As a utilization review (UR) nurse, you help ensure that patients are receiving the appropriate level of care while being mindful of expenditures to your employer, whether you work for a hospital, managed care facility, or insurance company.
Wondering where you might work in this role? The federal government requires that organizations participating in Medicare and Medicaid conduct utilization reviews. This means that you’ll find a variety of workplace options for UR nurse jobs.
Education and Certifications for Utilization Review Nursing Jobs
Before you can work in utilization review, you must complete a nursing program from an approved institution. Once you pass the NCLEX and receive your license, you’ll want to gain clinical experience in direct patient care. Registered nurses may also want to pursue experience as an RN case manager.
While likely not required for most jobs, specialty certification can increase both your knowledge and also your leverage when it comes time to look for a new utilization review nurse job. Certifications include:
Health Utilization Management Certification (HUMC)
Put some effort into customizing your utilization review nurse resume to each job posting. For instance, if an employer is seeking a candidate “proficient in insurance prior authorizations and medical necessity criteria for different payers,” include that phrase in your resume. This helps demonstrate that your skills are a good fit for the job.
In your UR nurse cover letter, explain a bit about what drew you to this particular position. Remember, you don’t want just any old job — you want this job. To reinforce this sentiment as you apply to UR nurse jobs, search the employer’s website for their mission statement and see where your values overlap.
Interviewing for a Utilization Review Nurse Job
A job interview has the potential to determine whether or not you’ll get a job offer. Need some pointers? Review our nursing interview tips in advance to help you formulate smart answers to common questions and boost your confidence.
Learn how to answer interview questions about your strengths as a nurse:
Utilization Review Nurse Salary
The average annual salary for a UR nurse is around $91,600 for a registered nurse. Your location, level of education and experience, and employer can impact this number. For a more accurate picture of utilization review nurse jobs’ salary estimates in your area, explore the current UR nursing jobs on IntelyCare.
Ready to Find Utilization Review Nurse Jobs?
Check out all the positions available right now. Want additional options? IntelyCare can match you with even more nursing jobs that interest you.
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. Location: Position is remote. Prefer candidate to live in PST time zone. Schedule: Looking for someone who will work Tuesday-Saturday. 8-5 PST. Position Purpose: Oversees correspondence letters based and supports overall team needs. Reviews outcomes in accordance with National Committee for Quality Assurance (NCQA) standards. Works with senior management to identify and implement opportunities for improvement. Oversees the clinical review of outcomes including creating and editing correspondence letters with the correspondence team based on determinations in accordance with National Committee for Quality Assurance (NCQA) standards Manages the audits of correspondence to ensure they are processed in accordance with Federal, State, and NCQA standards Provides expert insight and guidance on the clinical review process of correspondence to ensure compliance with all applicable State and Federal regulations Provides subject matter expertise insights to investigate and resolve issues including comprehensive review of clinical documentation, clinical criteria/guidelines, and policy, including insurance rejections due to coding issues and escalates as appropriate to resolve issues in a timely manner Acts as a point of contact for escalated, advanced issues and/or questions related to correspondence with the state, local, and federal agencies including third party payer and providers to ensure issues are resolved in a timely manner Oversees clinical quality and process improvement initiatives related to clinical quality indicators and financial metrics Manages data needed to identify trends and provide recommendations to senior management of process improvements within utilization management Manages and oversees cases to ensure timely resolution and logs of actions and/or decisions are appropriately documented Provides training and education to the interdepartmental teams on training needed within the utilization management team based on trends Partners with leadership to improve processes and procedures to prevent recurrences based on industry best practices Provides guidance, subject matter expertise and training as needed Performs other duties as assigned Complies with all policies and standards Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 5 – 7 years of related experience. Expert knowledge of Medicare and Medicaid regulations preferred. Expert knowledge of utilization management processes preferred. License/Certification: LPN - Licensed Practical Nurse - State Licensure required- Compact License Location: Position is remote. Prefer candidate to live in PST time zone. Schedule: Looking for someone who will work Tuesday-Saturday. 8-5 PST. Pay Range: $35.49 - $63.79 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
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
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. THIS POSITION IS REMOTE/WORK FROM HOME SUPPORTING PENNSYLVANIA HEALTH & WELLNESS MEDICAID CHIP PROGRAM. THE WORK SCHEDULE IS MONDAY – FRIDAY 8AM – 5PM EASTERN TIME ZONE/CENTRAL TIME ZONE. IDEAL APPLICANTS WILL HAVE CHILDREN/ADOLECENT BEHAVIORAL HEALTH EXPERIENCE AND HOLD A PENNSYLVANIA LICENSURE. Position Purpose: Performs reviews of member's care and health status of Applied Behavioral Analysis (ABA) services provided to determine medical appropriateness. Monitors clinical effectiveness and efficiency of member's care in accordance with ABA guidelines. Evaluates member’s care and health status before, during, and after provision of Applied Behavioral Analysis (ABA) services to ensure level of care and services are medically appropriate related to behavioral health (BH) and/or autism spectrum disorder needs and clinical standards Performs prior authorization reviews related to BH to determine medical appropriateness in accordance with ABA regulatory guidelines and criteria Analyzes BH member data to improve quality and appropriate utilization of services Interacts with BH healthcare providers as appropriate to discuss level of care and/or services provided to members receiving Applied Behavior Analysis Services Provides education to members and their families regrading ABA and BH utilization process Provides feedback to leadership on opportunities to improve care services through process improvement and the development of new processes and/or policies Performs other duties as assigned. Complies with all policies and standards. Education/Experience: Requires Graduate of an Accredited School of Nursing or Bachelor's degree and 2-4 years of related experience. For Enterprise Population Health 2+ years providing ABA services as a BCBA License to practice independently, and/or have obtained the state required licensure as outlined by the applicable state (BCBA) required. Master’s degree for behavioral health clinicians required. Behavioral health clinical knowledge and ability to review and/or assess ABA Treatment Plans required. Knowledge of ABA services and BH utilization review process required. Experience working with providers and healthcare teams to review care services related to Applied Behavior Analysis Services preferred. License/Certification: LCSW- License Clinical Social Worker required or LMHC-Licensed Mental Health Counselor required or LPC-Licensed Professional Counselor required or Licensed Marital and Family Therapist (LMFT) required or Licensed Mental Health Professional (LMHP) required or Board Certified Behavior Analyst (BCBA) required RN - Registered Nurse - State Licensure and/or Compact State Licensure RN - Registered Nurse- State Licensure and/or Compact State Licensure with BCBA required or Independent licensure with ABA experience and BCBA preferred. Licensed Behavior Analyst (LBA) where required by state required Pay Range: $26.50 - $47.59 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. This is a Remote position - Nevada LPN or RN License required Position Purpose: Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member. Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines Reviews member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities Collaborates with care management on referral of members as appropriate Performs other duties as assigned Complies with all policies and standards Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience. 2+ years of acute care experience required. Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. License/Certification: RN - NV State Licensure preferred Pay Range: $26.50 - $47.59 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
Grow Healthy If you are as passionate about helping those in need as you are about growing your career, consider AltaMed. At AltaMed, your passion for helping others isn’t just welcomed – it’s nurtured, celebrated, and promoted, allowing you to grow while making a meaningful difference. We don’t just serve our communities; we are an integral part of them. By raising the expectations of what a community clinic can deliver, we demonstrate our belief that quality care is for everyone. Our commitment to providing exceptional care, despite any challenges, goes beyond just a job; it’s a calling that drives us forward every day. Job Overview The LVN, Utilization Management Nurse position will provide routine review of authorization requests from all lines of business using respective national/state, health plans, and nationally recognized guidelines. Responsible for reviewing proposed hospitalization, home care, and inpatient/outpatient treatment plans for medical necessity and efficiency with coverage guidelines. The UM Nurse determines the medical appropriateness of inpatient and outpatient services following the evaluation of medical guidelines and benefit determination. Minimum Requirements Graduated from an accredited LVN school with a current LVN license issued by the State of California Vocational Nursing. Minimum of 2 years of managed care experience is required. BLS Certification is required. Compensation Pay for this job starts at $31.93 hourly Compensation Disclaimer Actual salary offers are considered by various factors, including budget, experience, skills, education, licensure and certifications, and other business considerations. The range is subject to change. AltaMed is committed to ensuring a fair and competitive compensation package that reflects the candidate's value and the role's strategic importance within the organization. This role may also qualify for discretionary bonuses or incentives. Benefits & Career Development Medical, Dental and Vision insurance 403(b) Retirement savings plans with employer matching contributions Flexible Spending Accounts Commuter Flexible Spending Career Advancement & Development opportunities Paid Time Off & Holidays Paid CME Days Malpractice insurance and tail coverage Tuition Reimbursement Program Corporate Employee Discounts Employee Referral Bonus Program Pet Care Insurance Job Advertisement & Application Compliance Statement AltaMed Health Services Corp. will consider qualified applicants with criminal history pursuant to the California Fair Chance Act and City of Los Angeles Fair Chance Ordinance for Employers. You do not need to disclose your criminal history or participate in a background check until a conditional job offer is made to you. After making a conditional offer and running a background check, if AltaMed Health Service Corp. is concerned about a conviction directly related to the job, you will be given a chance to explain the circumstances surrounding the conviction, provide mitigating evidence, or challenge the accuracy of the background report.
