadlines using various State portals Review deferred accounts and update according to payer request Review denied account to determine justification for Appeal requests Maintains clinical documentation according to HCA’S documentation policy Meet productivity requirement as established by leadership Assists in the orientation and training of new clinical staff Education: Successful completion of an accredited Licensed Practical/Vocational Nurse Program RN licensure is preferred Experience: A minimum of one-year experience reviewing medical records for medical necessity in a managed care, health plan, and/or hospital setting A minimum of one-year experience with denials and appeals in a clinical setting preferred A minimum of one-year experience in a patient care setting Experience working in a remote setting Work from home roles require employees must have high speed internet 60 MB download and 10 MB upload. Certificate/License: Currently licensed in applicable state Maintains an active LPN/LVN license in good standing " Parallon provides full-service revenue cycle management, or total patient account resolution, for HCA Healthcare. Our services include scheduling, registration, insurance verification, hospital billing, revenue integrity, collections, payment compliance, credentialing, health information management, customer service, payroll and physician billing. We also provide full-service revenue cycle management as well as targeted solutions, such as Medicaid Eligibility, for external clients across the country. Parallon has over 17,000 colleagues, and serves close to 1,000 hospitals and 3,000 physician practices, all making an impact on patients, providers and their communities. HCA Healthcare has been recognized as one of the World’s Most Ethical Companies® by the Ethisphere Institute more than ten times. In recent years, HCA Healthcare spent an estimated 3.7 billion in cost for the delivery of charitable care, uninsured discounts, and other uncompensated expenses. " "Good people beget good people." - Dr. Thomas Frist, Sr. HCA Healthcare Co-Founder We are a family 270,000 dedicated professionals! Our Talent Acquisition team is reviewing applications for our Clinical Reviewer LPN 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.
Description Introduction Do you want to join an organization that invests in you as a Clinical Nurse Reviewer? 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 Clinical Nurse Reviewer like you to be a part of our team. Job Summary and Qualifications The Clinical Nurse Reviewer WFH is responsible for performing retrospective medical reviews based on patient eligibility and contract requirements. Responsibilities: Perform a retrospective review of medical records using clinical expertise and Medicaid guidelines to determine medical necessity for emergent inpatient admissions and outpatient services. Perform clinical reviews and maintain clinical documentation in accordance with HCA policy, procedures, and job aids Submit authorization request based on state deadlines using various State portals Review deferred accounts and update according to payer request Review denied account to determine justification for Appeal requests Maintains clinical documentation according to HCA’S documentation policy Meet productivity requirement as established by leadership Assists in the orientation and training of new clinical staff Education: Successful completion of an accredited Licensed Practical/Vocational Nurse Program RN licensure is preferred Experience: A minimum of one-year experience reviewing medical records for medical necessity in a managed care, health plan, and/or hospital setting A minimum of one-year experience with denials and appeals in a clinical setting preferred A minimum of one-year experience in a patient care setting Experience working in a remote setting Work from home roles require employees must have high speed internet 60 MB download and 10 MB upload. Certificate/License: Currently licensed in applicable state Maintains an active LPN/LVN license in good standing " Parallon provides full-service revenue cycle management, or total patient account resolution, for HCA Healthcare. Our services include scheduling, registration, insurance verification, hospital billing, revenue integrity, collections, payment compliance, credentialing, health information management, customer service, payroll and physician billing. We also provide full-service revenue cycle management as well as targeted solutions, such as Medicaid Eligibility, for external clients across the country. Parallon has over 17,000 colleagues, and serves close to 1,000 hospitals and 3,000 physician practices, all making an impact on patients, providers and their communities. HCA Healthcare has been recognized as one of the World’s Most Ethical Companies® by the Ethisphere Institute more than ten times. In recent years, HCA Healthcare spent an estimated 3.7 billion in cost for the delivery of charitable care, uninsured discounts, and other uncompensated expenses. " "Good people beget good people." - Dr. Thomas Frist, Sr. HCA Healthcare Co-Founder We are a family 270,000 dedicated professionals! Our Talent Acquisition team is reviewing applications for our Clinical Reviewer LPN 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.
