As a utilization review (UR) nurse, you help ensure that patients are receiving the appropriate level of care while being mindful of expenditures to your employer, whether you work for a hospital, managed care facility, or insurance company.
Wondering where you might work in this role? The federal government requires that organizations participating in Medicare and Medicaid conduct utilization reviews. This means that you’ll find a variety of workplace options for UR nurse jobs.
Education and Certifications for Utilization Review Nursing Jobs
Before you can work in utilization review, you must complete a nursing program from an approved institution. Once you pass the NCLEX and receive your license, you’ll want to gain clinical experience in direct patient care. Registered nurses may also want to pursue experience as an RN case manager.
While likely not required for most jobs, specialty certification can increase both your knowledge and also your leverage when it comes time to look for a new utilization review nurse job. Certifications include:
Health Utilization Management Certification (HUMC)
Put some effort into customizing your utilization review nurse resume to each job posting. For instance, if an employer is seeking a candidate “proficient in insurance prior authorizations and medical necessity criteria for different payers,” include that phrase in your resume. This helps demonstrate that your skills are a good fit for the job.
In your UR nurse cover letter, explain a bit about what drew you to this particular position. Remember, you don’t want just any old job — you want this job. To reinforce this sentiment as you apply to UR nurse jobs, search the employer’s website for their mission statement and see where your values overlap.
Interviewing for a Utilization Review Nurse Job
A job interview has the potential to determine whether or not you’ll get a job offer. Need some pointers? Review our nursing interview tips in advance to help you formulate smart answers to common questions and boost your confidence.
Learn how to answer interview questions about your strengths as a nurse:
Utilization Review Nurse Salary
The average annual salary for a UR nurse is around $91,600 for a registered nurse. Your location, level of education and experience, and employer can impact this number. For a more accurate picture of utilization review nurse jobs’ salary estimates in your area, explore the current UR nursing jobs on IntelyCare.
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Quality Review Nurse - RN (Onsite) Full Time | Tampa, FL Trilogy Home Healthcare , a Humana company, is hiring a dedicated and organized Quality Review Registered Nurse (QRN) to join our award-winning team. We've been named Best of Best of Florida for Home Care services, and we pride ourselves on being a fun, supportive, and team-driven organization where your voice matters. What You'll Do: Review OASIS documentation and QAPI for accuracy and compliance Evaluate clinical practices and documentation to improve efficiency and outcomes Collaborate with clinicians to support quality patient care Analyze data for performance improvement Assist with clinical education and ongoing training Why Choose Trilogy? Supportive leadership Opportunities for advancement and growth A fun, team-spirited environment Full Time Employee Benefits Include: Medical ($0 deductible and $0 copay!), Dental, Vision, and Life Insurance 401k with company match Paid Time Off and Holiday Pay Employee Referral Bonus Program Qualifications: Active Registered Nurse (RN) license in Florida 1-2 years of experience in Medicare home health and OASIS documentation required OASIS Certification preferred Strong collaboration, judgement, and communication skills Ability to work independently and drive team goals To learn more please visit our website at www.trilogyhomehealthcare.com and follow us on Facebook and Instagram ! For more Information regarding the HB531 Florida Agency for Health Care Administration, please visit: https://info.flclearinghouse.com/
Description Areas of focus include Medicine, Oncology, Cardiac, and Psychiatry Services Preferences given to candidates with Medical Surgical and/or Psychiatry bedside experience. The Team: Completes clinical reviews for all areas: Inpatient, Observation, Extended Recovery 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 40 hrs/week (Monday-Friday) Weekend rotation 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.
It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you’ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development. Summary We are seeking a skilled Utilization Review Nurse to conduct prior authorization, prospective, concurrent, and retrospective reviews for medical necessity and appropriateness of services, following clinical criteria, coverage policies, and contract guidelines. This involves reviewing medical documentation, accurately documenting findings, and ensuring policy compliance. Your role in our mission Review admissions, procedures, services, and supplies for medical necessity and appropriateness, meeting quality and production goals. Use clinical criteria for decision-making, referring complex cases to Medical Directors when needed. Engage with providers to gather clinical information, apply guidelines, and make determinations. Document findings and rationale in medical management systems. Assist in training new nurses, provide feedback, and stay updated on clinical guidelines. Maintain RN license and meet continuing education requirements. What we're looking for Active RN license. 3+ years of inpatient clinical experience. 1+ year in prior authorization reviews using InterQual or MCG. Strong written communication skills in a fast-paced setting. Proficient in Microsoft Office and other computer applications. What you should expect in this role Home-based position. High-speed internet and a distraction-free workspace required. Core hours: 8:00 AM - 6:00 PM ET, with potential for extended hours. Occasional travel (up to 10%) based on business needs. This position is for pipeline purposes, and we welcome applications on an ongoing basis. The pay range for this position is $65,000.00 - $78,000.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits , and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities. We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings. Gainwell Technologies is an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics.
Location: METROHEALTH MEDICAL CENTER Biweekly Hours: 80.00 Shift: Days; Rotating Weekends and Holidays The MetroHealth System is redefining health care by going beyond medical treatment to improve the foundations of community health and well-being: affordable housing, a cleaner environment, economic opportunity and access to fresh food, convenient transportation, legal help and other services. The system strives to become as good at preventing disease as it is at treating it. Founded in 1837, Cuyahoga County’s safety-net health system operates four hospitals, four emergency departments and more than 20 health centers. Summary Responsible for supporting the physician and interdisciplinary team in the provision of patient care by ensuring the appropriate level of care at the point of entry. The utilization review nurse will work on defined patient populations and is responsible for an initial clinical review at the point of patient entry to the inpatient care setting, this includes observation status. Will collaborate with other interdisciplinary team members to develop and participate in a systematic approach to denial management, and in so doing reduce organizational exposure to revenue loss. Actively participates in the denial management process; improve reimbursement by optimizing revenue recovery due to inappropriate level of care, failure to meet medical necessity, and/or severity of illness. Upholds the mission, vision, values, and customer service standards of The MetroHealth System. Qualifications Required: Bachelor’s degree in Nursing (applies to placements after 1/1/2017). Current Registered Nurse License State of Ohio. Minimum of five years clinical experience. Able to work independently and as a member of an interdisciplinary team. Knowledge and experience with medical necessity criteria for inpatient admission and observation placement. Knowledge and experience of denials based on the absence of documented medical necessity or failure to meet severity of illness and intensity of service criteria. Knowledge of internal criteria set and Milliman Health Management Guidelines. Excellent interpersonal communication and negotiation skills. Strong analytical, data management, and PC skills. Current working knowledge of, utilization management, case-management, performance improvement, and managed care reimbursement. Strong organizational and time management skills. Preferred: Two years of experience with case management, utilization review. Physical Demands: May need to move around intermittently during the day, including sitting, standing, stooping, bending, and ambulating. May need to remain still for extended periods, including sitting and standing. Ability to communicate in face-to-face, phone, email, and other communications. Ability to read job related documents. Ability to use computer.
Baptist Health is the region’s largest not-for-profit healthcare organization, with 12 hospitals, over 28,000 employees, 4,500 physicians and 200 outpatient centers, urgent care facilities and physician practices across Miami-Dade, Monroe, Broward and Palm Beach counties. With internationally renowned centers of excellence in cancer, cardiovascular care, orthopedics and sports medicine, and neurosciences, Baptist Health is supported by philanthropy and driven by its faith-based mission of medical excellence. For 25 years, we’ve been named one of Fortune’s 100 Best Companies to Work For, and in the 2024-2025 U.S. News & World Report Best Hospital Rankings, Baptist Health was the most awarded healthcare system in South Florida, earning 45 high-performing honors. What truly sets us apart is our people. At Baptist Health, we create personal connections with our colleagues that go beyond the workplace, and we form meaningful relationships with patients and their families that extend beyond delivering care. Many of us have walked in our patients’ shoes ourselves and that shared experience fuels out commitment to compassion and quality. Our culture is rooted in purpose, and every team member plays a part in making a positive impact – because when it comes to caring for people, we’re all in. Description: The purpose of this position is to conduct initial, concurrent, retrospective chart review for clinical, financial and resource utilization. Coordinates with healthcare Team for optimal efficient patient outcomes, while decreasing length of stay and avoid delays and denied days. They are accountable for a designated patient caseload and provides intervention and coordination to decrease avoidable delays denial of reimbursement. Specific functions within this role include: Screens pre-admission, admission process using established criteria for all points of entry, Facilitates communication between payers, review agencies and healthcare team, Identify delays in treatment or inappropriate utilization and serves as a resource, Coordinates communication with physicians, Identify opportunities for expedited appeals and collaborates resolve payer issues and ensures, maintains effective communication with Revenue Cycle Departments. Estimated pay range for this position is $45.00 / hour depending on shift as applicable. Qualifications: Degrees: Associates. Licenses & Certifications: Registered Nurse. Additional Qualifications: RNs hired prior to 2/2012 (10/1/2017 at Bethesda or 7/1/2019 at BRRH) with an Associates Degree in Nursing are not required to have a BSN to continue their non-leadership role as an RN; however, required to complete the BSN within 5 years of hire. 3 years of hospital clinical experience preferred. Excellent written, interpersonal communication and negotiation skills. Strong critical thinking skills and the ability to perform clinical chart review abstract information efficiently. Strong analytical, data management and computer skills. Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components. Current working knowledge of payer and managed care reimbursement preferred. Ability to work independently and exercise sound judgment in interactions with the health care team and patients/families. Knowledgeable in local, state, and federal legislation and regulations, and ability to tolerate high volume production standards. Minimum Required Experience: 3 Years of Utilization Review experience in an acute care setting required EOE, including disability/vets
It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you’ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development. Summary We are seeking a talented individual for a DRG Nurse Reviewer Appeals and Hearings to coordinate and perform all appeal related duties including analyzing and responding appropriately to appeals from providers; reviewing documentation to ensure all aspects of the appeal have been addressed properly and accurately; prepare case files and case summaries for hearings; and participate in in virtual and on-site hearings. Your role in our mission Reviews provider appeals and redeterminations using approved clinical and coding guidelines and documents appeal determinations clearly and concisely. Analyzes and reviews appeal documentation to ensure all aspects of the appeal have been addressed properly and accurately while maintaining production goals and quality standards. Prepares case files and case summaries for hearings and actively participates in hearings in conjunction with the Medical Director. Assists management with training new reviewers to include daily monitoring, mentoring, feedback and education. Maintains current knowledge of clinical criteria guidelines and/or coding guidelines; successfully completes required CEUs to maintain RN license and/or coding certification. Responsible for attending training and scheduled meetings to enhance skills and working knowledge of clinical policies, procedures, rules, and regulations. Actively cross-trains to perform reviews of multiple claim types to provide a flexible workforce to meet client needs. What we're looking for Active, Unrestricted RN license from the United States and in the primary home residency, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), required Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or Certified Professional Medical Auditor (CPMA) required 5+ years clinical experience or 5+ years medical record coding experience preferred Working knowledge of the appeals and hearings process Excellent written communication skills including ability to write clear, concise, accurate, and fact-based rationales in support of appeal determinations. Excellent oral communication skills with particular emphasis on verbally presenting case summaries and decisions. Ability to multi-task in a fast-paced production environment. What you should expect in this role Remote (Work from Home) Up to 25% Travel for onsite hearing testimony This position is for pipeline purposes, and we welcome applications on an ongoing basis. The pay range for this position is $90,000.00 - $99,000.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits , and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities. We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings. Gainwell Technologies is an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics.