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. Must have an active New York State clinical license; and a NYS Driver's License or Identification card. Position Purpose: The Utilization Review Nurse I provides first level clinical review for all outpatient and ancillary services requiring authorization. Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services. Answers Utilization Management directed telephone calls; managing them in a professional and competent manner. Processes all prior authorizations to completion utilizing appropriate review criteria. Identifies and refers all potential quality issues to the Clinical Quality Management Department, and suspected fraud and abuse cases to Program Integrity. Acts as liaison between the TRICARE beneficiary and the Network Provider. Provides first level RN review for all outpatient and ancillary prior authorization requests for medical appropriateness and medical necessity using appropriate criteria, referring those requests that fail review to the medical director for second level review and determination. Completes data entry and correspondence as necessary for each review. Conducts rate negotiation with non-network providers, utilizing appropriate CMAC, DRG, HCPC reimbursement methodologies. Documents rate negotiation accurately for proper claims adjudication. Acts as liaison between the TRICARE beneficiary and the provider, facility and the MTF to utilize appropriate and cost effective medical resources within the direct care and purchased care system. Identifies and refers potential cases to Disease Management, Case Management, Demand Management and Transitional Care. Refers all potential quality issues and grievances to Clinical Quality Management and suspected fraud and abuse to Program Integrity. Performs other duties as assigned Complies with all policies and standards Education/Experience: Graduate of Nursing program; BSN desired or Graduate in Clinical Psychology or Clinical Social Work. Three years clinical experience in a health care environment; managed care experience desired. For Fidelis Care only: NYS RN, OT or PT license required Pay Range: $26.50 - $47.59 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
Job Description UW Medicine - Harborview's Medical Center's Clinical Documentation Department has an outstanding opportunity for a Registered Nurse - Second Level Review/Review Coordinator Clinical Documentation Integrity Specialist. WORK SCHEDULE Full-Time Mondays-Fridays Remote position Department Description This position will also participate in various projects and initiatives within the Clinical Documentation Program. Based on findings, department goals and initiatives and industry expectation, the SLR/Review Coordinator CDIS will participate in the education of the CDI team regarding findings and opportunities for documentation improvement in their record review. This position will assume responsibility for delegating daily assignments when directed by the CDP Operations Manager, as well as participate in quality improvement projects, audits and other duties also assigned by CDP Operations Manager. POSITION HIGHLIGHTS This person will perform duties and conduct interpersonal relationships in a manner that promotes a team approach and collaborative work environment with CDI staff, coders, leadership, and physicians. Primary Job Responsibilities Compliance with internal and external regulations and policies. Self-directed initiative for independent education with current evidenced-based practices. Review target DRGs specified by CDP Operations Manager, which is an evolving workflow. This review may have a focus on various elements including, but not limited to, CC/MCC capture rate and/or risk adjustment review (Vizient/Elixhauser) Ensure that pertinent patient conditions and treatments are documented such that appropriate reimbursement is received for the level of acuity and service rendered to all patients .using an MS-DRG and/or APR-DRG based payer methodology Requirements Bachelor's degree in Nursing (minimum) with current WA or compact RN Licensure 6 + years prior nursing experience in an acute inpatient hospital setting with in-depth knowledge of medical and surgical care Minimum 5 years of CDI experience; CDI leadership/educator experience preferred Risk adjustment experience preferred (Vizient and Elixhauser preferred) Denial/Appeal experience preferred About Harborview Medical Center As the region's only Level I Trauma and verified burn center, Harborview Medical Center is a comprehensive healthcare facility owned by King County and operated by UW Medicine. It is dedicated to providing specialized care for a broad spectrum of patients from throughout the Pacific Northwest, including the most vulnerable residents of King County. It provides exemplary patient care in leading-edge centers of emphasis, including emergency medicine, trauma and burn care, neurosciences, ophthalmology, vascular surgery, HIV/AIDS, rehabilitation, mental health and substance abuse care. We are a Magnet-designated hospital as recognized by the American Nurses Credentialing Center. Harborview employees are committed to the vital role the institution plays in the immediate community, as well as the entire Northwest region. Challenge. Collaboration. Compassion. About Uw Medicine - Where Your Impact Goes Further UW Medicine is Washington’s only health system that includes a top-rated medical school and an internationally recognized research center. UW Medicine’s mission is to improve the health of the public by advancing medical knowledge, providing outstanding primary and specialty care to the people of the region, and preparing tomorrow’s physicians, scientists and other health professionals. All across UW Medicine, our employees collaborate to perform the highest quality work with integrity and compassion and to create a respectful, welcoming environment where every patient, family, student and colleague is valued and honored. Nearly 29,000 healthcare professionals, researchers, and educators work in the UW Medicine family of organizations that includes: Harborview Medical Center, UW Medical Center - Montlake, UW Medical Center - Northwest, Valley Medical Center, UW Medicine Primary Care, UW Physicians, UW School of Medicine, and Airlift Northwest. Become part of our team . Join our mission to make life healthier for everyone in our community. Compensation, Benefits And Position Details Pay Range Minimum: $120,000.00 annual Pay Range Maximum $165,600.00 annual Benefits Other Compensation: For information about benefits for this position, visit https://www.washington.edu/jobs/benefits-for-uw-staff/ Shift Alternate Work Shift (United States of America) Temporary or Regular? This is a regular position FTE (Full-Time Equivalent) 100.00% Union/Bargaining Unit Not Applicable About The UW Working at the University of Washington provides a unique opportunity to change lives – on our campuses, in our state and around the world. UW employees bring their boundless energy, creative problem-solving skills and dedication to building stronger minds and a healthier world. In return, they enjoy outstanding benefits, opportunities for professional growth and the chance to work in an environment known for its diversity, intellectual excitement, artistic pursuits and natural beauty. Our Commitment The University of Washington is committed to fostering an inclusive, respectful and welcoming community for all. As an equal opportunity employer, the University considers applicants for employment without regard to race, color, creed, religion, national origin, citizenship, sex, pregnancy, age, marital status, sexual orientation, gender identity or expression, genetic information, disability, or veteran status consistent with UW Executive Order No. 81. To request disability accommodation in the application process, contact the Disability Services Office at 206-543-6450 or dso@uw.edu. Applicants considered for this position will be required to disclose if they are the subject of any substantiated findings or current investigations related to sexual misconduct at their current employment and past employment. Disclosure is required under Washington state law.