Description Introduction Do you want to join an organization that invests in you as a Clinical Nurse Reviewer? 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 Clinical Nurse Reviewer like you to be a part of our team. Job Summary and Qualifications The Clinical Nurse Reviewer WFH is responsible for performing retrospective medical reviews based on patient eligibility and contract requirements. Responsibilities: Perform a retrospective review of medical records using clinical expertise and Medicaid guidelines to determine medical necessity for emergent inpatient admissions and outpatient services. Perform clinical reviews and maintain clinical documentation in accordance with HCA policy, procedures, and job aids Submit authorization request based on state deadlines using various State portals Review deferred accounts and update according to payer request Review denied account to determine justification for Appeal requests Maintains clinical documentation according to HCA’S documentation policy Meet productivity requirement as established by leadership Assists in the orientation and training of new clinical staff Education: Successful completion of an accredited Licensed Practical/Vocational Nurse Program RN licensure is preferred Experience: A minimum of one-year experience reviewing medical records for medical necessity in a managed care, health plan, and/or hospital setting A minimum of one-year experience with denials and appeals in a clinical setting preferred A minimum of one-year experience in a patient care setting Experience working in a remote setting Work from home roles require employees must have high speed internet 60 MB download and 10 MB upload. Certificate/License: Currently licensed in applicable state Maintains an active LPN/LVN license in good standing " Parallon provides full-service revenue cycle management, or total patient account resolution, for HCA Healthcare. Our services include scheduling, registration, insurance verification, hospital billing, revenue integrity, collections, payment compliance, credentialing, health information management, customer service, payroll and physician billing. We also provide full-service revenue cycle management as well as targeted solutions, such as Medicaid Eligibility, for external clients across the country. Parallon has over 17,000 colleagues, and serves close to 1,000 hospitals and 3,000 physician practices, all making an impact on patients, providers and their communities. HCA Healthcare has been recognized as one of the World’s Most Ethical Companies® by the Ethisphere Institute more than ten times. In recent years, HCA Healthcare spent an estimated 3.7 billion in cost for the delivery of charitable care, uninsured discounts, and other uncompensated expenses. " "Good people beget good people." - Dr. Thomas Frist, Sr. HCA Healthcare Co-Founder We are a family 270,000 dedicated professionals! Our Talent Acquisition team is reviewing applications for our Clinical Reviewer LPN 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.
Description Introduction Do you want to join an organization that invests in you as a Clinical Nurse Reviewer? 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 Clinical Nurse Reviewer like you to be a part of our team. Job Summary and Qualifications The Clinical Nurse Reviewer WFH is responsible for performing retrospective medical reviews based on patient eligibility and contract requirements. Responsibilities: Perform a retrospective review of medical records using clinical expertise and Medicaid guidelines to determine medical necessity for emergent inpatient admissions and outpatient services. Perform clinical reviews and maintain clinical documentation in accordance with HCA policy, procedures, and job aids Submit authorization request based on state deadlines using various State portals Review deferred accounts and update according to payer request Review denied account to determine justification for Appeal requests Maintains clinical documentation according to HCA’S documentation policy Meet productivity requirement as established by leadership Assists in the orientation and training of new clinical staff Education: Successful completion of an accredited Licensed Practical/Vocational Nurse Program RN licensure is preferred Experience: A minimum of one-year experience reviewing medical records for medical necessity in a managed care, health plan, and/or hospital setting A minimum of one-year experience with denials and appeals in a clinical setting preferred A minimum of one-year experience in a patient care setting Experience working in a remote setting Work from home roles require employees must have high speed internet 60 MB download and 10 MB upload. Certificate/License: Currently licensed in applicable state Maintains an active LPN/LVN license in good standing " Parallon provides full-service revenue cycle management, or total patient account resolution, for HCA Healthcare. Our services include scheduling, registration, insurance verification, hospital billing, revenue integrity, collections, payment compliance, credentialing, health information management, customer service, payroll and physician billing. We also provide full-service revenue cycle management as well as targeted solutions, such as Medicaid Eligibility, for external clients across the country. Parallon has over 17,000 colleagues, and serves close to 1,000 hospitals and 3,000 physician practices, all making an impact on patients, providers and their communities. HCA Healthcare has been recognized as one of the World’s Most Ethical Companies® by the Ethisphere Institute more than ten times. In recent years, HCA Healthcare spent an estimated 3.7 billion in cost for the delivery of charitable care, uninsured discounts, and other uncompensated expenses. " "Good people beget good people." - Dr. Thomas Frist, Sr. HCA Healthcare Co-Founder We are a family 270,000 dedicated professionals! Our Talent Acquisition team is reviewing applications for our Clinical Reviewer LPN 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.