Capital Health is the region's leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advanced technology. Capital Health is a five-time Magnet-Recognized health system for nursing excellence and is comprised of 2 hospitals. Capital Health Medical Group is made up of more than 250 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region. Capital Health recognizes that attracting the best talent is key to our strategy and success as an organization. As a result, we aim for flexibility in structuring competitive compensation offers to ensure we can attract the best candidates. The listed pay range or pay rate reflects compensation for a full-time equivalent (1.0 FTE) position. Actual compensation may differ depending on assigned hours and position status (e.g., part-time). Pay Range: $39.40 - $59.19 Scheduled Weekly Hours: 40 Position Overview Performs chart review of identified patients to identify quality, timeliness and appropriateness of patient care. Conducts admission reviews for Medicare, Medicaid beneficiaries, as well as private insurers and self pay patients, based on appropriate guidelines. Uses these criteria guidelines to screen for appropriateness for inpatient level of care or observation services based on physician certification (physicians H&P, treatment plan, potential risks and basis for expectation of a 2 midnight stay). Refers cases as appropriate, to the UR physician advisor for review and determination. Gathers clinical information to conduct continued stay utilization review activities with payers on a daily basis. Performs concurrent and retrospective clinical reviews with various payers, utilizing the appropriate guidelines as demonstrated by compliance with all applicable regulations, policies and timelines. Adheres to CMS guidelines for utilization reviews as evidenced by utilization of the relevant guidelines and appropriate referrals to the physician advisor and the UR Committee. Identifies, develops and implements strategies to reduce length of stay and resource consumption. . Confers proactively with admitting physician to provide coaching on accurate level of care determinations at point of hospital entry. Keeps current on all regulatory changes that affect delivery or reimbursement of acute care services. Uses knowledge of national and local coverage determinations to appropriately advise physicians. Understands and applies federal law regarding the use of Hospital Initiated Notice of Non-Coverage (HINN) and Lifetime Reserve Days letters. Identifies and records consistently any information on any progression of care or patient flow barriers using the Avoidable Days tool in the Utilization software program. Consults with medical staff, care team and case managers as necessary to resolve immediate progression of care barriers through appropriate administrative and medical channels. Engages care team colleagues in collaborative problem solving regarding appropriate utilization of resources. Recognizes and responds appropriately to patient safety and risk factors. Represents Utilization Management at various committees, professional organizations an physician groups as needed. Promotes the use of evidence based protocols and or order sets to influence high quality and cost effective care. Identifies, develops and implements strategies to reduce lengths of stay and resource consumption in the patient population. Participates in performance improvement activities. Promotes medical documentation that accurately reflects findings and interventions, presence of complication or comorbidities, and patient's need for continued stay. Identifies and records episodes of preventable delays or avoidable days due to failure of progression of care processes. Maintains appropriate documentation in the Utilization software system on each patient to include specific information of all resource utilization activities. Participates actively in daily huddles, patient care conferences, and hospitalist or nurse handoff reports to maintain knowledge about intensity of services and the progression of care. Identifies potentially wasteful or misused resources and recommends alternatives if appropriate by analyzing clinical protocols. Maintains related continuing education credits = 15 per calendar year. MINIMUM REQUIREMENTS Education: Minimum of Associate's degree in Nursing. Graduate of an accredited school of nursing. CPHQ, CCM or CPUR preferred. Experience: Three years of clinical nursing or two years quality management, utilization review or discharge planning experience. Other Credentials: Registered Nurse - NJ Knowledge and Skills: Three years of clinical nursing or two years quality management, utilization review or discharge planning experience. CPHQ, CCM or CPUR preferred. Special Training: Basic computer skills including the working knowledge of Microsoft Office, UR software and EMR. Possesses familiarity with MCG guidelines. Mental, Behavioral and Emotional Abilities: Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form. Usual Work Day: 8 Hours PHYSICAL DEMANDS AND WORK ENVIRONMENT Frequent physical demands include: Sitting , Standing , Walking Occasional physical demands include: Climbing (e.g., stairs or ladders) , Carry objects , Push/Pull , Twisting , Bending , Reaching forward , Reaching overhead , Keyboard use/repetitive motion , Talk or Hear Continuous physical demands include: Lifting Floor to Waist 10 lbs. Lifting Waist Level and Above 5 lbs. Sensory Requirements include: Accurate Near Vision, Accurate Far Vision, Accurate Color Discrimination, Accurate Depth Perception, Accurate Hearing Anticipated Occupational Exposure Risks Include the following: N/A This position is eligible for the following benefits: Medical Plan Prescription drug coverage & In-House Employee Pharmacy Dental Plan Vision Plan Flexible Spending Account (FSA) - Healthcare FSA - Dependent Care FSA Retirement Savings and Investment Plan Basic Group Term Life and Accidental Death & Dismemberment (AD&D) Insurance Supplemental Group Term Life & Accidental Death & Dismemberment Insurance Disability Benefits – Long Term Disability (LTD) Disability Benefits – Short Term Disability (STD) Employee Assistance Program Commuter Transit Commuter Parking Supplemental Life Insurance - Voluntary Life Spouse - Voluntary Life Employee - Voluntary Life Child Voluntary Legal Services Voluntary Accident, Critical Illness and Hospital Indemnity Insurance Voluntary Identity Theft Insurance Voluntary Pet Insurance Paid Time-Off Program The pay range listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future. When determining base salary and/or rate, several factors may be considered including, but not limited to location, years of relevant experience, education, credentials, negotiated contracts, budget, market data, and internal equity. Bonus and/or incentive eligibility are determined by role and level. The salary applies specifically to the position being advertised and does not include potential bonuses, incentive compensation, differential pay or other forms of compensation, compensation allowance, or benefits health or welfare. Actual total compensation may vary based on factors such as experience, skills, qualifications, and other relevant criteria.
Kaweah Health is a publicly owned, community healthcare organization that provides comprehensive health services to the greater Visalia area in central California. With more than 5,000 employees, Kaweah Health provides state-of-the-art medicine and high-quality preventive services in our acute care hospital, specialized health centers and clinics. Our eight-campus healthcare district has 613 beds and offers comprehensive health services across a broad continuum of care. It takes a special person to work for Kaweah Health. We serve a region where the needs are great, which makes the rewards even greater. Every day, we care for people facing unique challenges and in need of healing. Throughout it all, our focus is to make a difference, and we do — in the health of our patients, our loved ones, and our community. Benefits Eligible Full-Time Benefit Eligible Work Shift Day - 8 Hour or less Shift (United States of America) Department 8790 Case Management The RN Case Manager assesses plans, coordinates care, evaluates and advocates for services to meet patients health needs as they move through the continuum of care to promote quality and cost effective outcomes. QUALIFICATIONS License /Certification Required: California RN license BLS Education Preferred: BSN, MSN, or currently enrolled in RN-BSN program Experience Required: Two years of acute care clinical nursing experience (LVN/RN) with at least one year as a RN Department Specific Requirements For Emergency Department: must have three years of RN experience in an Emergency Department or Critical Care setting. JOB RESPONSIBILITIES Essential Identifies needs and facilitates provision of services with physicians, nurse managers and multidisciplinary team members as the patient moves through the continuum of care. Assessment Acts as a resource person for clinical care issues, identifies action plans, and facilitates communication with appropriate physician(s) for direction. Assists and communicates with physician offices and all appropriate departments to discuss new admissions, demographic information, and other data pertinent to the patient/family which may affect their care. Evaluates the assessment process of new patients within 30 days of admission to determine needs and develop a Care Management Plan to address Social Determinants of Health (SDOH) barriers. Planning Establishes a specific plan with action steps for each patient within assigned population. Collaborates with the patient/family, care team, and physician(s) to determine goals and objectives to achieve patient/family outcomes, which include physical and psychological factors. Takes the lead in assessing care plan progression and revising care plan as necessary. Rounds with physicians and multidisciplinary team. Coordinates with the multidisciplinary team to ensure graduation planning goals and objectives are developed and modified as needed. Implementation Takes the lead in moving patients through the continuum of care in a timely, cost effective, and safe manner. Assists in the organization and integration of resources needed to meet stated goals and plans. Works with patient, family, multidisciplinary team, and outside services to accomplish set outcomes. Supervises implementation of treatment plan, including appropriate use of pre-printed orders. Documents in patient Progress Notes information including significant patient data, problems identified, assessment needs, and treatment goals. Documents findings in the electronic health record. Makes timely referrals for services. Evaluation Evaluates care plan for appropriateness and monitors progress towards outcomes. Suggests appropriate level of care when changes in level of function, medical, and psychological issues arise. Reviews medical records of patients for proper and timely documentation of services provided, evidence of functional progress. In collaboration with patient, family, and multidisciplinary team, changes the plan of care as appropriate. The nurse's practice is guided by the Code for Nurses. Decisions and actions on behalf of patients/residents are determined in an ethical manner. Maintains patient confidentiality within legal and regulatory parameters. Acts as a patient/resident advocate and assists patients/residents in developing skills so they can advocate for themselves. Delivers care in a nonjudgmental and nondiscriminatory manner that preserves patient autonomy, dignity and rights. Addendum (essential for specific dept) POST ACUTE CARE CASE MANAGER: Reviews and screens 100% of patients same day referred to TCS using InterQual Criteria. Interviews, researches and gathers data to identify patient's needs and formulate a post-acute plan of care in collaboration with the patient, family, physician, acute case manager and other disciplines which enhances appropriate utilization of post-acute levels of care. Facilitates transition of patient more efficiently to TCS by ensuring proper documentation, orders, and arrangements are complete for timely transfer. PROGRAM LIAISON FOR INPATIENT REHABILITATION: Assumes responsibility for the implementation of each individual patient program. Assists the patient/family to become adequately oriented to their program. Enables the patient's program to proceed in an orderly, purposeful, and goal directed manner. Promotes the participation of the person served on an ongoing basis. Participates consistently in team conferences concerning the person served. Facilitates the exit/discharge process and arranged for follow-up and appropriate supportive services. Monitors the patient/family response to treatment and determines need for intervention and/or referral. CARDIAC SURGERY CARE COORDINATOR: Serves as the Cardiac surgery program liaison to patients, their families, and the cardiac care team. Provides periodic updates during surgery, concentrating on emotional support and education to the family. Facilitates and coordinates care with referral physicians, outside hospitals, admission staff, and surgical department to arrange transfer of potential patients referred to open heart surgery. Collaborates with nurse managers. Acts as a resource person for clinical care issues. Available for educational needs of nursing staff. Facilitates movement through the continuum of care insuring all services, consults and treatments needed by patient are being provided. Collaborates with multidisciplinary team and case manager for individual patient discharge needs and plan. Rounds daily rounds with physician to identify patient needs related to diagnosis, treatment, prognosis, and projected discharge. Assists with current and accurate data collection pertaining to the cardiac surgery program. POPULATION HEALTH RN CASE MANAGER: Serves as a clinical resource for patients and families enrolled in Population Health Management programs such as Enhanced Care Management (ECM), Chronic Care Management, Transitional Care Management with goal of improving health outcomes, reducing unnecessary healthcare utilization and addressing Social Determinants of Health (SDOH) in partnership with a multidisciplinary team to include Primary Care Provider, Community Care Coordinator, Pharmacist, Medical Assistant, etc. Additional Demonstrates the knowledge and skills necessary to provide care and services appropriate to the population served on the assigned unit or work area. Knowledgeable of growth and development for all patient/family cultural, linguistic, spiritual, gender, and age specific needs. Able to effectively communicate and care for patient and family as reflected in the Plan for Provision of Care. Performs other duties as assigned. Pay Range $46.44 -$69.66 If you want to use your talents alongside people who face each day with courage and purpose, in an environment that empowers you to do your absolute best, this is where you belong.