Inspire health. Serve with compassion. Be the difference. Job Summary Screens patients to obtain clinical information and make timely contacts with insurers to provide clinical information to support physician referrals. In collaboration with physicians, leads the multidisciplinary team including clinical staff and payors to ensure efficient delivery of quality, cost-effective care. Essential Functions All team members are expected to be knowledgeable and compliant with Prisma Health's values: Inspire health. Serve with compassion. Be the difference. Uses established clinical guidelines for initial/admission and continued stay reviews for patients within assigned unit to ensure medical necessity, appropriate level of care and timely implementation of plan of care in accordance with hospital(s) Utilization Review Plan and CMS regulation. Maintains expert level knowledge of body systems and expected clinical outcomes for patient disease process. Maintains current knowledge of changes in state and federal regulatory requirements related to the provision of care management services in the acute care setting. Serves as a resource for patients and families with regard to their rights and responsibilities, when payment of care is denied or when care is no longer medically necessary. Includes, but not limited to, delivery of the regulatory documents as provided by CMS. Consults with interdisciplinary team, Physician Advisor and administrative leadership as necessary to resolve barriers regarding progression of care. Collaborates with physicians throughout hospitalization, develops an effective working relationship, and provides expertise regarding payor and regulatory guidelines. Promotes effective and efficient utilization of clinical resources, ensuring quality, cost effective care. Provides timely clinical reviews to third party payors. Responds to requests for additional information within 24 hours or next business day. Partners with RN Hospital Care Managers and SW Hospital Care Managers to resolve payer related barriers. Maintains care management knowledge to provide services in accordance with standards of practice as established by department and management. Performs other duties as assigned. Supervisory/Management Responsibility This is a non-management job that will report to a supervisor, manager, director, or executive. Minimum Requirements Education - Bachelor's degree in Nursing Experience - Two (2) years acute care nursing experience. One (1) year acute case management or utilization management experience preferred. Utilization management experience is preferred. In Lieu Of Employees in this title prior to 6/1/2025 are grandfathered into the job profile and are only required to have an AD N or Nursing Diploma. Required Certifications, Registrations, Licenses Holds a current RN compact/multistate license recognized by the NCSBN Compact State or is licensed to practice as an RN in the state the team member is working. Knowledge, Skills and Abilities Medical Necessity Criteria (Interqual, MCG) knowledge preferred. Work Shift Day (United States of America) Location Corporate Facility 7001 Corporate Department 70017535 Utilization Management Share your talent with us! Our vision is simple: to transform healthcare for the benefits of the communities we serve. The transformation of healthcare requires talented individuals in every role here at Prisma Health.
JOB DESCRIPTION Job Summary The Care Review Clinician RN provides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care. We are seeking a candidate with a RN licensure that has previous UM and Inpatient Hospital experience. Candidates with MCO experience are highly preferred. The Care Review Clinician must be able to work independently in a high-volume environment. Further details to be discussed during our interview process. Remote- requires RN license Work schedule: Saturday 8:am-12:00pm, Monday- Friday: 8:00am- 5:00pm Sunday- 10:00am-2:00pm, Monday-Thursday: 8:00am- 5:00pm Monday- Friday: 9:30am- 6:00pm Essential Job Duties • Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines. • Analyzes clinical service requests from members or providers against evidence based clinical guidelines. • Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. • Conducts reviews to determine prior authorization/financial responsibility for Molina and its members. • Processes requests within required timelines. • Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner. • Requests additional information from members or providers as needed. • Makes appropriate referrals to other clinical programs. • Collaborates with multidisciplinary teams to promote the Molina care model. • Adheres to utilization management (UM) policies and procedures. Required Qualifications • At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience. • Registered Nurse (RN). License must be active and unrestricted in state of practice. • Ability to prioritize and manage multiple deadlines. • Excellent organizational, problem-solving and critical-thinking skills. • Strong written and verbal communication skills. • Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications • Certified Professional in Healthcare Management (CPHM). • Recent hospital experience in an intensive care unit (ICU) or emergency room. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $26.41 - $61.79 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
Overview Prime Healthcare is an award-winning health system headquartered in Ontario, California. Prime Healthcare operates 51 hospitals and has more than 360 outpatient locations in 14 states providing more than 2.5 million patient visits annually. It is one of the nation’s leading health systems with nearly 57,000 employees and physicians. Eighteen of the Prime Healthcare hospitals are members of the Prime Healthcare Foundation, a 501(c)(3) not-for-profit public charity. Prime Healthcare is actively seeking new members to join our corporate team! #LI-KT1 Responsibilities Responsible for the quality and resource management of all authorizations and referrals with the Prime Healthcare Employee EPO. Works on behalf of the advocate, promoting cost containment and demonstrates leadership to integrate the health care providers to achieve a perceived seamless delivery of care. The methodology is designed to facilitate and insure the achievement of quality, clinical and cost-effective outcomes and to perform a holistic and comprehensive review of the medical record for the medical necessity, intensity of service and severity of illness. Qualifications Required qualifications: Minimum 7 years Post Graduate of an accredited school of nursing and a current state Registered Nurse license. Minimum 3 years RN Utilization Manager working for a Health Plan. At least 3 years of experience in utilization review, referrals, authorizations, denials and appeals. Current BCLS (AHA) certificate upon hire and maintain current. Knowledge of MCG Criteria and/or InterQual Criteria required. Experience and knowledge in basic to intermediate computer skills. Preferred qualifications: Five years acute care nursing experience preferred. Experience with self-funded health plan preferred. Pay Transparency Prime Healthcare offers competitive compensation and a comprehensive benefits package that provides employees the flexibility to tailor benefits according to their individual needs. Our Total Rewards package includes, but is not limited to, paid time off, a 401K retirement plan, medical, dental, and vision coverage, tuition reimbursement, and many more voluntary benefit options. Benefits may vary based on employment status, i.e. full-time, part-time, per diem or temporary. A reasonable compensation estimate for this role, which includes estimated wages, benefits, and other forms of compensation, is $68,640.00 to $104,000.00 on an annualized basis. The exact starting compensation to be offered will be determined at the time of selecting an applicant for hire, in which a wide range of factors will be considered, including but not limited to, skillset, years of applicable experience, education, credentials and licensure. Employment Status Full Time Shift Days Equal Employment Opportunity Company is an equal employment opportunity employer. Company prohibits discrimination against any applicant or employee based on race, color, sex, sexual orientation, gender identity, religion, national origin, age (subject to applicable law), disability, military status, genetic information or any other basis protected by applicable federal, state, or local laws. The Company also prohibits harassment of applicants or employees based on any of these protected categories. Know Your Rights: https://www.eeoc.gov/sites/default/files/2022-10/EEOC_KnowYourRights_screen_reader_10_20.pdf Privacy Notice Privacy Notice for California Applicants: https://www.primehealthcare.com/wp-content/uploads/2024/04/Notice-at-Collection-and-Privacy-Policy-for-California-Job-Applicants.pdf
Interested in a career with both meaning and growth? Whether your abilities are in direct patient care or one of the many other areas of healthcare administration and support, everyone at Parkland works together to fulfill our mission: the health and well-being of individuals and communities entrusted to our care. By joining Parkland, you become part of a diverse healthcare legacy that’s served our community for more than 125 years. Put your skills to work with us, seek opportunities to learn and join a talented team where patient care is more than a job. It’s our passion. Primary Purpose Parkland Community Health Plan's (PCHP's) Utilization Management (UM) Clinician is responsible for processing authorization requests for members requiring physical and/or behavioral healthcare for outpatient and inpatient service. UM responsibilities include but are not limited to processing of prior and concurrent review authorizations, discharge planning and transitions of care. Oversees the application of clinical guidelines in determining appropriateness of requested and continued healthcare services. Ensures that all clinical decisions are completed according to evidence based best practice guidelines and meets regulatory requirements. Seeks Medical Director review of cases not meeting criteria and monitors time frames for decision making and notifications of decision. Minimum Specifications Education Bachelor's degree in Nursing; or Master's Degree in Social Work or a related field required. If serving physical health populations, graduation from an accredited school of nursing is required. Experience 3+ years of acute clinical nursing or medical management experience required. If serving behavioral health populations, at least three 3+ years of clinical social work or behavioral health experience required. 3+ years of experience in Texas Medicaid, Medicaid, or a Medicaid managed care organization or health plan preferred. 