Description Areas of focus include Surgery, Women's, and Children's at UNCMC. The team: Completes clinical reviews for all areas: pediatric, adult surgical, and postpartum patients Ensures compliance in accordance to government's federal rules and regulations related to patient care and reimbursement Interacts with the Interdisciplinary Team for patient care progression Protects hospital revenue by working with payors for insurance authorizations, denials, and appeals Delivers mandated federal notices to patients/ patient representatives related to their payer source Preferences given to candidates with Medical Surgical bedside experience. 40 hrs/week with flexible schedule options available Primarily on-site with option to work remotely twice monthly Holiday rotation No Nights No on-call 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: STATE Entity: UNC Medical Center Organization Unit: UNCH Care Mgmt-Medical Center Work Type: Full Time Standard Hours Per Week: 40.00 Salary Range: $35.87 - $51.57 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:Chapel Hill Exempt From Overtime: Exempt: Yes This is a State position employed by UNC Health Care System with UNC Health benefits. If, however, you are presently an employee of another North Carolina agency and currently participate in TSERS or the ORP, you will be eligible to continue participating in those plans at UNC Health. 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.
Overview Job Summary Manages the care for a specific population; facilitates the safe transition of patients throughout the continuum of care for appropriate utilization of resources, service delivery and compliance with federal and other payer requirements. Provides early assessment of transitional needs identified during their hospitalization, illness, and/or life situation. Performs other duties as assigned. Responsibilities Utilization Review Discharge planning Readmission Reduction Participation Payer Communication and denial reduction Completes assigned goals. Specifications Experience Minimum Required RN with at least one (1) year of clinical experience Preferred/Desired RN with 3 years of clinical experience with Case Management experience in a hospital or payer setting Education Minimum Required Diploma or Associate Degree in Nursing Preferred/Desired BSN or MSN Training Minimum Required Preferred/Desired Certified Case Manager Special Skills . Minimum Required Critical thinking skills, communication, organization, interpersonal and computer skills. Problem solving; and governmental regulations. Preferred/Desired Critical thinking skills, communication, organization, interpersonal and computer skills. Knowledge of payer requirements; problem solving; and governmental regulations. Licensure RN Minimum Required RN Preferred/Desired RN;CCM;ACM
Overview Assists the hospital healthcare team in maintaining quality efficient patient centered care. Serves as a resource to physicians; conducts admission and concurrent reviews; identifies patients who do not meet criteria and takes action to ensure the patient is placed in the most appropriate alternative level of care and determines the correct admission status and level of care for those patients who meet hospital admission criteria (ambulatory surgery, observation, and inpatient). Qualifications Minimum Education and Experience Requirements: Registered nurse (RN) with current Florida license with three (3) years critical care nursing experience, five (5) years medical-surgical nursing experience or three (3) years utilization/case management or 3rd party payer work experience. Ability to adjust priorities quickly. Ability to organize multiple tasks simultaneously. Ability to work independently. Ability to work interdependently with many levels of staff. Attention to detail. Excellent organizational, interpersonal and communication skills. Innovative problem solving skills. Scheduled work hours and days may vary depending upon departmental needs determined by department director/manager. Motor Vehicle Operator Designation: Employees in this position: Will not operate vehicles for an assigned business purpose NOTE: A frequent driver is defined as one who uses his/her personal or Shands automobile a) at least once daily, b) at least five individual trips per week or c) drives, on average, over 150 miles per week in the performance of his/her job. Please indicate the appropriate operator designation on the Request for Personnel (RFP) form at the time a RFP is submitted to post the position. Licensure/Certification/Registration: Registered Nurse (RN) with current Florida License
This position is eligible for up to $15,000.00 Sign on Bonus for those that are eligible. ($7,500.00 for those with less than one year of experience) Summary The LPN Utilization Management (UM) Reviewer, in collaboration with Care Coordination, Guthrie Clinic offices, other physician offices, and the Robert Packer Hospital Business Office, is responsible for the coordination of Utilization Management (UM) processes and requirements of prior authorization/certification for reimbursement of patient care services. The responsibilities include: - Facilitating communication between physician offices, payers, Care Coordination and other hospital departments as appropriate to obtain prior authorization required to meet contractual reimbursement requirements and to assist in ensuring generation of clean claims in a timely manner - Securing authorization as appropriate - Documenting payer authorization - Facilitating issue resolution with payer sources in collaboration with other hospital departments or clinic offices as appropriate - Demonstrating ongoing competence in payer requirements, as defined collaboratively with Patient Business Services and Care Coordination Additionally, the position works closely with the Care Coordination department to support data collection and aggregation associated with UM processes and operations. Experience Minimum of five years clinical experience in an acute health care setting. 