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.
Summary GENERAL SUMMARY: Conducts day-to-day activities for the clinical, financial and utilization coordination of the patient’s hospital experience. Proactively consults with the interdisciplinary team which includes, but is not limited to, hospital patient care staff, physicians, patient support and family to ensure the patient’s hospital stay meets medical necessity and insurance authorizations are obtained in order to facilitate the patient’s and hospitals financial well-being. PRINCIPAL JOB FUNCTIONS: 1. *Commits to the mission, vision, beliefs and consistently demonstrates our core values. 2. *Performs utilization review activities, including concurrent and retrospective reviews as required. 3. *Determines the medical necessity of request by performing first level reviews, using approved evidence based guidelines/criteria. 4. *Collaborates with the patient’s provider and other healthcare team members in managing the patient’s length of stay and determining the continuing medical necessity of continued stays. 5. *Refers cases to reviewing physician when the treatment request does not meet criteria per appropriate algorithm. 6. *Participates in concurrent and retrospective denials and appeals process by researching issues surrounding the denial, participating in all levels of the appeal and process follow-up. 7. *Serves as an internal and external resource regarding appropriate level of care; admission status/classification; Medicare/Medicaid rules, regulations, and policies; 3rd party and managed care contracts; discharge planning; and length of stay. 8. Ensures appropriate resource utilization relevant to the financial, regulatory and clinical aspects of care; proposes alternative treatment to ensure a cost effective and efficient plan of care. 9. *Maintains awareness of financial reimbursement methodology, utilization management, payer/reimbursement practices and regulations and participates in resource stewardship. 10. *Promotes quality improvement initiatives and health care outcomes based on currently accepted clinical practice guidelines and total quality improvement initiatives. 11. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise. 12. Participates in meetings, committees and department projects as assigned. 13. Performs other related projects and duties as assigned. (Essential Job functions are marked with an asterisk “*”. Refer to the Job Description Guide for the definition of essential and non-essential job functions.) Attach Addendum for positions with slightly different roles or work-specific differences as needed. REQUIRED KNOWLEDGE, SKILLS AND ABILITIES: 1. Maintains clinical competency as required for the unit including but not limited to age-specific competencies relative to patient’s growth and developmental needs, annual skill competency verification and mandatory education and competencies. 2. Knowledge of governmental and third party payer regulations and requirements related to patient hospitalization and acute rehabilitation admission, stay and discharge activities, i.e., CMS, CARF, FIM (TM). 3. Knowledge of computer hardware equipment and software applications relevant to work functions. 4. Skill in conflict diffusion and resolution. 5. Ability to communicate effectively both verbally and in writing. 6. Ability to perform crucial conversations with desired outcomes. 7. Ability to establish and maintain effective working relationships with all levels of personnel and medical staff. 8. Ability to problem solve and engage independent critical thinking skills. 9. Ability to maintain confidentiality relevant to sensitive information. 10. Ability to prioritize work demands and work with minimal supervision. 11. Ability to perform crucial conversations with desired outcomes. 12. Ability to maintain regular and punctual attendance. EDUCATION AND EXPERIENCE: Current Registered Nurse licensure from the State of Nebraska or approved compact state of residence as defined by the Nebraska Nurse Practice Act. Minimum of two (2) years recent clinical experience required. Prior care coordination and/or utilization management experience preferred. OTHER CREDENTIALS / CERTIFICATIONS: Basic Life Support (CPR) certification required. Bryan Health recognizes American Heart Association (for healthcare professionals), American Red Cross (for healthcare professionals) and the Military Training Network. PHYSICAL REQUIREMENTS: (Physical Requirements are based on federal criteria and assigned by Human Resources upon review of the Principal Job Functions.) (DOT) – Characterized as sedentary work requiring exertion up to 10 pounds of force occasionally and/or a negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects, including the human body.
Responsibilities Granite Hills Hospital offers high-quality, patient centered behavioral health care for the greater Milwaukee community. Our 120-bed facility will feature evidence-based treatment for adolescents, adults, and older adults. We are looking for looking for a PRN Utilization Review (UR) Coordinator to join our new team. The UR Coordinator has responsibility for organizing and conducting the managed care process. The duties shall be directed toward supporting the hospital's mission in the pursuit of excellence in care/service and will include (but not limited to): conducting timely admission and continued stay record reviews with external payers, utilizing approved criteria to make determinations of medical necessity and level of care planning, verifying active treatment by completing internal audit reviews within approved time frames, assisting the treatment team when indicated in the discharge planning process, and acting as liaison with MD/Clinical Treatment Team and external agencies. Report authorizations, denials, and documentation concerns, as well as collaborate effectively accross departments to minimize denials/facilitate optimal use of hospital resources. Granite Hills Hospital offers comprehensive benefits such as: Competitive Compensation Excellent Medical, Dental, Vision, and Prescription Drug Plan Generous Paid Time Off 401(K) with company match and discounted stock plan Career development opportunities within UHS and its Subsidiaries Education Assistance Challenging and rewarding work environment Interested applicants may apply directly through our website https://granitehillshospital.com/ and apply through the Careers tab. One of the nation’s largest and most respected hospital companies, Universal Health Services, Inc. (UHS) has built an impressive record of achievement and performance. Steadily growing from a startup to an esteemed Fortune 500 corporation, UHS today has annual revenue nearing $10 billion. UHS is recognized as one of the World’s Most Admired Companies by Fortune; ranked #276 on the Fortune 500, and listed #275 in Forbes inaugural ranking of America’s Top 500 Public Companies. Qualifications The UR Coordinator position requires: Education: Bachelor degree in social work, psychology, or counseling. Master’s degree in social work, psychology, or counseling preferred. LPN/LVN required. ADN, BSN preferred. Limited or full licensure is preferred. Experience: Experience in psychiatric or substance abuse treatment preferred. Hospital utilization review/utilization management experience required. Experience in settings that include inpatient or partial hospitalization preferred. Familiarity with managed health care process, medical terminology, experience in case management, discharge planning, and/or utilization review preferred. EEO Statement All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws. We believe that diversity and inclusion among our teammates is critical to our success. Notice At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skillset and experience with the best possible career path at UHS and our subsidiaries. We take pride in creating a highly efficient and best in class candidate experience. During the recruitment process, no recruiter or employee will request financial or personal information (Social Security Number, credit card or bank information, etc.) from you via email. The recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc. If you are suspicious of a job posting or job-related email mentioning UHS or its subsidiaries, let us know by contacting us at: https://uhs.alertline.com or 1-800-852-3449. Licensure/Certification: Must possess a valid Driver’s License Knowledge: Prefer knowledge of the Milwaukee behavioral health marketplace, insurance plans, target markets and referral sources, psychiatric and chemical dependency treatment and, age-specific programming.