1+ year experience with the implementation of utilization management policies, procedures, and protocols for physical health and/or behavioral health services and knowledge of utilization management and case management principles is preferred. Experience managing pediatric population with complex PH/BH conditions preferred. Experience in Texas Medicaid and NCQA is preferred. Certification/Registration/Licensure If primarily serving members with physical health needs, current and unrestricted licensure as a RN in the State of Texas required. If primarily serving members with behavioral health needs, must have and maintain an unrestricted license such as a RN, LPC, LMFT, or LCSW in the State of Texas. Skills or Special Abilities Knowledge of community resources, local service systems including indigent physical health and/or behavioral health systems. Knowledge of utilization management and case management principles. Understanding of utilization management principles, objectives, standards and methods, and of program policies and procedures. For those reviewing BH authorizations, demonstrate knowledge and utilization of evidence-based practices relevant to population served (persons who have experienced trauma, members with substance use disorder, members with serious mental illness or serious emotional disturbance). Competency in prior and concurrent review authorization functions including application of criteria and timelines. Demonstrated ability to analyze clinical information and accurately apply clinical criteria. Excellent verbal and written communication skills including the ability to communicate effectively and professionally across disciplines. Ability to communicate complex information in understandable terms. Proven history of effective communication and counseling skills Strong interpersonal and conflict resolution skills with the ability to establish and maintain effective working relationships across and beyond the organization. Excellent analytical and problem-solving skills. Strong time management and organizational skills with the ability to manage multiple demands and respond to rapidly changing priorities. Ability to write clearly and succinctly with a high level of attention to detail. Proficient computer and Microsoft Office skills. Ability to learn new software programs. Knowledge of Texas Medicaid, National Committee for Quality Assurance (NCQA), the Uniformed Managed Care Contract, and the Uniform Managed Care Manual. - Familiar with InterQual and Texas Medicaid Provider Procedures Manual and utilization guidelines. Solid understanding of managed care and medical terminology. Knowledge of and competence in use of UM software. Foster strong, positive, and effective working relationships with inter-system and intra-system team members, encouraging and supporting interaction among various team members across organizational lines. Responsibilities Care Coordination and Clinical Review Performs clinical utilization reviews of pre-authorization, concurrent and retrospective requests per clinical information submitted by providers using clinical criteria for medical necessity and appropriateness of care. Approves services or forwards requests to the appropriate medical director for further review, as appropriate. Performs utilization management functions competently and adheres to the guidelines for authorization turn-around times. Reviews clinical service requests from members or providers using evidence based clinical guidelines, analyzes clinical information and correctly applies clinical criteria. Requests additional information from members or providers in a timely manner and makes referrals to other clinical programs as needed. Identifies members that are high risk or who have conditions that may need service coordination or disease management and facilitates appropriate referrals. Works collaboratively with provider network and health services team to coordinate member care. Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services. Answers utilization management directed telephone calls, managing them in a professional and competent manner. Conducts ongoing availability, monitoring, and oversight of non-clinical staff activities. Uses effective relationship management, coordination of services, resource management, education, patient advocacy and related interventions to assure appropriate levels of care are received by members. Identifies and utilizes appropriate alternative and non-traditional available resources in managing cases. Documentation Provides accurate and complete documentation along with an explanation of the rationale that was used to approve requests. Documents and maintains clinical information in health management systems ensuring all pertinent information is entered in a timely manner and in accordance with department guidelines. Performs medical necessity documentation to expedite approvals and ensure that appropriate follow up is performed. Regulatory Ensures work is carried out in compliance with regulatory and/or accreditation standards as well as contractual requirements. Professional Accountability Promotes and supports a culturally welcoming and inclusive work environment. Acts with the highest integrity and ethical standards while adhering to Parkland's Mission, Vision, and Values. Adheres to organizational policies, procedures, and guidelines. Completes assigned training, self-appraisal, and annual health requirements timely. Adheres to hybrid work schedule requirements. Attends required meetings and town halls. Recognizes and communicates ethical and legal concerns through the established channels of communication. Demonstrates accountability and responsibility by independently completing work, including projects and assignments on time, and providing timely responses to requests for information. Maintains confidentiality at all times. Performs other work as requested that is reasonably related to the employee's position, qualifications, and competencies. Parkland Health and Hospital System prohibits discrimination based on age (40 or over), race, color, religion, sex (including pregnancy), sexual orientation, gender identity, gender expression, genetic information, disability, national origin, marital status, political belief, or veteran status. As part of our commitment to our patients and employees’ wellness, Parkland Health is a tobacco and smoke-free campus.
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. This position is an inpatient CCR staff role supporting three health plans across Washington, Iowa, and Nebraska. Standard schedule: Monday–Friday, 8:00 a.m.–5:00 p.m. Mandatory requirement to work at least one weekend day each week; the ability to work both weekend days is preferred Participation in a rotational holiday schedule is required. Active compact RN license required. Position Purpose: Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member. Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines Reviews member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities Collaborates with care management on referral of members as appropriate Performs other duties as assigned Complies with all policies and standards Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience. 2+ years of acute care experience required. Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. License/Certification: LPN - Licensed Practical Nurse - State Licensure required Pay Range: $26.50 - $47.59 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. Position Purpose: Performs a clinical review and assesses care related to mental health and substance abuse. Monitors and determines if level of care and services related to mental health and substance abuse are medically appropriate. Evaluates member’s treatment for mental health and substance abuse before, during, and after services to ensure level of care and services are medically appropriate Performs prior authorization reviews related to mental health and substance abuse to determine medical appropriateness in accordance with regulatory guidelines and criteria Performs concurrent review of behavioral health (BH) inpatient to determine overall health of member, treatment needs, and discharge planning Analyzes BH member data to improve quality and appropriate utilization of services Provides education to providers members and their families regrading BH utilization process Interacts with BH healthcare providers as appropriate to discuss level of care and/or services Engages with medical directors and leadership to improve the quality and efficiency of care Formulates and presents cases in staffing and integrated rounds Performs other duties as assigned. Complies with all policies and standards. Ideal candidate will have the following experience: Clinical Auditing Expertise: Proven experience in auditing Medicaid charts. Licensure & Location: Must hold an active license and reside in Florida. Communication Skills: Skilled in delivering constructive feedback to behavioral health providers. Education/Experience: Requires Graduate of an Accredited School Nursing or Bachelor's degree and 2 – 4 years of related experience. License to practice independently, and/or have obtained the state required licensure as outlined by the applicable state required. Master’s degree for behavioral health clinicians required. Clinical knowledge and ability to review and/or assess treatment plans related to mental health and substance abuse preferred. Knowledge of mental health and substance abuse utilization review process preferred. Experience working with providers and healthcare teams to review care services related to mental health and substance abuse preferred. License/Certification: LCSW- License Clinical Social Worker required or LMHC-Licensed Mental Health Counselor required or LPC-Licensed Professional Counselor required or Licensed Marital and Family Therapist (LMFT) required or Licensed Mental Health Professional (LMHP) required or RN - Registered Nurse - State Licensure and/or Compact State Licensure required Pay Range: $26.50 - $47.59 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
Location Address: 4194 Lexington Ave N Shoreview, MN 55126-6106 Date Posted: December 02, 2025 Department: 62206600 Allina Health Group Urgent Care Shoreview Shift: Shift Length: Variable shift length Hours Per Week: 30 Union Contract: Non-Union-NCT Weekend Rotation: Every Other Job Summary: Allina Health is a not-for-profit health system that cares for individuals, families and communities throughout Minnesota and western Wisconsin. If you value putting patients first, consider a career at Allina Health. Our mission is to provide exceptional care as we prevent illness, restore health and provide comfort to all who entrust us with their care. This includes you and your loved ones. We are committed to providing whole person care, investing in your well-being, and enriching your career. Key Position Details: **$2,000 starting bonus for eligible external talent** 0.75 FTE (60 hours per two-week pay period) Variable shift length, day/evening shifts Every other weekend rotation Floating to other sites may be required for training and/or coverage at other sites after training Job Description: Provides support to providers and the nursing staff in the delivery of timely, quality patient health care services. Some duties include assisting with rooming patients, managing patient flow, administer medication, communication with patients. Principle Responsibilities Rooms patients, manages patient flow and obtains adequate patient medical information/data. Confirms information with patient when necessary and document per practice. Collects patient information via interview, questionnaires, vital signs and accurately document in EMR according to rooming standards. Assists with the collection, labeling, and processing of specimens. Facilitates obtaining lab/imaging results and notify provider of abnormalities. Works with the electronic medical records in basket, responding to messages as delegated for provider. May need to help cover front desk and provide backup to patient registration/scheduling. Performs patient care tasks as delegated by Provider or RN Performs injections. Assists with procedures. Provides patient information regarding test/procedure preparation, treatment plan, preventative or other health information. Coordinates results of tests, procedures etc. with provider or RN. Prepares refill information for provider to review and prescribe. Assists with patient transportation. Contributes to an environment that is safe for patients, visitors, and employees. Reports environmental risks or equipment malfunctions to Supervisor. Uses equipment following policies, procedures and manufacturer directions or standards. Follows all policies, procedures, standard work, and proper techniques when providing patient care. Cleans, stocks, maintains inventory for exam, medication and supply rooms. Reports any acute problems and changes in