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 LPN licensure or eligibility for licensure required Essential Functions 1. Conducts validation of the authorization/certification process for elective short procedures and inpatient care services in collaboration with physician offices, hospital Business Office, Care Coordination and other hospital departments as appropriate.2. Ensures documentation and communication of authorizations and certifications as appropriate. 3. Performs routine admission and discharge notification according to payer requirements. 4. Assists to ensure compliance with documentation requirements and guidelines of third-party payers, regulatory and government agencies. 5. Develops and maintains collaborative relationships with members of the healthcare team. - Proactively researches case findings related to payer audits of UM decisions and prepares input for supporting documentation to complete the revenue cycle process, coordinates as necessary with the hospital Business Office, physician offices, Care Coordination, Medical Director and other hospital departments as appropriate.1. Serves as liaison with payers, hospital Business Office, physician offices, Care Coordination and other hospital departments as appropriate for resolution of issues or questions. 2. Collaborates with the hospital Business Office, physician offices, Care Coordination and other hospital departments as appropriate to track and monitor the status for denials and appeals. - Participates in performance improvement and educational activities.1. Serves as an educational resource to other members of the healthcare team with regards to changes in reimbursement, payers, and/or utilization requirements. 2. Participates in departmental long-range planning to meet the needs identified through utilization management activities. 3. Demonstrates appropriate problem solving and decision-making skills. 4. Maintains the required 8 hours of continuing education per year. 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. Pay Range $20.38-$31.81/hr Dependent on years of applicable experience.
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: $35.87 - $51.57 per hour (Hiring Range) Pay offers are determined by experience and internal equity Work Assignment Type: Onsite Work Schedule: Weekend 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.
JOB DESCRIPTION Job SummaryProvides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines. • Analyzes clinical service requests from members or providers against evidence based clinical guidelines. • Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. • Conducts reviews to determine prior authorization/financial responsibility for Molina and its members. • Processes requests within required timelines. • Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner. • Requests additional information from members or providers as needed. • Makes appropriate referrals to other clinical programs. • Collaborates with multidisciplinary teams to promote the Molina care model. • Adheres to utilization management (UM) policies and procedures. Required Qualifications • At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience. • Registered Nurse (RN). License must be active and unrestricted in state of practice. • Ability to prioritize and manage multiple deadlines. • Excellent organizational, problem-solving and critical-thinking skills. • Strong written and verbal communication skills. • Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications • Certified Professional in Healthcare Management (CPHM). • Recent hospital experience in an intensive care unit (ICU) or emergency room. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $26.41 - $61.79 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
Department: 11200 Atrium Health Cabarrus - Case Management Status: Full time Benefits Eligible: Yes Hou rs Per Week: 40 Schedule Details/Additional Information: Regular, FT Pay Range $35.50 - $53.25 Essential Functions Coordination with members of the healthcare team and payors to facilitate placement of patients in the appropriate level of care related to medical necessity. Promotes an open communication between utilization management and the health care team concerning level of care. Responsible for timely provision/flow of specific clinical information to third-party payors to ensure authorization of stay. Maintaining compliance with professional standards, national and local coverage determinations, the Centers for Medicare, and Medicaid Services (CMS) as well as state and federal regulatory requirements, as applicable. Performs admission and continued stay utilization reviews to assure the medical necessity of hospital admissions, appropriate level of care, continued stay and supportive services, and to examine delays in the provision of services, in accordance with the utilization management plan. Demonstrates proficiency in applying nationally accepted evidence-based criteria to assure appropriate hospital level of service. Maintains timely and appropriate documentation of all utilization management activities. Utilizes critical thinking skills based upon extensive knowledge of disease processes and clinical outcomes to identify the need for further clarification of physician documentation within the medical record. Prioritize work to facilitate timely accurate utilization management activities for