Summary GENERAL SUMMARY: Conducts day-to-day activities for the clinical, financial and utilization coordination of the patient’s hospital experience. Proactively consults with the interdisciplinary team which includes, but is not limited to, hospital patient care staff, physicians, patient support and family to ensure the patient’s hospital stay meets medical necessity and insurance authorizations are obtained in order to facilitate the patient’s and hospitals financial well-being. PRINCIPAL JOB FUNCTIONS: 1. *Commits to the mission, vision, beliefs and consistently demonstrates our core values. 2. *Performs utilization review activities, including concurrent and retrospective reviews as required. 3. *Determines the medical necessity of request by performing first level reviews, using approved evidence based guidelines/criteria. 4. *Collaborates with the patient’s provider and other healthcare team members in managing the patient’s length of stay and determining the continuing medical necessity of continued stays. 5. *Refers cases to reviewing physician when the treatment request does not meet criteria per appropriate algorithm. 6. *Participates in concurrent and retrospective denials and appeals process by researching issues surrounding the denial, participating in all levels of the appeal and process follow-up. 7. *Serves as an internal and external resource regarding appropriate level of care; admission status/classification; Medicare/Medicaid rules, regulations, and policies; 3rd party and managed care contracts; discharge planning; and length of stay. 8. Ensures appropriate resource utilization relevant to the financial, regulatory and clinical aspects of care; proposes alternative treatment to ensure a cost effective and efficient plan of care. 9. *Maintains awareness of financial reimbursement methodology, utilization management, payer/reimbursement practices and regulations and participates in resource stewardship. 10. *Promotes quality improvement initiatives and health care outcomes based on currently accepted clinical practice guidelines and total quality improvement initiatives. 11. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise. 12. Participates in meetings, committees and department projects as assigned. 13. Performs other related projects and duties as assigned. (Essential Job functions are marked with an asterisk “*”. Refer to the Job Description Guide for the definition of essential and non-essential job functions.) Attach Addendum for positions with slightly different roles or work-specific differences as needed. REQUIRED KNOWLEDGE, SKILLS AND ABILITIES: 1. Maintains clinical competency as required for the unit including but not limited to age-specific competencies relative to patient’s growth and developmental needs, annual skill competency verification and mandatory education and competencies. 2. Knowledge of governmental and third party payer regulations and requirements related to patient hospitalization and acute rehabilitation admission, stay and discharge activities, i.e., CMS, CARF, FIM (TM). 3. Knowledge of computer hardware equipment and software applications relevant to work functions. 4. Skill in conflict diffusion and resolution. 5. Ability to communicate effectively both verbally and in writing. 6. Ability to perform crucial conversations with desired outcomes. 7. Ability to establish and maintain effective working relationships with all levels of personnel and medical staff. 8. Ability to problem solve and engage independent critical thinking skills. 9. Ability to maintain confidentiality relevant to sensitive information. 10. Ability to prioritize work demands and work with minimal supervision. 11. Ability to perform crucial conversations with desired outcomes. 12. Ability to maintain regular and punctual attendance. EDUCATION AND EXPERIENCE: Current Registered Nurse licensure from the State of Nebraska or approved compact state of residence as defined by the Nebraska Nurse Practice Act. Minimum of two (2) years recent clinical experience required. Prior care coordination and/or utilization management experience preferred. OTHER CREDENTIALS / CERTIFICATIONS: Basic Life Support (CPR) certification required. Bryan Health recognizes American Heart Association (for healthcare professionals), American Red Cross (for healthcare professionals) and the Military Training Network. PHYSICAL REQUIREMENTS: (Physical Requirements are based on federal criteria and assigned by Human Resources upon review of the Principal Job Functions.) (DOT) – Characterized as sedentary work requiring exertion up to 10 pounds of force occasionally and/or a negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects, including the human body.
Description Become part of an inclusive organization with over 40,000 teammates, whose mission is to improve the health and well-being of the unique communities we serve. Summary: The Utilization Manager (UM) assesses new admissions, continued stay and discharge review cases for medical necessity, appropriate class and level of care (LOC). This position works collaboratively with an interdisciplinary team (including physicians, other care providers, payers, etc.) to ensure the patient’s needs are met and care delivery is coordinated. The UM completes utilization reviews in accordance with federal regulations and the health system’s Utilization Review Plan. Responsibilities: Uses approved criteria and conducts admission review/class change review as trigger by patient admission to the hospital to ensure appropriateness of the setting and timely implementation of the plan of care. Identifies and obtains observation services as appropriate . Partners with physicians, nursing, and other care providers to help ensure timely and accurate documentation of patient data and treatments. Communicates daily with the Care Manager to manage level of care transitions & appropriate utilization of services. Coordinates with the appropriate staff/payers to assure third party payer pre-certification and/or re-certifications when required . Discharge Facilitation: Utilizes high risk screening criteria to make appropriate referrals . Identifies patient/families with the complex psychosocial, on-going medical transition planning issues , continuing care needs by initiating appropriate care management referrals. Initiates appropriate social work referrals. Performs utilization management assessments and interventions, using collaboration with interdisciplinary team approach, on assigned patients as appropriate to ensure optimal patient outcomes. Using approved criteria, conducts initial and continued stay reviews to monitor the patient's progress along the continuum of care and intervenes as necessary to ensure appropriateness of setting and that the services provided are quality-driven, efficient, and effective. Enters all pertinent review data into the correct computer system in a timely manner . Consults with Physician Advisor as necessary to resolve barriers through appropriate administrative and medical channels. Monitors and guides to trend interdisciplinary documentation and guides medical staff in documentation that will assist in coding accuracy, enhance quality of care, reflect accurate severity of illness and appropriate reimbursement . Facilitates patient movement to appropriate (acuity) level of care including observation services issues through collaboration with patient/patient representative, multidisciplinary team, third party payers and care managers/social workers. Provides information regarding denials and approvals to appropriate staff and/or designated entities. Documents and delivers notifications to patients, patient representative and/or appropriate staff . Reviews Pre-Scheduled surgery admissions for proper status order for inpatient-only procedures. Collaborates to problem-solve issues with complex patients and identify trends. Formulates potential solutions with Care Manager and Social Worker and continuously monitors cases/follows up on all action items. Proactively identify high risk cases that need to be escalated to the list that are not scheduled for discussion that week. PARDEE Other information: Required Must be licensed to practice as a Registered Nurse in the state of North Carolina or one of compact states. Two (2) years of experience working as a Registered Nurse. Strong verbal and written communication. Basic Life Support (BLS) certification. Preferred Bachelor's of Science in Nursing (BSN) Certification in Case Management 01.6015.1542 Job Details Legal Employer: Pardee - HCHC Entity: Pardee UNC Health Care Organization Unit: Acute Care Case Management Work Type: Full Time Standard Hours Per Week: 40.00 Work Assignment Type: Onsite Work Schedule: Day Job Location of Job: PARDEEHOSP Exempt From Overtime: Exempt: No Qualified applicants will be considered without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, status as a protected veteran or political affiliation.
Description Penn Medicine is dedicated to our tripartite mission of providing the highest level of care to patients, conducting innovative research, and educating future leaders in the field of medicine. Working for this leading academic medical center means collaboration with top clinical, technical and business professionals across all disciplines. Today at Penn Medicine, someone will make a breakthrough. Someone will heal a heart, deliver hopeful news, and give comfort and reassurance. Our employees shape our future each day. Are you living your life's work? LOCATION: Fully remote position after 12-week onsite orientation HOURS: Full Time (40 hours per week). Monday-Friday, one weekend every 11 weeks. Flexible start time from 6:30am-9am. No holidays Penn Medicine Lancaster General Health is looking for an experienced RN to join our Utilization Management Specialist team! In this critical role, you’ll advocate for patients by conducting thorough chart reviews, communicating with payors to secure timely authorizations, and ensuring accurate patient status throughout their stay. You’ll collaborate closely with physicians, clinical staff, and financial teams to support optimal outcomes and minimize denials—all while meeting tight deadlines in a fast-paced acute care environment. If you have deep clinical knowledge, strong decision-making skills, and thrive under pressure, we’d love to hear from you! Summary : The Utilization Management Specialist - Admissions is responsible for evaluating medical records to determine severity of patient's illness and the appropriate patient class in accordance with industry guidelines. Serves as a liaison for patients and hospital with insurance companies. Qualified individuals must have the ability with or without reasonable accommodation to perform the following duties: Complete chart review and communicate patient status medical needs with insurance companies in order to advocate for patients and facilitate appropriate reimbursement while meeting tight payor deadlines, often less than 24 hours. Amend patient status and complete order requests to Attending Physician/Advance Practice Provider urgently. Deep and thorough knowledge of clinical process in the Acute Care setting with the ability to make bold, independent decisions in regard to patient status and authorization requests. Ensure that patients are assigned the appropriate patient class throughout patient stay by using Industry standard review tools, department policies, and critical thinking. Frequently coordinate with clinical staff to facilitate appropriate documentation to support patient class, optimal patient outcomes, and minimize denied days. Work closely with physician advisers to provide timely, accurate and thorough clinical reviews to assist in patient class decision-making process. Ability to handle an unpredictable workload shaped by census and payor demands. Must be able to complete assignment by end of day to comply with department standards and payor requests. Complete all documentation, including authorizations and denials according to departmental standard operating procedures. Communicate with Patient Financial Services staff regarding changes to patient class to ensure proper billing. Work with Financial Clearance and Registration staff to ensure proper billing. Facilitate Peer to Peer appeal processes post-denial in a timely fashion. Follow up with payers to account for all bed days for authorization prior to discharge. Maintain knowledge of specific payer requirements to ensure efficient review process. Serve as a point of contact subject matter expert in the process of outside facilities transferring patients to Lancaster General Hospital. The following duties are considered secondary to the primary duties listed above: Participates in Continuous Improvement for the department and the organization. Identifies professional needs to maintain expertise and keep current with health care trends, both clinical and financial. Participates in orientation and education of individuals to the functions of this position. Participate in weekend coverage based on department rotation Other duties as assigned. Minimum Required Qualifications: Current licensure as a Registered Nurse, issued by the Pennsylvania Board of Nursing Bachelor’s of Science in Nursing Minimum of five years of nursing experience which includes a minimum of three years in an acute care hospital setting Excellent written, interpersonal communication and negotiation skills. Strong critical thinking skills and the ability to perform clinical chart review efficiently. Strong analytical, data management and computer skills. Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components. Ability to advocate for the patient, as well as the hospital’s best interests. Ability to adjust adapt to varying needs of the department and the ever-changing industry requirements Ability to work independently and exercise sound judgment in interactions with the health care team Ability to tolerate high volume production standards. Preferred Qualifications: Knowledge of health care and managed care delivery systems. This includes standards of medical practice; insurance benefit structures and related legal medical issues. Knowledge of utilization management and quality improvement processes. Experience working within the managed care environment. #LI-LJ1 We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region. Penn Medicine employees are actively engaged and committed to our mission. Together we will continue to make medical advances that help people live longer, healthier lives. Live Your Life's Work We are an Equal Opportunity employer. Candidates are considered for employment without regard to race, ethnicity, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, age, disability, marital status, familial status, genetic information, domestic or sexual violence victim status, citizenship status, military status, status as a protected veteran or any other status protected by applicable law.