patient's condition. Applies High reliable safety principles to all interactions. Other duties as assigned. Required Qualifications Must be 18 years of age with education and/or experience needed to meet required principle competencies as listed on the job description Non-Certified Applicants with less than six (6) months of Medical Assistant experience must have graduated from an accredited school with a clinical externship Preferred Qualifications Previous Medical Assistant experience Knowledge of medical terminology Licenses/Certifications Must meet at least ONE of the requirements below: ◦ Current BLS certification from the American Heart Association ◦ Current BLS certification from the American Red Cross ◦ Allina in-house BLS training (within 30 days of hire) Certified Medical Assistant (CMA) from the American Association of Medical Assistants preferred Physical Demands Medium Work*: Lifting weight up to 32 lbs. occasionally (*Allina Safe Patient Moving Policy), up to 25 lbs. frequently Pay Range Pay Range: $21.55 to $29.35 per hour The pay described reflects the base hiring pay range. Your starting rate would depend on a variety of factors including, but not limited to, your experience, education, and the union agreement (if applicable). Shift, weekend and/or other differentials may be available to increase your pay rate for certain shifts or work. Benefit Summary Allina Health believes the best way to provide safe and compassionate care for our patients is by nurturing the passion of those who care for them. That’s why we devote extraordinary resources to help you grow and thrive — not only as a professional but also as a whole person. When you join our team, you have access to a wealth of valuable employee benefits that support the total well-being — mind, body, spirit and community — of you and your family members. Allina Health is all in on your well-being. Because well-being means something different to everyone, our award-winning program provides you with the resources you need to help you navigate your personal journey. This includes up to $100 in well-being dollars, dedicated well-being navigators, and many programs, activities, articles, videos, personal coaching and tools to support you on your journey. In addition, Allina Health offers employee resources groups (ERGs) -- voluntary, employee-led groups that serve as a resource for members and organizations by fostering a diverse, inclusive workplace aligned with the organization's mission, values, goals, business practices, and objectives. Allina Health also engages employees in various community involvement and volunteering events. Benefits include: Medical/Dental PTO/Time Away Retirement Savings Plans Life Insurance Short-term/Long-term Disability Paid Caregiver Leave Voluntary Benefits (vision, legal, critical illness) Tuition Reimbursement or Continuing Medical Education as applicable Student Loan Support Benefits to navigate the Federal Public Service Loan Forgiveness Program Allina Health is a 501(c)(3) eligible employer *Benefit eligibility/offerings are determined by FTE and if you are represented by a union.
Department/Unit: Care Management/Social Work Work Shift: Day (United States of America) Salary Range: $71,612.39 - $110,999.20 Responsible for Utilization Management, Quality Screening and Delay Management for assigned patients. • Completes Utilization Management and Quality Screening for assigned patients. • Applies MCG criteria to monitor appropriateness of admissions and continued stays, and documents findings based on Departmental standards. • While performing utilization review identifies areas for clinical documentation improvement and contacts appropriate department. • Identifies at-risk populations using approved screening tool and follows established reporting procedures. • Monitors LOS and ancillary resource use on an ongoing basis. Takes actions to achieve continuous improvement in both areas. • Refers cases and issues to Medical Director and Triad Team in compliance with Department procedures and follows up as indicated. • Communicates covered day reimbursement certification for assigned patients. • Discusses payor criteria and issues and a case-by-case basis with clinical staff and follows up to resolve problems with payors as needed. • Uses quality screens to identify potential issues and forwards information to the Quality Department. • Demonstrates proper use of MCG and documentation requirements through case review and inter-rater reliability studies. • Facilitates removal of delays and documents delays when they exist. Reports internal and external delays to the Triad Team. • Collaborates with the health care team and appropriate department in the management of care across the continuum of care by assuring communication with Triad Team and health care team. Minimum Qualifications: • Registered nurse with a New York State current license. • Bachelor's degree preferred. • Minimum of three years clinical experience in an assigned service. • Recent experience in case management, utilization management and/or discharge planning/home care in a high volume, acute care hospital preferred. PRI and • Case Management certification preferred. • Assertive and creative in problem solving, critical thinking skills, systems planning and patient care management. • Self-directed with the ability to adapt in a changing environment. • Basic knowledge of computer systems with skills applicable to utilization review process. • Excellent written and verbal communication skills. • Working knowledge of MCG criteria and ability to implement and utilize. • Understanding of Inpatient versus Outpatient surgery and ICD10-Coding (preferred) and Observation status qualifications. • Ability to work independently and demonstrate organizational and time management skills. • Strong analytic, data management and PC skills. • Working knowledge of Medicare regulatory requirements, Managed Care Plans Thank you for your interest in Albany Medical Center! Albany Medical is an equal opportunity employer. This role may require access to information considered sensitive to Albany Medical Center, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that: Access to information is based on a “need to know” and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Med Center policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification.
Job Description: The role of the inpatient case manager is one of patient advocate of appropriate utilization of resources. The inpatient case manager applies the process of assessment, planning, implementation, monitoring, evaluation and coordination of care to meet the patient’s health care needs through hospitalization and transition back to the community and does this in coordination with the interdisciplinary health team. The RN Case Manager is expected to function within the full scope of the nursing practice with specialized focus on care coordination, compliance, transition management, education, and utilization management. Education: Bachelor's Degree Accredited School of Nursing Required Experience: 3 years Nursing - Medical/Surgical Preferred or 3 years Nursing - Critical Care Preferred 2 years Care Coordination - Case Management Preferred or Equivalent Work Experience Certifications/Licensures: RN Registered Nursing - California Board of Nursing Required BLS Basic Life Support - American Heart Association Required ACM Accredited Case Manager - ACMA American Case Management Association or CCM Certified Case Manager - CCMC Commission for Case Manager Certification Strongly Preferred Skills: Strong written and verbal communication skills. Effectively motivates teams. Strong knowledge of Medicare and Medi-Cal guidelines and benefit resources as applicable to hospitalization and transition planning. Working know ledge of common diagnoses and procedures and the impact this w ill have to patients/families and their ability to manage their care outside of the hospital. Specialized know ledge may be required for certain areas of practice. Knowledge of individual and family development over the life span, and the influences of cultural and spiritual values in health care. General knowledge of commercial coverage plans and usually covered benefits. Strong understanding of various reimbursement models and impact to care delivery, patient management and reimbursements such as ACOs, DRGs, Full Risk, etc. Strong understanding of the criteria, rules and regulations around Inpatient, Observation and Outpatient levels of patient management. Strong know ledge of geriatrics and the impact to health and function in the aged as w ell as a working know ledge of chronic/progressive disease states such as CHF, COPD, Diabetes and End Stage Renal Disease, etc. Clear understanding of the role of the inpatient Social Worker and Palliative Care Resources. Ability to plan, organize, manage time and prioritize work in collaboration with others. Ability to work independently and as a part of a multidisciplinary team. Effective problem solving and conflict resolution skills. Ability to work respectfully and creatively with clients of diverse functional abilities, social, economic, and cultural backgrounds to support both client autonomy and client safety. Leadership skills to delegate and provide direction/guidance to staff and hold others accountable. Able to learn and work in a variety of computer programs, including EPIC, Allscripts, InterQual, and Microsoft Outlook. Days worked per week: 5/4 Work schedule: Week 1- Tues-Sat & Week 2- Wed-Sat Work Shift: 08.0 - 08:00 - 16:30 No Waive (United States of America) Pay Range: $84.77 - $115.51 Hourly Offer amounts are based on demonstrated/relevant experience and/or licensure. Pay will be adjusted to the local market if hired outside of the Bay Area . Note: Positions at JMH which are exempt (not eligible for overtime) under the level of Manager are listed as hourly for compensation purposes on this posting. The work shift will contain the word ‘exempt’ on it. Scheduled Weekly Hours: 36
Must live in MICHIGAN and have MICHIGAN RN LICENSE Scope of Work: Provides health information, interacts and acts as a resource for nursing units for complex clinical situations to ensure appropriate use of acute care services and diagnosis-related group (DRG) management. Assesses appropriateness of inpatient admissions and continued stay. Educates medical staff/other health care professionals regarding utilization management and quality requirements. Makes recommendations and provides financial and utilization management (UM) information to other members of the care facilitation teams for work prioritization. Works closely with inpatient care facilitators and Medical Social Workers to move patients through the continuum appropriately. Assesses and interprets clinical information and assists in case management of complex patient population, through use of independent judgment, mature problem solving skills, and guidelines for appropriateness of acute care setting upon admission and continued stay. Adjusts patient registration status code, as needed, to maximize reimbursement and be consistent with regulatory standards. Communicates with physicians, medical social workers, and other hospital personnel concerning change in level of care on the medically complex patient population. Makes recommendations and discusses alternatives. Provides financial/DRG, UM, health information to other facilitation team members for work prioritization. Communicates and collaborates with physicians and members of the team to ensure continuity and coordination of services. Documents any instances where services were delayed, inappropriate, refused, complicated, etc. for resource management functions. Identifies quality indicators to facilitate process improvement and physician education. Qualifications Required Associate's Degree Nursing Preferred Bachelor's Degree Nursing 2 years of relevant experience acute care, clinical nursing, preferably multiple clinical settings, or related experience Required Registered Nurse (RN) - State of Michigan required How Corewell Health cares for you Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here . On-demand pay program powered by Payactiv Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more! Optional identity theft protection, home and auto insurance, pet insurance Traditional and Roth retirement options with service contribution and match savings Eligibility for benefits is determined by employment type and status Primary Location SITE - 4700 60th St - Grand Rapids Department Name Utilization Management - GR Employment Type Part time Shift Day (United States of America) Weekly Scheduled Hours 0.04 Hours of Work 8:00 a.m. to 4:30 p.m. Days Worked Monday to Friday Weekend Frequency N/A CURRENT COREWELL HEALTH TEAM MEMBERS – Please apply through Find Jobs from your Workday team member account. This career site is for Non-Corewell Health team members only. Corewell Health is committed to providing a safe environment for our team members, patients, visitors, and community. We require a drug-free workplace and require team members to comply with the MMR, Varicella, Tdap, and Influenza vaccine requirement if in an on-site or hybrid workplace category. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process, to perform the essential functions of a job, or to enjoy equal benefits and privileges of employment due to a disability, pregnancy, or sincerely held religious belief. Corewell Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category. An interconnected, collaborative culture where all are encouraged to bring their whole selves to work, is vital to the health of our organization. As a health system, we advocate for equity as we care for our patients, our communities, and each other. From workshops that develop cultural intelligence, to our inclusion resource groups for people to find community and empowerment at work, we are dedicated to ongoing resources that advance our values of diversity, equity, and inclusion in all that we do. We invite those that share in our commitment to join our team. You may request assistance in completing the application process by calling 616.486.7447.
Current Saint Francis Employees - Please click HERE to login and apply. Full Time Nights #ALDIND Shift: Nights; Hybrid after 6 months in the role. Job Summary: Provides administrative and clinical support to the hospital and treatment teams throughout the review of patients including, but not limited to their placement in various levels of care and receipt of necessary services. The Utilization Management (UM) Registered Nurse will communicate with providers the details of reimbursement issues and participate in treatment teams, Patient Care Committee, and the Utilization Review Staff Committee by providing data and contributing to the improvement of internal processes. Minimum Education: Has completed the basic professional curricula of a school of nursing as approved and verified by a state board of nursing, and holds or is entitled to hold a diploma or degree therefrom or Master's degree in Nursing. Licensure, Registration and/or Certification: Valid multi-state or State of Oklahoma Registered Nurse License. Work Experience: Minimum 2 years of related experience in an acute care setting. Knowledge, Skills and Abilities: Ability to organize and prioritize work in an effective and efficient manner. Effective interpersonal, written, and oral communication skills. Demonstrated ability to integrate the analysis of data to discover facts or develop knowledge, concepts, or interpretations. Ability to be detail oriented as required in the examination of numerical data. Ability to synthesize clinical case data into concise summaries. Working knowledge of Microsoft Word, Excel and Access in the preparation of correspondence and reports. Essential Functions and Responsibilities: Gathers, prepares and supplies required clinical/treatment information needed to obtain authorization within the review interval(s) time requirements. Participates in treatment team and/or Patient Care Committee by providing information about eligibility, benefits, and criteria for the selected level of care. Assists in discharge planning, as needed. Identifies QI Triggers for individual patient situations, reporting them promptly to the UM Manager, appropriate clinicians and Process Improvement/Quality Director. Reviews eligibility and benefits of patients to validate accurate level of care utilization. Investigates and prepares appeals for insurance companies when denial of reimbursement is related to medical necessity or to other treatment issues. Participates in quality-of-care and UM process improvement on an ongoing basis and assists with development of the UR Staff Committee's process improvement goals. Provides staff education to further the goals of UR. Decision Making: The carrying out of non-routine procedures under constantly changing conditions, in conformance with general instructions from supervisor. Working Relationship: Works directly with patients and/or customers. Works with internal customers via telephone or face to face interaction. Works with other healthcare professionals and staff. Works frequently with individuals at Director level or above. Special Job Dimensions: None. Supplemental Information: This document generally describes the essential functions of the job and the physical demands required to perform the job. This compilation of essential functions and physical demands is not all inclusive nor does it prohibit the assignment of additional duties. Utilization Review Management - Yale Campus Location: Tulsa, Oklahoma 74136 EOE Protected Veterans/Disability
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. ***POSITION IS REMOTE*** Position Purpose: Performs reviews of member's care and health status of Applied Behavioral Analysis (ABA) services provided to determine medical appropriateness. Monitors clinical effectiveness and efficiency of member's care in accordance with ABA guidelines. Evaluates member’s care and health status before, during, and after provision of Applied Behavioral Analysis (ABA) services to ensure level of care and services are medically appropriate related to behavioral health (BH) and/or autism spectrum disorder needs and clinical standards Performs prior authorization reviews related to BH to determine medical appropriateness in accordance with ABA regulatory guidelines and criteria Analyzes BH member data to improve quality and appropriate utilization of services Interacts with BH healthcare providers as appropriate to discuss level of care and/or services provided to members receiving Applied Behavior Analysis Services Provides education to members and their families regrading ABA and BH utilization process Provides feedback to leadership on opportunities to improve care services through process improvement and the development of new processes and/or policies Performs other duties as assigned. Complies with all policies and standards. Education/Experience: Requires Graduate of an Accredited School of Nursing or Bachelor's degree and 2-4 years of related experience. For Enterprise Population Health 2+ years providing ABA services as a BCBA License to practice independently, and/or have obtained the state required licensure as outlined by the applicable state (BCBA) required. Master’s degree for behavioral health clinicians required. Behavioral health clinical knowledge and ability to review and/or assess ABA Treatment Plans required. Knowledge of ABA services and BH utilization review process required. Experience working with providers and healthcare teams to review care services related to Applied Behavior Analysis Services preferred. License/Certification: LCSW- License Clinical Social Worker required or LMHC-Licensed Mental Health Counselor required or LPC-Licensed Professional Counselor required or Licensed Marital and Family Therapist (LMFT) required or Licensed Mental Health Professional (LMHP) required or Board Certified Behavior Analyst (BCBA) required RN - Registered Nurse - State Licensure and/or Compact State Licensure RN - Registered Nurse- State Licensure and/or Compact State Licensure with BCBA required or Independent licensure with ABA experience and BCBA preferred. preferred Licensed Behavior Analyst (LBA) where required by state required Pay Range: $26.50 - $47.59 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
25012327 Clinical Reviews, Denial and Appeals RN Bring your passion to THR so we are Better + Together Work location : Remote (Local candidates only) Work hours : Monday – Friday from 8:00am – 4:30pm Clinical Review And Denials Department Highlights Flexible schedule Remote work environment Collaborative team approach Work/life balance Opportunities for advancement Opportunities for tuition reimbursement for approved degrees Here’s What You Need Associates Degree in Nursing required Bachelor’s Degree in Nursing preferred 3 years Inpatient clinical nursing experience in an acute hospital setting required and 1 year UM experience including knowledge and application of Milliman or InterQual criteria required Case management experience preferred Denials and Appeals experience preferred RN license to practice in the state of Texas upon hire required What You Will Do Communicates and collaborates as needed with physicians, Care Management staff, Business Office, Nursing, and ancillary departments to proactively address patient care issues and denials management Conducts the necessary research for appealing denied days/stays through electronic record review. Requires access to Care Connect patient records for all THR hospitals. Collaborates with physicians when needed to develop comprehensive and effective appeal strategies for medical necessity denials. Reviews clinical documentation in order to determine if medical necessity criteria were met. Prepares appeal letters and notifications to appropriate parties and hospital departments within the specified time frames and files appeal per contracted agreement. Tracks, monitors, manage clinical denials and appeals and appeal outcomes for reporting as requested. Reports denial trends to the respective departments are used for educational corrective action. Develops and maintains relationships with other departments related to appeals and denial management. Serves as an educator and resource to the Care Management Staff, Physicians and other hospital disciplines as required/designated regarding Medicare, Medicaid and Commercial payer guidelines. Reviews Medicare one day stays and conducts medical necessity internal audits (100% one day stays) Additional perks of being a Texas Health employee Benefits include 401k, PTO, medical, dental, Paid Parental Leave, flex spending, tuition reimbursement, Student Loan Repayment Program as well as several other benefits. Delivery of high quality of patient care through nursing education, nursing research and innovations in nursing practice. Strong Unit Based Council (UBC). A supportive, team environment with outstanding opportunities for growth Entity Highlights At Texas Health Resources, our mission is “to improve the health of the people in the communities we serve”. Our award-winning culture is a tribute to our amazing employees. We’re thrilled to be a 2023 FORTUNE Magazine’s “100 Best Companies to Work For®” for the 9th year in a row! We strive to create an atmosphere of respect, integrity, compassion and excellence for all. We’re committed to diversity in our workforce, and our mission to serve spreads across ethnic, cultural, economic and generational boundaries. Join us and to do your life’s best work here! Explore our Texas Health careers site for info like Benefits, Job Listings by Category, recent Awards we’ve won and more. Do you still have questions or concerns? Feel free to email your questions to recruitment@texashealth.org.