each evidence-based product type. Collaborates to improve quality throughput coordination of care impacting length of stay with minimizing cost and ensuring optimum outcomes. Identification and documentation of potentially avoidable delays. Demonstrates the ability to utilize the licensed software tool to perform and record daily medical reviews. Communicates information effectively, including comprehensive clinical information, to third-party payors, to secure timely authorization forthe appropriate level of service. Provides payor feedback to case managers, social workers, and providers. Escalates and resolves denials to secure payment for the necessary care and services provided to the patient. Collaborates with payor, physician advisor, attending provider and multi-disciplinary team to reconcile payor-issued denials. Demonstrates proficiency and knowledge of various reimbursement criteria, including documentation necessary for reimbursement from regulatory bodies. Assist in process improvement of various committees, interdepartmental and departmental as assigned by the VP, AVP, Director, Medical Director, Manager or Team Supervisor. Supports and contributes to the Patient Centered Care Philosophy by understanding that every staff member is a Caregiver whose role is to meet the needs of the patient. Performs other duties and responsibilities as assigned and within the time frame specified. Physical Requirements Works in an office type setting, extensive walking throughout the facility. Prolonged periods of sitting reviewing medical records and documentation. Repetitive wrist motion and occasional lifting of 10-20 pounds. Intact sight and hearing with or without assistive devices are required. Must speak English fluently and write English in understandable terms Education, Experience and Certifications Bachelor's in Nursing from an accredited school of nursing, required. Master's degree in business or healthcare related field, preferred. Previous utilization review experience preferred. Current RN license or temporary license as a Registered Nurse Petitioner in the state in which you work and reside or if declaring a National License Compact (NLC) state as your primary state of residency, meet the licensure requirements in your home state; or for Non-National License Compact states, current RN license or temporary license as a Registered Nurse Petitioner required in the state where the RN works. 5 years of related nursing experience preferred. Clinical experience within the assigned population. Extensive knowledge of disease processes and clinical outcomes. Case Management experience or background preferred. Strong financial and analytical skills preferred. Appropriate Professional certification required within 3 years of hire and per Clinical Care Management Certification Guidelines. Additional education, training, certifications, or experience may be required within the department by the department leader. Our Commitment to You: Advocate Health offers a comprehensive suite of Total Rewards: benefits and well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more – so you can live fully at and away from work, including: Compensation Base compensation listed within the listed pay range based on factors such as qualifications, skills, relevant experience, and/or training Premium pay such as shift, on call, and more based on a teammate's job Incentive pay for select positions Opportunity for annual increases based on performance Benefits and more Paid Time Off programs Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability Flexible Spending Accounts for eligible health care and dependent care expenses Family benefits such as adoption assistance and paid parental leave Defined contribution retirement plans with employer match and other financial wellness programs Educational Assistance Program About Advocate Health Advocate Health is the third-largest nonprofit, integrated health system in the United States, created from the combination of Advocate Aurora Health and Atrium Health. Providing care under the names Advocate Health Care in Illinois; Atrium Health in the Carolinas, Georgia and Alabama; and Aurora Health Care in Wisconsin, Advocate Health is a national leader in clinical innovation, health outcomes, consumer experience and value-based care. Headquartered in Charlotte, North Carolina, Advocate Health services nearly 6 million patients and is engaged in hundreds of clinical trials and research studies, with Wake Forest University School of Medicine serving as the academic core of the enterprise. It is nationally recognized for its expertise in cardiology, neurosciences, oncology, pediatrics and rehabilitation, as well as organ transplants, burn treatments and specialized musculoskeletal programs. Advocate Health employs 155,000 teammates across 69 hospitals and over 1,000 care locations, and offers one of the nation’s largest graduate medical education programs with over 2,000 residents and fellows across more than 200 programs. Committed to providing equitable care for all, Advocate Health provides more than $6 billion in annual community benefits. Utilization Management RN supports medical necessity, revenue integrity and denial prevention while coordinating with members of the healthcare team and payors for authorization of appropriate level of care and length of stay for medically necessary services. Accurately conducts medical necessity reviews, utilizing the electronic medical record, in accordance with all state and federal regulations and the Utilization Management Plan. Advocates for the patient while balancing the responsibility of stewardship for their organization, and in general, the judicious management of resources.