Description Become part of an inclusive organization with over 40,000 teammates, whose mission is to improve the health and well-being of the unique communities we serve. Summary: Works in collaboration with the patient/family, and interdisciplinary team (including physicians, other care providers, and payors), and assesses the patient care progression from acute care episode through post discharge for quality, efficiency, and effectiveness. The Utilization Manager works collaboratively with other Clinical Care Management staff to ensure patient needs are met and care delivery is coordinated across the continuum. The Utilization Manager completes admission, continued stay, and discharge reviews in accordance with federal regulations & the Hospitals? Utilization Management Plan. In addition, the Utilization Manager is responsible for revenue protection by reconciling physician orders, bed billing type, and medical necessity. This may include delivering notifications to patients directly. Interface is completed verbally, via email, data base tasks, or other electronic communication and via telephone. Responsibilities: 1. Clinical Review Process - Uses approved criteria and conducts admission review/status change review within 24 hours of patient admission to the hospital to ensure appropriateness of the setting and timely implementation of the plan of care. Identifies and obtains observation status as appropriate. Partners with physicians, nursing, and other care providers to help ensure timely and accurate documentation of patient data and treatments. Communicates daily with the Case Manager to manage level of care transitions & appropriate utilization of services. Coordinates with the support center to assure third party payor pre-certification and/or re-certifications when required. Utilizes high risk screening criteria to make appropriate referrals to Manager. 2. Discharge Facilitation - Identifies patient/families with the complex psychosocial, on-going medical discharge planning issues, continuing care needs by initiating appropriate case management referrals. Initiates appropriate social work referrals. 3. Utilization Management Process - Performs utilization management assessments and interventions, using collaboration with interdisciplinary team approach, on assigned patients as appropriate to ensure optimal patient outcomes. Using approved criteria, conducts continued stay and quality reviews to monitor the patient's progress along the continuum of care and intervenes as necessary to ensure appropriateness of setting and that the services provided are quality-driven, efficient, and effective. Enters all pertinent review data into the correct computer system in a timely manner. Consults with Physician Advisor as necessary to resolve barriers through appropriate administrative and medical channels. 4. Utilization Outcomes Management - Monitors and guides to trend interdisciplinary documentation and guides medical staff in documentation that will assist in coding accuracy, enhance quality of care, reflect accurate severity of illness and appropriate reimbursement. Facilitates patient movement to appropriate (acuity) level of care including observation status issues through collaboration with patient/family, multidisciplinary team, third party payors and resource center. Provides information regarding denials and approvals to designated entities. Assists in coordination of practice parameter development with the assigned departments/sections/specialties of Medical Staff. Oversees collection and analysis of patient care and financial data relevant to the target case types. Directs delivery of notifications to patients (includes traveling to hospital(s) to deliver notifications. Other Information Other information: Education Requirements: ● Graduation from a state-accredited school of professional nursing ● If hired after October 1, 2015, must be enrolled in an accredited program within four years of employment, and obtain a Bachelor's degree with a major in Nursing or a Master's degree with a major in Nursing within seven years of employment date. Licensure/Certification Requirements: ● Licensed to practice as a Registered Nurse in the state of North Carolina. Professional Experience Requirements: ● Two (2) years of clinical experience in a medical facility and/or comparable Utilization Management experience. Knowledge/Skills/and Abilities Requirements: Job Details Legal Employer: NCHEALTH Entity: Johnston Health Organization Unit: Care Management - Work Type: Per Diem Standard Hours Per Week: 4.00 Salary Range: $35.52 - $51.05 per hour (Hiring Range) Pay offers are determined by experience and internal equity Work Assignment Type: Onsite Work Schedule: 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.
Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job Summary The Utilization Management Nurse Specialist RN II facilitates, coordinates, and approves medically necessary referrals that meet established criteria. Assures timely and accurate determination and notification of referrals and reconsiderations based on the referral determination status. Generates approval, modification and denial communications, to include member and provider notification of referral determination. Actively monitors for admissions in any inpatient setting. Performs telephonic and/or onsite admission and concurrent review, and collaborates with onsite staff, physicians, providers, member/family interaction to develop and implement a successful discharge plan. Works with the UM Manager and Physician Advisor on case reviews for pre-service, concurrent, post-service and retrospective claims medical review. Monitors and oversees the collection and transfer of data (medical records) and referral requests by Providers. Acts as a department resource for medical service requests /referral management and processes. Receives incoming calls from providers, professionally handles complex calls, researches to identify timely and accurate resolution steps. Follows up with caller to provide response or resolution steps. Answers all inquiries in a professional and courteous manner. Duties Promote and support team engagements, programs and activities to create and ensure a positive and productive workplace environment. Perform telephonic and/or onsite admission and concurrent review, and collaborates with onsite staff, physicians, providers, the member and significant others to develop and implement a successful discharge plan. Process, finalize and facilitate inbound requests that are received from providers. Generate appropriate member and provider communication for all determinations within the required timelines as defined by the most current department policy. Facilitate/review requests for Higher level of care or skilled nursing/discharge planning needs. Research for appropriate facilities, specialty providers and ancillary providers to utilize for all lines of business. Identification of potential areas of improvement within the provider network. Identify and initiate referrals for appropriate members to the various L.A. Care programs/processes and external community based programs or Linked and Carve Out Services (e.g. DDS/CCS/MH). Potential quality of care/potential fraud issues are identified and documented per L.A. Care policy. High risk/high cost cases and reports are maintained and referred to the Physician Advisor/UM Director. Document in platform/system of record. Utilize designated software system to document reviews and/or notes. Receive incoming calls from providers, professionally handle complex calls, research to identify timely and accurate resolution steps. Follow up with caller to provide response or resolution steps. Answer all inquiries in a professional and courteous manner. Perform other duties as assigned. Duties Continued Education Required Associate's Degree in Nursing Education Preferred Bachelor's Degree in Nursing Experience Required: At least 5 years of varied RN clinical experience in an acute hospital setting. At least 2 years of Utilization Management/Case Management experience in a hospital or HMO setting . Preferred: Managed Care experience performing UM and CM at a medical group or management services organization. Experience with Managed Medi-Cal, Medicare, and commercial lines of business. Skills Required: Must be computer literate, with expertise in Outlook, Word, Excel, PowerPoint. Effectively utilizes computer and appropriate software and interacts as needed with L.A. Care Information System. Knowledge of personal computer, keyboarding, and appropriate software to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment. Prepare clear, comprehensive written and oral reports and materials. Provision of excellent customer service required due to frequent communication with providers and other members of the interdisciplinary team Excellent time management and priority-setting skills. Maintains strict member confidentiality and complies with all HIPAA requirements. Strong verbal and written communication skills. Preferred: Knowledge of National Committee for Quality Assurance (NCQA) requirements for Utilization Management or Care Management (CM). Knowledge of Department of Health Care Services (DHCS) or Centers for Medicare and Medicaid Services(CMS) requirements for health plan compliance with UM or CM. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California License Licenses/Certifications Preferred Certified Case Manager (CCM) Required Training Physical Requirements Light Additional Information May work on occasional weekends and some holidays depending on business needs. Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. L.A. Care offers a wide range of benefits including Paid Time Off (PTO) Tuition Reimbursement Retirement Plans Medical, Dental and Vision Wellness Program Volunteer Time Off (VTO)
Salary: 74,431.50-111,637.50 USD Facility: Kenmore Mercy Hospital Shift: Shift 1 Status: Full Time FTE: 1.000000 Bargaining Unit: ACE Associates Exempt from Overtime: Exempt: Yes Work Schedule: Days with Weekend and Holiday Rotation Hours: 8 am- 4 pm Summary: The Registered Nurse (RN), Utilization Review, as an active member of the Middle Revenue Cycle and interdisciplinary care team, provides comprehensive Utilization Review to patients and families in the hospital setting. Utilizing foundational nursing clinical skills Utilization Review nurse collaborates with the interdisciplinary team to maintain appropriate levels of care and to facilitate movement of the patient through the continuum. The Utilization Review RN identifies and removes barriers for delays of treatment. This individual also works to maintain third-party payer relationships related to Utilization Review Activities. This includes, but is not limited to, concurrent review, responding to inquiries, complaints, and other correspondence, and may include setting up discussions between parties. Knowledge of state and federal laws relating to contracts and utilization review process processes is vital. Responsibilities: EDUCATION BSN degree or RN with a BS in health-related field and working knowledge/experience in documentation utilization review in an acute care/inpatient setting Unrestricted NYS RN license Holds, or will obtain within one year of hire, Certified Case Manager (CCM) Certification in a Nationally Recognized Utilization Review Criteria set is preferred At least 1 year of experience in working with third party payers strongly preferred EXPERIENCE Minimum of three (3) years of experience working in an Acute Care Hospital Setting Proficiency in utilization management and regulatory requirements preferred Experience in working with people who are geographically dispersed preferred Experience in working with third party payers strongly preferred KNOWLEDGE, SKILL AND ABILITY Strong clinical assessment skills and ability to articulate findings in a fast-paced environment. Possess the ability to make independent decisions within the professional scope of practice Possess ability to educate, inform, advocate, promote and facilitate health care options, and demonstrate the willingness to work harmoniously with a team approach Possesses ability to effectively and efficiently utilize technology within daily work with the care team and ability to quickly learn and adapt to new technology tools and software Extensive knowledge of third-party payer guidelines, accreditation and regulatory requirements preferred Knowledge of Managed Care Organization contracts/agreements preferred WORKING CONDITIONS: Willingness to work beyond normal working hours, and in other positions temporarily, and/or at other locations when necessary Variable schedule which may include weekends and holidays. May be requested to travel to multiple hospital and community sites ENVIRONMENT Normal heat, light space, and safe working environment; typical of most office jobs Occasional exposure to one or more mildly unpleasant physical conditions Minimum physical effort required, typical of most office work Significant amount of walking within the acute care facility