Job Description To maintain high-quality, medically necessary, evidence-based care, and efficient treatment of all patients, regardless of payment source, by ensuring the patients receive the right care, at the right time, in the right place. Case Management Model: utilize an Integrated Case Management Model. Under this model the Case Managers will follow patients through the continuum while facilitating the functions of utilization review, utilization management, and cost containment. Track and trend denials and payor issues to provide feedback and education to payer relations and the case management department. Responsibilities Clinical review of 100% acute bedded patients admitted to Inpatient or Observation status at The Christ Hospital against medical necessity criteria (Interqual and MCG) for appropriateness of admission. Demonstrate understanding of evidenced based medical necessity criteria. Maintains efficient methods of ensuring the medical necessity and appropriateness of all hospital admissions. Identify/facilitate patient status from observation to inpatient as patient clinical condition warrants. Compliance with all Medicare regulatory requirements Work with external payers completing/securing authorization for all services provided. Monitors cases for appropriateness of continued stay, level of care and services, and quality of care using approved screening criteria. Communicate with physicians when alternatives to inpatient care are indicated by clinical review. Identify cases needed for second level of review- refers cases to the Physician Advisor that do not meet established guidelines for admission or continued stay. Consistent collaboration with the RN Case Manager to prevent extended length of stays and appropriate status determination. Identifies potential delays in service or treatment and refers to the appropriate individuals within the multidisciplinary patient care teams for action/resolution. Track and trends avoidable day information in Midas per process. Identifies problems related to the quality of patient care and refers such problems to the Performance Improvement Department. Adherence to department productivity standards. Initial, concurrent, and retro reviews should be completed timely including all necessary information for approval of claims. All reviews should contain information only pertinent to IS/SI (Intensity of Service/Severity of Illness). Compliance with documentation methods for monthly reporting and statistics for presentation to the Utilization Review Committee. Interfaces with patient registration and patient financial services etc. to collaborate on financial issues. Establish an effective rapport and relationship with third party payers to promote cost effective clinical outcomes. Assist in denial and appeal process Performs other duties as assigned, including but not limited to: Demonstrates professional responsibility required for a Utilization Review Nurse Complies with department and hospital policies at all times Maintains compliance with State/Federal Guidelines and standards Conforms to all requirements of Medicare Keep current on changing laws and requirements of Medicare Demonstrate a positive attitude at all times Qualifications KNOWLEDGE AND SKILLS: Please describe any specialized knowledge or skills, which are REQUIRED to perform the position duties. Do not personalize the job description, credentials, or knowledge and skills based on the current associate. List any special education required for this position. EDUCATION: Bachelor’s Degree. Graduate of an accredited school of nursing with current licensure OR actively enrolled in a BSN program with completion date within 3 years of hire date and a graduate of an accredited school of nursing with current licensure. YEARS OF EXPERIENCE: 3-5 years of medical/surgical nursing necessary and a minimum of 3 years of utilization review experience required. REQUIRED SKILLS AND KNOWLEDGE: Experience with case management, utilization review, and discharge planning that is related to the clinical or operational functional areas. Knowledge and application of a wide variety of advanced case management tools and methods. Knowledge of clinical and operations research methodology and design. Proficient in state of the art business trends, benchmarking, and case management tools and techniques. Ability to operate PC based software programs or automated database management systems. Expertise in meeting regulatory and accreditation requirements. Strong presentation, written and oral communication skills, with strong analytical and problem-solving skills as well as time/project management skills. Ability to work with a variety of disciplines and levels of staff across departments and the organization is required. LICENSES & CERTIFICATIONS: Licensed to practice in the State of Ohio Certified Case Management (CCM) or Accredited Case Management (ACM) preferred.
At UnitedHealthcare, we're simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and optimized. Ready to make a difference? Join us to start Caring. Connecting. Growing together. Under direct supervision of the Manager and Supervisors, Clinical Claims Review, conducts retrospective reviews for appropriateness of diagnostic procedures, inpatient, ambulatory, emergency room, and evaluation & management services, coding levels, etc., utilizing standardized criteria, protocols, and guidelines. This RN will train and provide coverage for the Medical Adjudication and Coding Units in Clinical Claims Review. If you reside within a commutable distance from the Las Vegas, NV area, you will have the flexibility to work remotely* as you take on some tough challenges. Primary Responsibilities Provide support to all units within Claims to ensure all clinical components are met for CMS, NCQA, URAC, DOL, DOI, and all other State and Federal entities Identify business priorities and necessary processes to triage and deliver work Use appropriate business metrics (e.g. case turnaround time, productivity) and applicable processes/tools to optimize decisions and clinical outcomes Review assigned claims (e.g. ER, inpatient, diagnostic procedures) to evaluate medical necessity and determine appropriate levels of care and site of service Maintain incoming pended claims, electronic inquiries and medical records work queue Identify information missing from clinical documentation; request additional clinical documentation as appropriate Make determinations per relevant protocols (e.g., deny, return to claims system, designate as inappropriate referral, proceed with clinical or non-clinical research) Prepare claims for medical director review by completing summary and attaching all pertinent medical information. Interpret codes and determine coding accuracy Use available resources to further interpret coding accuracy Identify relevant information needed to make clinical determination Review other approved sources of clinical information and use data for making clinical determinations (e.g., previous diagnoses, authorizations/denials) Participate in various special projects as assigned Attend assigned meetings relating to clinical reviews and other aspects of job function Perform all job functions with a high degree of discretion and confidentiality in compliance with federal, company & departmental confidentiality guidelines Candidate must be available to complete 3-6 week onsite training. *** You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications Current, unrestricted RN license for the state of Nevada 2+ years of nursing experience in clinical claims review or utilization review 1+ years of acute clinical nursing experience Proficiency with Microsoft Word, Excel and Outlook Preferred Qualifications Bachelor's degree CPC certification Knowledge of managed care delivery system concepts such as HMO/PPO Knowledge of evidenced based and standardized criteria such as InterQual Knowledge of CPT, and ICD-10 coding Broad knowledge of medical conditions, procedures and management Demonstrated ability to learn and differentiate between company products and the benefits All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $28.27 to $50.48 per hour based on full-time employment. We comply with all minimum wage laws as applicable. At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission. UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations. UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.