Quality Management - Acute Full Time Day Shift 8-430 Lexington Health is a comprehensive network of care that includes six community medical and urgent care centers, nearly 80 physician practices, more than 9,000 health care professionals and Lexington Medical Center, a 607-bed teaching hospital in West Columbia, South Carolina. It was selected by Modern Healthcare as one of the Best Places to Work in Healthcare and was first in the state to achieve Magnet with Distinction status for excellence in nursing care. Consistently ranked as best in the Columbia Metro area by U.S. News & World Report, Lexington Health delivers more than 4,000 babies each year, performs more than 34,000 surgeries annually and is the region's third largest employer. Lexington Health also includes an accredited Cancer Center of Excellence, the state’s first HeartCARE Center, the largest skilled nursing facility in the Carolinas, and an Alzheimer’s care center. Its postgraduate medical education programs include family medicine and transitional year residencies, as well as an informatics fellowship. Job Summary The Quality Review Specialist-RN provides consultative services regarding quality assessment and trends to medical staff and to hospital ancillary department personnel. In this role, the employee will perform comprehensive retrospective reviews in a timely manner utilizing criteria developed and approved by the medical staff, hospital, and regulatory agents. Minimum Qualifications Minimum Education: High School Diploma or Equivalent Minimum Years of Experience: 4 Years of clinical or hospital experience; 2 Years of experience in quality or utilization review. Substitutable Education & Experience (Optional): None. Required Certifications/Licensure: Registered Nurse (RN) Required Training: None. Essential Functions Utilizes in-depth knowledge of clinical workflows, policies and procedures, patient care / clinical business processes, regulatory requirements, and best practices to: Risk Management- Perform daily review of new occurrence reports. Identify occurrences that require additional follow-up and reports these to the Director or designee in a timely manner. Ensure that occurrences are categorized correctly and all fields completed and correct. Verifies data accuracy with medical record if necessary. Ensure that occurrence reports are forwarded to all appropriate persons. Access other sources of data as needed for investigation and follow up. Serves as System Administrator for the occurrence reporting system. Primary liaison between Risk Management, Information Services, and system users. Manages access to the occurrence reporting system. Adds new locations and new users and provides new-user training. Assigns passwords. Removes users as needed. Provides new user training and ongoing user support, paying keen attention to user needs and opportunities to offer solutions and modify processes to improve efficiencies. Coordinates with vendor and Information Services to troubleshoot system as needed. Center for Best Practice & PN Quality- Assists with development, implementation, and evaluation of the hospital’s overall quality improvement program. Assist with coordination, preparation, and maintenance of performance improvement assessment and improvement activities. Responsible for data integrity and follows well defined processes for maintaining data integrity as well as manage assigned database. Assists in evaluation, analysis, maintenance and development of system functionality of the EHR to meet clinical objectives including participating in project plan development/tracking and workflow analysis. Duties & Responsibilities Provides accurate and timely routine statistical analyses and reports to designated parties. Identifies need for new reports and develops and creates reports. Generates user-friendly reports from other databases. Evaluates and analyzes data for trends, identifies areas of concern, and uses data display techniques to provide reports for various meetings and hospital committees. Prepares materials for meetings and assists with maintenance of performance improvement project records. Represents department on committees / teams as assigned. Participates and supports department goals, objectives and timelines, working with a sense of urgency and accuracy to ensure effective implementation. Successfully engages in multiple initiatives simultaneously and demonstrates flexibility in role and a willingness to help others. Attains an annual minimum of 12 hours of continuing education in topics related to role. May prepare materials for meetings and assists with maintenance of performance improvement project records. May represent department on committees / teams as assigned. Risk Management: Resolves problems and recommends solutions through research, inquiry, and data analysis, maintaining support call logs and tracking of issues. Compiles and maintains accurate