Overview CentraState Healthcare System, headquartered in Freehold, New Jersey, is a leading nonprofit healthcare provider dedicated to serving the community. Its comprehensive network includes CentraState Medical Center, a community-focused hospital, along with an ambulatory campus, two senior living facilities, three free-standing community health pavilions, and a charitable foundation. As the third-largest employer in Monmouth County, CentraState has earned repeated recognition as a Great Place to Work-Certified™ company, reinforcing its reputation as an exceptional workplace. CentraState Medical Center has an employment opportunity available for a Utilization Review Nurse . The Utilization Review RN (UR RN) applies professional nursing judgment and critical thinking skills to assess patients for appropriate levels of care and to mitigate potential denials. This role requires a strong knowledge of evidence-based clinical criteria and federal and state utilization management requirements. The UR RN identifies key clinical information to support hospital admissions and continued stays, collaborates with the care management team to optimize resource utilization, and secures payer approvals. The UR RN also reviews escalated cases that do not meet medical necessity prior to initiating secondary review. Responsibilities Responsibilities include, but are not limited to: Provides timely and thorough clinical information to insurance companies and other intermediaries to secure payer authorizations and avoid denials or reduction in level of care. Performs daily surveillance of observation cases and works with APNs and PA discussing any barriers to progression of care or discharge. Intervenes proactively to avoid denials or delays in authorization. Actively communicates information to other CM team members and interdisciplinary teams regarding progress or payer issues related to continued hospitalization and post-acute service associated with the patients discharge plan. Refers cases and issues to Physician Advisors or Designees in compliance with department procedures with timely follow up as indicated. Assists in identification and collection of avoidable days and management of the expected discharge date. Coordinates with the CM RN and/or CMA to identify and complete the process for CMS required patient notices. Completes and documents utilization reviews, physician advisor referrals and other communications related to assigned cases in accordance with department policy and procedure. Complies with the Condition of Code 44 process, CMS required patient notices and other regulatory requirements within the utilization management process. Maintains proficiency in the application of organization selected clinical review criteria sets evidenced through IRR testing Assists in facilitating and coordinating clinical progression of assigned patients Other duties as assigned by management Qualifications BSN or Bachelor’s Degree in related field or current enrollment in BSN or related Bachelor’s Degree program required. Prior clinical experience in care and management of hospitalized patients. Experience in acute care case management, preferred. Utilization review or case management training from a professional Case Management organization, preferred. RN license required/NJ. Case Management certification preferred. Excellent communication, negotiation, and conflict resolution skills Data and computer skills Knowledge of relevant and state utilization review and appeals requirements Rapid cycle change or clinical performance improvement expertise About Us CentraState Healthcare System, in partnership with Atlantic Health System, is a fully accredited, not-for-profit, community-based health system dedicated to providing comprehensive health services in central New Jersey. Beyond offering a wide range of advanced diagnostic and treatment options, CentraState is committed to being a valuable health partner, focusing on disease prevention, promoting healthy behaviors, and helping individuals of all ages live well. Located in Freehold, CentraState includes a 284-bed acute-care hospital, a dynamic health and wellness campus, two award-winning senior living communities, a charitable foundation, and convenient satellite health pavilions. These pavilions offer primary care, specialty physician practices, and access to outpatient services such as lab work and physical therapy. CentraState is proud to be among the less than two percent of hospitals nationwide to earn Magnet® designation for nursing excellence five times. Additionally, it has been recognized as a Great Place to Work-Certified™ Company by Great Place to Work® for four consecutive years. Joining CentraState means becoming part of a pioneering healthcare facility committed to high-quality, patient-focused care. We invite you to make a difference in our community and advance your career with us. We support our employees with work/life balance initiatives, tuition assistance, career advancement opportunities, and more. Discover why our employees love their jobs and being part of the CentraState family! CentraState Health System offers a competitive and comprehensive Total Rewards package that supports the health, financial security, and well-being of all team members. What We Offer: Medical, Dental, Vision, Prescription Coverage (30 hours per week or above for full-time and part-time team members) Life & AD&D Insurance Long-Term Disability (with options to supplement) 403(b) Retirement Plan with employer match 401(a) Retirement Plan with employer contribution PTO Tuition Reimbursement Well-Being Rewards Employee Assistance Program (EAP) Fertility Coverage, Healthy Pregnancy Program Flexible Spending & Commuter Accounts Pet, Home & Auto, Identity Theft and Legal Insurance Growth Opportunity and Workforce Development Initiatives Continuing Education / Onsite Training A warm, welcoming company culture based upon mutual respect and a collaborative goal of providing excellent patient care Concierge Services with Work & Family Benefits Magnet recognized healthcare facility Compensation Range: $93,600 - $159,120 annually The compensation above reflects the established range from CentraState Healthcare System (CSHS) for this position at the time the job was posted. CSHS considers many factors to determine compensation, including education, experience, skills, licenses, certification, and training. As such, team member compensation may fall outside this range. Additionally, the compensation range reflects base salary and does not include extra shift rates or incentives tied to quality, productivity, etc., as applicable. The benefits outlined also reflect CSHS’ policy at the time of posting. Benefits as are made available to other similarly situated team members of CSHS, although participation is at all times in accordance with and subject to the eligibility and other provisions of such plans and programs. CSHS may modify its benefits plans or programs at any time. CSHS is proud to comply with all pay equity and pay transparency laws.
Position Summary The Peer Review QNS works closely with medical staff leaders to organize and conduct all Professional Practice Evaluation (PPE) activities, which include Focused Professional Practice Evaluation (FPPE) for initial and additional privileges, Peer Review of clinical activity, professionalism and behavior, and Ongoing Professional Practice Evaluation (OPPE). Responsibilities Synthesize information from relevant resources to demonstrate current practice and identify opportunities for improvement. Identify sources of valid and reliable information and metrics to monitor performance trends. Analyze information from disparate sources. Analyze comparative data, benchmarks, and evidence-based practices for possible adaptation into the organization. Use valid and reliable data to support opportunity recommendations and illuminate key trends for stakeholders. Demonstrate expertise in the use of analytical and statistical tools and techniques including understanding of how process goals are established, measured and monitored; apply techniques and tools to identify variation and its causes; analyze input variable to identify critical factors that must be addressed to achieve optimal process performance. Communicate improvement priorities and results using narrative and visual tools by create graphs and charts that accurately reflect valid interpretation of findings; develop dashboards and scorecards to depict internal metrics and benchmark comparisons; create written and verbal communication to tell a story appropriate to the audience. Design and develop project plans including providing project coordination using project management tools, measurement plans, estimates costs to determine budget, incorporates evidence-based guidelines. Uses change management principles. Communicates project progress to all stakeholders through the project. Promote a safety culture and infrastructure by engaging stakeholders to understand all perspectives when addressing patient safety issues; model behaviors that promotes a safety culture; educate staff; support adoption of high reliability principles; design sustainable actions to improve patient safety. Minimum Requirements Bachelor's degree in applicable field or higher is required. Active RN license 3 years or more experience in healthcare field Certification in specialty preferred within 3 years and maintained thereafter. ECU Health About ECU Health Medical Center ECU Health Medical Center, one of four academic medical centers in North Carolina, is the 974-bed flagship hospital for ECU Health and serves as the primary teaching hospital for The Brody School of Medicine at East Carolina University. ECU Health Medical Center has achieved Magnet® designation twice and provides acute and intermediate care, rehabilitation and outpatient health services to a 29-county region that is home to more than 1.4 million people. General Statement It is the goal of ECU Health and its entities to employ the most qualified individual who best matches the requirements for the vacant position. Offers of employment are subject to successful completion of all pre-employment screenings, which may include an occupational health screening, criminal record check, education, reference, and licensure verification. We value diversity and are proud to be an equal opportunity employer. Decisions of employment are made based on business needs, job requirements and applicant’s qualifications without regard to race, color, religion, gender, national origin, disability status, protected veteran status, genetic information and testing, family and medical leave, sexual orientation, gender identity or expression or any other status protected by law. We prohibit retaliation against individuals who bring forth any complaint, orally or in writing, to the employer, or against any individuals who assist or participate in the investigation of any complaint.