Department: 11215 Behavioral Health Contract Management Group: Charlotte - Utilization Management Status: Part time Benefits Eligible: No Hou rs Per Week: 4 Schedule Details/Additional Information: PRN, primarily weekdays, but might also request weekend or holiday hours. Candidate must reside in North Carolina or South Carolina to be considered. Pay Range $34.90 - $52.35 Major Responsibilities • Identifies clinical, financial, and psychosocial needs of patients/families and provides leadership and guidance to the multidisciplinary team to develop an individualized plan of care. • Ensures essential information and necessary forms are placed in the revenue cycle tool and available for the revenue cycle team and other disciplines. •Provides necessary documentation and information to third party administrators as needed. •Performs admission and concurrent reviews. •Applies clinical guidelines during Admission and Concurrent reviews and identifies potential third-party denials. Works with multidisciplinary team to identify and implement alternative plans of care. •Initiates and request authorizations for post-acute care as needed to facilitate care coordination. •Refers pertinent cases to the Medical Director, Service Director, and/or Physician Advisor in a timely manner. •Collaborates as needed with the physician to plan and implement medical and multidisciplinary plan(s) of care, utilizing clinical pathways when appropriate and available. •Identify and escalate barriers and problems to the multidisciplinary team and leadership for intervention and resolution. •Develops and maintains accurate case records of assigned cases. Documents in the patient's medical record according to department and facility standards. Minimum Job Requirements Education Graduation from an accredited School of Nursing required. Bachelor's degree in nursing preferred. applicable state RN licensure required. Related experience preferred Certification / License Basic Life Support (BLS) for Healthcare Provider (HCP) per facility requirements Physical Requirements and Working Conditions Works in an office setting, extensive walking throughout the facility. Prolonged periods of sitting reviewing medical records and documentation. Repetitive wrist motion and occasional lifting of 10-20 pounds. Requires frequent verbal and written communication in English. Intact sight and hearing with or without assistive devices are required. DISCLAIMER All responsibilities and requirements are subject to possible modification to reasonably accommodate individuals with disabilities. This job description in no way states or implies that these are the only responsibilities to be performed by an employee occupying this job or position. Employees must follow any other job-related instructions and perform any other job-related duties requested by their leaders. Our Commitment to You: Advocate Health offers a comprehensive suite of Total Rewards: benefits and well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more – so you can live fully at and away from work, including: Compensation Base compensation listed within the listed pay range based on factors such as qualifications, skills, relevant experience, and/or training Premium pay such as shift, on call, and more based on a teammate's job Incentive pay for select positions Opportunity for annual increases based on performance Benefits and more Paid Time Off programs Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability Flexible Spending Accounts for eligible health care and dependent care expenses Family benefits such as adoption assistance and paid parental leave Defined contribution retirement plans with employer match and other financial wellness programs Educational Assistance Program About Advocate Health Advocate Health is the third-largest nonprofit, integrated health system in the United States, created from the combination of Advocate Aurora Health and Atrium Health. Providing care under the names Advocate Health Care in Illinois; Atrium Health in the Carolinas, Georgia and Alabama; and Aurora Health Care in Wisconsin, Advocate Health is a national leader in clinical innovation, health outcomes, consumer experience and value-based care. Headquartered in Charlotte, North Carolina, Advocate Health services nearly 6 million patients and is engaged in hundreds of clinical trials and research studies, with Wake Forest University School of Medicine serving as the academic core of the enterprise. It is nationally recognized for its expertise in cardiology, neurosciences, oncology, pediatrics and rehabilitation, as well as organ transplants, burn treatments and specialized musculoskeletal programs. Advocate Health employs 155,000 teammates across 69 hospitals and over 1,000 care locations, and offers one of the nation’s largest graduate medical education programs with over 2,000 residents and fellows across more than 200 programs. Committed to providing equitable care for all, Advocate Health provides more than $6 billion in annual community benefits.
Overview St. Francis Medical Center is one of the leading comprehensive healthcare institutions in Los Angeles. St. Francis provides vital healthcare services for the 700,000 adults and 300,000 children in our community who count on the hospital for high quality and compassionate medical care. St. Francis is recognized for its full range of diagnostic and treatment services in specialties including Cardiovascular, Surgical, Orthopedics, Obstetrics, Pediatrics, Behavioral Health, and Emergency and Trauma Care. In addition, the hospital offers a broad array of education and outreach programs that advance community health. St. Francis Medical Center is a Comprehensive Stroke Center, STEMI Receiving Center, ED Approved for Pediatrics, Geriatric ED, Level III Neonatal ICU, and Level II Trauma Center. Please visit www.stfrancismedicalcenter.com for more information. Join an award-winning team of dedicated professionals committed to compassion, quality, and service! Responsibilities Responsible for the quality and resource management of all patients that are admitted to the facility from the point of their admission and across the continuum of the health care management. Works on behalf of the advocate, promoting cost containment and demonstrates leadership to integrate the health care providers to achieve a perceived seamless delivery of care. The methodology is designed to facilitate and insure the achievement of quality, clinical and cost effective outcomes and to perform a holistic and comprehensive admission and concurrent review of the medical record for the medical necessity, intensity of service and severity of illness. Qualifications EDUCATION, EXPERIENCE, TRAINING 1. Starting April 1 2015. Minimum 5 years work experience post-graduation of an accredited school of nursing and a current state Registered Nurse license.2. Grandfathered prior to April 1, 2015. Minimum 5 years post graduate of an accredited school Of Social Work for Licensed Clinical Social Worker. However, RN Case Manager preferred.3. Five years acute care nursing experience preferred. At least one year experience in case management, discharge planning or nursing management, preferred.4. Current BCLS (AHA) certificate, preferred. 5. Knowledge of Milliman Criteria and InterQual Criteria preferred.6. Experience and knowledge in basic to intermediate computer skills. Pay Transparency St. Francis Medical Center offers competitive compensation and a comprehensive benefits package that provides employees the flexibility to tailor benefits according to their individual needs. Our Total Rewards package includes, but is not limited to, paid time off, a 401K retirement plan, medical, dental, and vision coverage, tuition reimbursement, and many more voluntary benefit options. Benefits may vary based on collective bargaining agreement requirements and/or the employment status, i.e. full-time or part-time. The current compensation range for this role is $45.83 to $61.61. The exact starting compensation to be offered will be determined at the time of selecting an applicant for hire, in which a wide range of factors will be considered, including but not limited to, skillset, years of applicable experience, education, credentials and licensure. Employment Status Full Time Shift Days Equal Employment Opportunity Company is an equal employment opportunity employer. Company prohibits discrimination against any applicant or employee based on race, color, sex, sexual orientation, gender identity, religion, national origin, age (subject to applicable law), disability, military status, genetic information or any other basis protected by applicable federal, state, or local laws. The Company also prohibits harassment of applicants or employees based on any of these protected categories. Know Your Rights: https://www.eeoc.gov/sites/default/files/2022-10/EEOC_KnowYourRights_screen_reader_10_20.pdf Privacy Notice Privacy Notice for California Applicants: https://www.primehealthcare.com/wp-content/uploads/2024/04/Notice-at-Collection-and-Privacy-Policy-for-California-Job-Applicants.pdf
Total Rewards "Your life - our Mission" OSF HealthCare is dedicated to provide Mission Partners with a comprehensive and market-competitive total rewards package that includes benefits, compensation, recognition and well-being offerings that focus on the whole person and engage with their current stage of life and career. Click here to learn more about benefits and the total rewards at OSF. Pay range for this position is $34.25 - $51.13/hour. Actual pay is based on years of licensure. This is a Salaried position. Overview POSITION SUMMARY: The Utilization Management and Review Specialist (UMR Specialist) evaluates patient care and activities against objective criteria in an effort to take a proactive approach in addressing appropriate admission status of each patient. In addition the UMR Specialist will identify utilization issues involving under or over utilization of services, resolves and/or refers utilization issues in accordance with established procedures. Reviews medical records to determine appropriateness and medical necessity of admission and hospital stay and use of ancillary services. Qualifications REQUIRED QUALIFICATIONS: Education: Bachelor's Degree in Nursing must be obtained within 3 years of date of hire into role. Experience: 2 years of clinical experience in an acute care or managed care setting Licensure/Certifications: Current state license as Registered Nurse Other skills/knowledge: Working knowledge of clinical EMR system PREFERRED QUALIFICATIONS: Education: Bachelor's Degree in Nursing Other Skills/Knowledge: Working knowledge of Microsoft Office applications OSF HealthCare is an Equal Opportunity Employer.