statistics pertaining to occurrence data. Participates in and contributes to patient safety / risk reduction activities, including: Participates in and contributes to investigations of serious unanticipated events and "close-calls". Participates in and contributes to development, implementation and evaluation of corrective action plans. Supports a culture of safety by encouraging staff to speak up and report safety and quality issues. Center for Best Practice & PN Quality: Identifies opportunities for improvement and coordinates/participates in the development and implementation of action plans to make improvements- recommends changes to systems/processes that do not contribute to desired outcomes. Works collaboratively and communicates effectively with administration, IS, and clinical care teams through participation in the planning, development, and evaluation and maintenance of the Clinical Information system. Audits database contents for accuracy and validity. Acts as a resource person in quality assessment activities with hospital departments and committees. Works directly with hospital personnel to provide assistance and guidance in establishing criteria, reviewing medical records, etc. Requires efficient use of numerous software products (Word, Excel, PowerPoint, Outlook, etc.) Performs all other duties as assigned. We are committed to offering quality, cost-effective benefits choices for our employees and their families: Day ONE medical, dental and life insurance benefits Health care and dependent care flexible spending accounts (FSAs) Employees are eligible for enrollment into the 403(b) match plan day one. LHI matches dollar for dollar up to 6%. Employer paid life insurance – equal to 1x salary Employee may elect supplemental life insurance with low cost premiums up to 3x salary Adoption assistance LHI provides its full-time employees employer paid short-term disability and long-term disability coverage after 90 days of eligible employment Tuition reimbursement Student loan forgiveness Equal Opportunity Employer It is the policy of Lexington Health to provide equal opportunity of employment for all individuals, and to remain compliant with applicable state and federal laws and regulations. Lexington Health strives to provide a discrimination-free environment, and to recruit, select, on-board, and employ all employees without regard to race, color, religion, sex, age, disability, national origin, veteran status, or pregnancy, childbirth, or related medical conditions, including but not limited to, lactation. Lexington Health endeavors to upgrade and promote employees from within the hospital where possible and consistent with the employee’s desires and abilities and the hospital’s needs.
The RN Case Manager is to support the physician and interdisciplinary team in facilitating patient care, with the underlying objective of enhancing the quality of clinical outcomes and patient satisfaction while managing the cost of care and providing timely and accurate information to payers. This role integrates and coordinates Utilization management, care coordination and discharge planning functions. The Case Manager is accountable for a designated patient caseload and plans effectively in order to meet patient needs, manage the length of stay, and promote efficient use of resources. Education: Minimum of A.S.N. from an accredited college or university (BSN Preferred) and current Alabama licensure. Experience: Three years acute care experience required. Additional Skills/Abilities: Excellent interpersonal communication and negotiation skills; strong organizational and time management skills as evidenced by capacity to prioritize multiple tasks and role components; ability to work independently and exercise sound judgment in interactions with physicians, patients and their families, and payers. DeKalb Regional Medical Center celebrated its 35th anniversary in October 2021. Throughout its history, the team of healthcare providers here have been proud to serve the people of Fort Payne, Alabama. Today, DeKalb Regional is 134-beds and offers comprehensive services including cardiac catheterization, geriatric psychiatric services, women’s and children’s services, bariatric services, orthopedics services, and many more. DeKalb Regional and its physicians serve patients from throughout Northeast Alabama and Western Georgia. DeKalb Regional is committed to providing quality care close to home. The hospital is accredited by The Joint Commission and the American College of Cardiology as a Primary Stroke Center and Chest Pain Center. It was also awarded the 2023 Get with the Guidelines Rural Stroke Bronze Quality Award from the American Heart Association. In fall of 2023, DeKalb Regional was one of seven hospitals in Alabama to receive an “A” grade from The Leapfrog Group. DeKalb Regional Medical Center has 500 employees and more than 100 members of the medical staff.