Division: Eskenazi Health Sub-Division: Hospital Req ID: 24795 Schedule : Full Time Shift : Days Salary Range: Eskenazi Health serves as the public hospital division of the Health & Hospital Corporation of Marion County. Physicians provide a comprehensive range of primary and specialty care services at the 327-bed hospital and outpatient facilities both on and off of the Eskenazi Health downtown campus as well as at 10 Eskenazi Health Center sites located throughout Indianapolis. FLSA Status Exempt Job Role Summary The Utilization Payor Specialist, RN is responsible for working behind the scenes to maximize the quality and cost of efficiency of health services. This position coordinates pre-certifications, re-certifications, the denial management and appeals process, and initial and concurrent reviews. Through regular reviews and audits, the Utilization Payor Specialist ensures that patients receive the care needed without burdening the health care system with unnecessary procedures, ineffective treatments or lengthy hospital stays. #EXPRN Essential Functions and Responsibilities Communicates secondary review decisions determining appropriate patient status provided by secondary reviewer process Communicates and negotiates with payers to obtain approvals for the appropriate care level Serves as a resource on payor requirements for severity and intensity of service determinations for outpatient and acute inpatient admissions Provides timely payor feedback to Case Managers and Social Workers; notifies the Case Manager when additional clinical information may be required that is not currently identified within the electronic medical record or bedside documentation to ensure that services will be approved at the acute level of care as required by the payor Ensures pre-certification/authorizations for post-acute services, initial, concurrent reviews, authorizations not obtained by Patient Registration/Admitting or the doctor's office and clinics for direct admissions and procedures Reviews patient admission for appropriateness and type; refers case to Medical Director/department leadership for review and course of action when case fails to meet admission standards Coordinates and facilitates the most accurate and appropriate patient status for care across the continuum Actively communicates and documents payor issues and concerns regarding the initial level of care, continued stay, denials and discharge plans to the Medical Director/department leadership as appropriate Supports the denial management process and participates in tracking and reporting denials Ensures payor and customer satisfaction through effective communication with the Interdisciplinary Team Obtains payor certification for unplanned admissions, homecare and post-acute services as required Initiates contact with payers for continued stay; reviews utilizing clinical information; pursues additional information as needed Utilizes conflict resolution, critical thinking, and negotiation skills as necessary to ensure timely resolution of issues Identifies concurrent third-party payers denials and notifies Case Managers for immediate intervention and escalation to the Medical Director/department leadership Coordinates denial and appeals process and responds to all third-party payer denials Applies appropriate clinical criteria to complete initial reviews within 24-48 hours of patient presentation Facilitates tracking and payment approval processes for the outpatient parenteral antimicrobial therapy program (OPAT) Assists with coordination, data entry and needed follow up support to the OPAT program Provides post-hospitalization telephonic follow up for OPAT patients in the community for care coordination regarding care outcomes that support the OPAT program Facilitates tracking and payment approval processes for Eskenazi Health inpatient overlaps receiving services at IUH Facilitates tracking and payment approval processes for Eskenazi Health Cardiac send-out receiving services at IUH Reviews claims for both inpatient overlaps and cardiac send-outs and verifies dates of service; provides to Revenue Cycle for adjudication and payment Facilitates tracking and payment approval processes for vendor picc lines to include charge reconciliation in EPIC Provides oversight and maintains readmission initiatives directly related to Target Diagnosis, Bedside education, follow-ups for vendor-automated calls Provides assistance for complex discharge planning placement and programs, departmental projects, authorizations and accounts payable Facilitates referral, tracking and payment approval processes for Eskenazi Health requiring home wound-vac services provided by in-network vendors for specialty clinics and patients discharging home Job Requirements Current Indiana RN nursing license required Four years of clinical nursing experience required Two or more years of Utilization Review experience strongly preferred Knowledge, Skills & Abilities Must demonstrate knowledge of the Utilization Management managed care processes Must demonstrate knowledge of levels of care of Inpatient and Outpatient status Excellent interpersonal, written and verbal communication, and negotiation skills Demonstrated ability to be diplomatic and flexible, and demonstrates a high level of professionalism Ability to cohesively network with the Interdisciplinary Team Accredited by The Joint Commission and named one of the nation’s 150 best places to work by Becker’s Hospital Review for four consecutive years and Forbes list of best places to work for women, and Forbes list of America’s best midsize employers’ Eskenazi Health’s programs have received national recognition while also offering new health care opportunities to the local community. As the sponsoring hospital for Indianapolis Emergency Medical Services, the city’s primary EMS provider, Eskenazi Health is also home to the first adult Level I trauma center in Indiana, the only verified adult burn center in Indiana, the first community mental health center in Indiana and the Eskenazi Health Center Primary Care – Center of Excellence in Women’s Health, just to name a few.
Nashville General Hospital is hiring a Sr. Director of Patient Access and Utilization Management. Join our leadership team and make a lasting impact on patient care! We are seeking an experienced and visionary Senior Director to lead our Patient Access and Utilization Management functions. In this key role, you will oversee registration, financial clearance, insurance verification, and utilization review programs, ensuring seamless patient flow and optimal revenue cycle performance. If you are a strategic thinker with a passion for improving processes, leading high-performing teams, and driving compliance with state, federal, and accreditation standards we want to hear from you! Education: Bachelor’s - Nursing, Business Administration, Healthcare Administration, or related field (Required) Master’s in Healthcare Administration (MHA), Business Administration (MBA), or related advanced degree (Required) Job Requirement: Minimum 10 years of progressive administrative and supervisory experience Minimum 8 years in a healthcare management position (preferred) Proven ability to handle multiple projects simultaneously with strong budgeting and negotiation skills Functional knowledge of computers, word processing, spreadsheets, and hospital information systems (HIS Affinity preferred) Thorough knowledge of patient access, utilization management, and medical terminology Detailed knowledge of Joint Commission, NCQA, CMS, state, and federal requirements Experience with insurance verification, coverage interpretation, and revenue cycle optimization Strong verbal and written communication skills with a proven ability to collaborate with hospital-wide teams Demonstrated ability to independently identify problems, implement solutions, and meet deadlines About Nashville General Hospital Nashville General Hospital (NGH) is Nashville’s original community-based hospital. Joint Commission accredited, NGH readily accommodates a wide range of needs from emergency services and acute care to ancillary and ambulatory services. NGH continues to maintain its strong commitment to the healthcare needs of Nashville and Davidson County underserved, while also providing care to all segments of the community Core Competencies • Financial & Revenue Cycle Acumen: Expertise in revenue cycle management, budget oversight, and claim denial reduction. • Operational & Technical Expertise: Skilled at improving workflows, using data analytics, and enhancing patient satisfaction. • Regulatory & Compliance Knowledge: Deep knowledge of payer regulations and compliance standards for ethical operations. • Strategic Planning & Leadership: Capable of setting direction, leading change, and driving performance improvements. • Collaborative Communication: Builds strong relationships with physicians, senior leaders, and payers to achieve results. Primary Duties & Responsibilities Leadership & Oversight • Plan, organize, and direct the overall operations of Patient Access (PA) and Utilization Management (UM). • Oversee scheduling, registration, insurance verification, financial counseling, and admissions functions. • Direct, implement, and integrate PA functions (scheduling, financial clearance, registration) and UM functions (denials management, peer-to-peer reviews, concurrent/retrospective reviews). • Ensure accurate patient status identification and optimal revenue cycle outcomes. • Develop and lead the Utilization Review Committee with consistent physician participation. • Maintain compliance with NCQA, Joint Commission, CMS, and state regulations. Financial & Operational Management • Develop inventory and cost accounting policies and reporting. • Analyze departmental performance trends to support forecasting and strategic planning. • Present performance outcomes and improvement initiatives to senior leadership. Quality, Risk & Compliance • Identify and resolve quality and risk issues. • Develop and implement policies and procedures to increase efficiency and compliance. • Ensure compliance with federal, state, and local regulations, as well as NCQA and Joint Commission standards. Risk, Auditing & Investigations • Provide strategic oversight for billing and coding compliance. • Partner with executive leadership on Enterprise Risk Management (ERM) to mitigate compliance risks. • Lead comprehensive auditing and monitoring programs. • Manage confidential reporting systems and investigate compliance concerns. • Design and deliver compliance training for staff, medical providers, and board members. Community & Academic Partnership • Lead and oversee contract management, including review, approval, and storage. • Mitigate risk by maintaining a centralized, compliant contract management system. Our benefits include: Medical, Dental, and Vision Insurance within first 31 days of employment Metro Health Incentive Program - Access to high quality healthcare without incurring out-of-pocket expenses Short and Long-Term Disability - up to 60% of eligible weekly pay Life Insurance - Metro provides you with basic life and AD&D coverage equal to $50,000 ($32,500 if you are age 65 or older), at no cost to you. Retirement Plan - eligible up to IRS max limits and includes company contribution Shift and Weekend Differential Pay Offered on Nights and Weekends Tuition Reimbursement for employee and dependents 12 paid holidays - any holiday worked is another holiday banked Flexible Spending Accounts Free Parking for all employees Nashville General Hospital is an Equal Opportunity Employer/Disability/Veteran # INDOTH2025
Summary Samaritan Health Plans (SHP) provides health insurance options to Samaritan employees, community employers, and Medicare and Medicaid members. SHP operates a portfolio of health plan products under several different legal structures: InterCommunityHealth Plans, Inc. (IHN) is designated as a regional Coordinated Care Organization (CCO) for Medicaid beneficiaries; Samaritan Health Plans, Inc. offers Medicare Advantage, Commercial Large Group, and Commercial Large Group PPO and EPO plans; SHP is also the third-party administrator for Samaritan Health Services’ self-funded employee health benefit plan. As part of an Integrated Delivery System, Samaritan Health Plans is strategically and operationally aligned with Samaritan Health Services’ mission of Building Healthier Communities Together. This is a remote position in which we are able to employ in the following states: Arizona, Arkansas, Connecticut, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Mexico, North Carolina, Oklahoma, Oregon, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, or Wisconsin Occasionally JOB SUMMARY/PURPOSE The Clinical Program Manager RN serves as the cornerstone of SHP’s regulatory infrastructure within the utilization management department. This role is responsible for the development, testing, and validation of complex report queries that support federal and state regulatory deliverables. It also oversees the creation and maintenance of policies, procedures, work instructions, and audit tools, while ensuring staff are adequately trained on these materials. The Clinical Program Manager leads all aspects of program development and execution, collaborates with internal teams and external partners, and serves as a subject matter expert across the organization. The position will also oversee and partner other health plan functions such non-emergency medical transport and delegation audits. EXPERIENCE/EDUCATION/QUALIFICATIONS Current unencumbered Oregon RN License required within 90 days of hire. BSN preferred. Master's degree in a related field preferred. One (1) year clinical nursing experience plus four (4) years health plan, case management and/or utilization management experience required. Experience or training in the following required: Health care delivery systems and/or managed care patients. Computer applications including electronic documentation (e.g., MS Office, EPIC, Clinical Care Advanced). Experience in the following preferred: Team leadership. Case management. Medicare and Medicaid rules and regulations and health plan benefit structure and policy. KNOWLEDGE/SKILLS/ABILITIES Leadership - Inspires, motivates, and guides others toward accomplishing goals. Achieves desired results through effective people management. Conflict resolution - Influences others to build consensus and gain cooperation. Proactively resolves conflicts in a positive and constructive manner. Critical thinking - Identifies complex problems. Involves key parties, gathers pertinent data and considers various options in decision making process. Develops, evaluates and implements effective solutions. Communication and team building - Lead effectively with excellent verbal and written communication. Delegates and initiates/manage cross-functional teams and multi-disciplinary projects. PHYSICAL DEMANDS Rarely (1 - 10% of the time) (11 - 33% of the time) Frequently (34 - 66% of the time) Continually (67 - 100% of the time) CLIMB - STAIRS LIFT (Floor to Waist: 0"-36") 0 - 20 Lbs LIFT (Knee to chest: 24"-54") 0 - 20 Lbs LIFT (Waist to Eye: up to 54") 0 - 20 Lbs CARRY 1-handed, 0 - 20 pounds BEND FORWARD at waist KNEEL (on knees) STAND WALK - LEVEL SURFACE ROTATE TRUNK Standing REACH - Upward PUSH (0 - 20 pounds force) PULL (0 - 20 pounds force) SIT CARRY 2-handed, 0 - 20 pounds ROTATE TRUNK Sitting REACH - Forward MANUAL DEXTERITY Hands/wrists FINGER DEXTERITY PINCH Fingers GRASP Hand/Fist
Description Introduction This Work from Home position requires that you live and will perform the duties of the position; within 60 miles of an HCA Healthcare Hospital (Our hospitals are located in the following states: FL, GA, ID, KS, KY, MO, NV, NH, NC, SC, TN, TX, UT, VA). Do you want to join an organization that invests in you as an Inpatient Authorization Review Services Registered Nurse or Licensed Practical Nurse -NICU (Code Pink)? At Parallon, you come first. HCA Healthcare has committed up to 300 million in programs to support our incredible team members over the course of three years. Benefits Parallon offers a total rewards package that supports the health, life, career and retirement of our colleagues. The available plans and programs include: Comprehensive medical coverage that covers many common services at no cost or for a low copay. Plans include prescription drug and behavioral health coverage as well as free telemedicine services and free AirMed medical transportation. Additional options for dental and vision benefits, life and disability coverage, flexible spending accounts, supplemental health protection plans (accident, critical illness, hospital indemnity), auto and home insurance, identity theft protection, legal counseling, long-term care coverage, moving assistance, pet insurance and more. Free counseling services and resources for emotional, physical and financial wellbeing 401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service) Employee Stock Purchase Plan with 10% off HCA Healthcare stock Family support through fertility and family building benefits with Progyny and adoption assistance. Referral services for child, elder and pet care, home and auto repair, event planning and more Consumer discounts through Abenity and Consumer Discounts Retirement readiness, rollover assistance services and preferred banking partnerships Education assistance (tuition, student loan, certification support, dependent scholarships) Colleague recognition program Time Away From Work Program (paid time off, paid family leave, long- and short-term disability coverage and leaves of absence) Employee Health Assistance Fund that offers free employee-only coverage to full-time and part-time colleagues based on income. Learn more about Employee Benefits Note: Eligibility for benefits may vary by location. You contribute to our success. Every role has an impact on our patients’ lives and you have the opportunity to make a difference. We are looking for a dedicated Inpatient Authorization Review Services Registered Nurse or Licensed Practical Nurse -NICU (Code Pink) like you to be a part of our team. Job Summary and Qualifications The Inpatient Authorization Review Services Registered Nurse or Licensed Practical Nurse NICU (Code Pink) will review post discharge, prebill accounts that do not have authorization on file, ALOS versus days authorized variances, and/or other account discrepancies identified that will result in the account being denied by the payor that require clinical expertise. Communicates with third party payors to resolve discrepancies prior to billing. Accurately and concisely documents all communications and action taken on the account in accordance with policies and procedures. Escalate medical review request and /or denial activities to management as needed. What you will do in this role: Work post discharge, prebill accounts efficiently and effectively daily to resolve accounts with “no auth numbers, ALOS vs. authorized days or other discrepancies. Evaluates clinical documentation on multiple patient accounts and escalates issues through the established channels. Perform accurate and timely documentation of all review activities based on policy and procedure. Demonstrates a working knowledge of managed care agreements based on available resources which may include and not be limited to payer UM Manual, policy and procedure, facility contract information. Escalates variations timely. Work assigned accounts in eRequest to resolve outstanding issues. Report insurance denial trends identified during daily operational assignments. Contact facilities, physicians’ offices and/or insurance companies to resolve denials/appeals if needed. Demonstrates knowledge of regulatory requirements, Ethics and Compliance policies, and quality initiatives; monitors self-compliance and implements process changes to ensure compliance to such regulations and quality initiatives. Assess CPT code(s) for outpatient accounts that require authorization when accounts have not been coded. Qualifications that you will need: Registered Nursing degree and current licensure or Vocational nursing degree required. Healthcare experience in an acute care hospital. Utilization Review, appeals, denials, managed care contracting, experienced preferred. Currently licensed as a registered nurse (RN) in the state(s) of practice and/or has an active compact license, in accordance with law and regulation or Licensed Practical Nurse -Currently licensed as a licensed practical nurse in the state in which he or she resides and practices, in accordance with law and regulation. Multi-state nursing licensure for compact states Parallon provides full-service revenue cycle management, or total patient account resolution, for HCA Healthcare. Our services include scheduling, registration, insurance verification, hospital billing, revenue integrity, collections, payment compliance, credentialing, health information management, customer service, payroll and physician billing. We also provide full-service revenue cycle management as well as targeted solutions, such as Medicaid Eligibility, for external clients across the country. Parallon has over 17,000 colleagues, and serves close to 1,000 hospitals and 3,000 physician practices, all making an impact on patients, providers and their communities. HCA Healthcare has been recognized as one of the World’s Most Ethical Companies® by the Ethisphere Institute more than ten times. In recent years, HCA Healthcare spent an estimated 3.7 billion in cost for the delivery of charitable care, uninsured discounts, and other uncompensated expenses. "Good people beget good people." - Dr. Thomas Frist, Sr. HCA Healthcare Co-Founder We are a family 270,000 dedicated professionals! Our Talent Acquisition team is reviewing applications for our Inpatient Auth Review Services RN or LPN -NICU opening. Qualified candidates will be contacted for interviews. Submit your resume today to join our community of caring! We are an equal opportunity employer. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.
Overview Works with physicians and multidisciplinary team members to develop a plan of care for assigned patients. Ensures patient is progressing towards desired outcomes by monitoring care through assessments and/or patient records. Identifies and resolves barriers that hinder effective patient care. Actively involved in discharge planning process. **UR specific experience preferred Responsibilities Works with Medical Director and appropriate physician(s) to establish Dartmouth-Hitchcock (D-H) ambulatory and inpatient procedure list, updates and maintains list. Reviews reservation forms and the log of emergent and urgent admissions daily. Identifies areas that require intervention and education around the use of definitions. Reviews “one day stays” to assess appropriate use of level of care (LOC) determinations. Works with individual physicians and office staff when they are experiencing discrepancies with pre-certifications. Assumes responsibility for the oversight of inpatient denials, including, but not limited to, reviewing denial letters, collaborating with the Medical Director and appropriate physicians to determine the decision to appeal or accept, assisting in the response to Health Plan, etc. Develops and implements communication strategies to keep clinicians and staff informed of changes and current practice. Works closely with others to transition level of care determinations. Provides information to departmental leadership that reflects trends and practices that may need organization, intervention, and change. Collaborates with Health Plans to understand their definitions, articulates the definitions of D-H, and assists in the development of strategies for resolution of differences. Benchmarks with other facilities concerning admission and denial experience and policies. Performs other duties as required or assigned. Qualifications Graduate from an accredited Nursing Program required. Bachelor of Science Degree in Nursing (BSN) with 3 years of experience. Masters of Science Degree in Nursing (MSN) preferred. Strong leadership, communication and computer skills desired. Required Licensure/Certifications Licensed Registered nurse with NH eligibility
Health and Hospital Corporation is an organization that celebrates diversity, and seeks to employ a diverse workforce. We actively encourage all individuals to apply for employment and to seek advancement opportunities. Health and Hospital Corporation also provides reasonable accommodations to qualified individuals with disabilities as required by law. For additional questions please contact us at: hrmail@hhcorp.org. Job Role Summary Assists the Long Term Care department in the review and analysis of care and services provided by HHC owned nursing homes and licensed residential facilities. Performs on site, overnight as needed, and office review of various clinical resident care services and management operations at HHC affiliated long term care facilities and participates in the preparation of related reports for the long term care department, individual facilities and the contract management company. Assists in the analysis of various aspects of nursing home operations using professional standards of practice and industry benchmarks. This position is responsible for promoting health and wellbeing of long term care residents of Health & Hospital Corporation Marion County nursing facilities by promoting preventive, therapeutic, and supportive care based on standards of practice and in compliance with all applicable regulatory requirements with an emphasis on resident behavior health needs including dementia, addiction and current DSM manual (DSM-5-TR). Essential Duties Responsibility 1: 70% • Performs quality review oversight, including overnight as directed, visits to HHC owned nursing homes and retirement communities as assigned. May serve as a member of a quality review team or at times may visit assigned facilities as the sole representative from the HHC Long Term Care Department. Maintains a professional and supportive role when interacting with the nursing home and licensed residential facility staff providing helpful observations and suggestions. • Performs various auditing/review activities during the site visits including but not limited to: meal service observations, resident care observations, resident and family interviews, staff interviews, clinical record reviews and review of facility management records. At times may assist the other members of the quality review team to complete their assigned tasks. • Performs various auditing/review activities during the site visits including but not limited to: observations of resident behavioral interaction/intervention, medication administration, wound care, personal care services, meal service, clinical record reviews and review of nursing management records. • Participates in the exit conferences held with facility management and the quality reviewers and provides summary information regarding significant observations during the facility visit including specific resident and employee identification when possible. • Prepares a written site visit report following each facility visit in cooperation with other quality review team members who participated in the facility visit. Reviews report for accuracy, and clarity. Distributes reports in a confidential manner to all parties and maintains HHC records. • Assures the retention and confidentiality of all data materials from facility visits and forwards to the department Executive Assistant for proper storage/retention. Responsibility 2: 30% • Participates in the compilation and completion of quarterly and other reports prepared for the HHC Board of Trustees’. • Accepts phone calls from residents, family members and interested parties in the absence of other Long Term Care Department staff or as assigned. Receives concerns or information in a manner that reflects good customer service practices and prepares detailed written information for the Vice President’s review and processing. • Attends community and professional association functions and meetings representing HHC Long Term Care division, as requested. • Follows departmental travel policy for travel arrangements/reservations for out of town facility site visits. Qualifications • Registered nurse with four or more years experience including two or more years of behavioral health background. Licenses/Certifications Required Registered Nurse (RN) Knowledge, Skills & Abilities • Good judgment and discretion in communication (written, verbal and non-verbal).Must be able to prioritize work, meet deadlines, and work well under pressure. • Flexibility to adjust to changing program/department needs and activities. • Excellent verbal and written skills. • Must be proficient with Microsoft Office, Word, Internet Explorer, and all usual and customary office equipment. • Must possess the ability to work independently, and as part of a team. Working Environment Unconfined sitting 75% Confined sitting 15% Standing or walking 10% (50% - on site visit days) Steady use of hands or fingers – Typing and filing 85% Lift, carry, etc. with arms and legs – 15% Ability to perform driving functions in normal course of workday with confined sitting for several hours at times All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.
