Utilization Review Nurse Jobs

RN Utilization Review Full-time
St. Luke's University Health Network

RN DRG Downgrades Appeals Review Specialist

St. Luke's University Health Network Allentown, PA
St. Luke's is proud of the skills, experience and compassion of its employees. The employees of St. Luke's are our most valuable asset! Individually and together, our employees are dedicated to satisfying the mission of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care. The RN DRG Downgrades Appeals Review Specialist is responsible for the retrospective clinical review and defense of inpatient DRG downgrades, clinical validation denials, and medical necessity determinations issued by governmental and commercial payers. JOB DUTIES AND RESPONSIBILITIES: Conduct retrospective clinical record reviews to evaluate DRG downgrades, clinical validation denials, and medical necessity determinations. Analyze documentation in conjunction with MS-DRG logic and ICD-10-CM/PCS coding guidelines to determine appeal opportunity. Develop and submit defensible first- and second-level appeal letters using clinical evidence, regulatory guidance, coding standards, and payer policy. Collaborate with Physician Advisors, Coding leadership, and CDI to support higher-level appeals (e.g., IRO, ALJ, payer conferences). Identify denial trends and provide structured feedback to Coding and CDI leadership to reduce future payer vulnerability. Participate in payer audit response processes (RAC, QIO, MIC, commercial auditors) and assist in preparation for formal appeal proceedings. Maintain accurate documentation within EPIC, payer audit platforms, and internal tracking tools to support reporting and performance monitoring. Review denial data and appeal outcomes to assist leadership in assessing revenue impact, case resolution trends, and operational improvement opportunities. Maintain current knowledge of MS-DRG methodology, ICD-10-CM/PCS coding guidelines, clinical validation standards, federal and commercial payer policies, and medical necessity criteria. Serve as a clinical resource regarding documentation specificity and disease process validation as it relates to reimbursement defense. PHYSICAL AND SENSORY REQUIREMENTS: Sitting, standing and light lifting. Repetitive arm/finger use retrieving/viewing computerized patient medical record and abstracting of patient information. Corrected vision and hearing to within normal range. Hearing as it relates to normal conversation. Works inside with adequate lighting, comfortable temperature and ventilation. EDUCATION: Registered Nurse required. BSN preferred. Active RN license required. CDI certification (CDIP, CCDS) preferred. TRAINING AND EXPERIENCE: Minimum five (5) years RN experience in adult inpatient acute care (medical/surgical or critical care). Strongly preferred: Clinical Documentation Improvement (CDI) experience. Strongly preferred: DRG downgrade or clinical validation denial experience. Strongly preferred: Utilization review or payer medical review experience. Familiarity with MS-DRG reimbursement methodology. Demonstrated understanding of disease pathophysiology and documentation specificity requirements. Working knowledge of ICD-10-CM/PCS fundamentals. Understanding of payer audit and appeal processes. Experience with EPIC and encoder tools (e.g., 3M) preferred. Please complete your application using your full legal name and current home address. Be sure to include employment history for the past seven (7) years, including your present employer. Additionally, you are encouraged to upload a current resume, including all work history, education, and/or certifications and licenses, if applicable. It is highly recommended that you create a profile at the conclusion of submitting your first application. Thank you for your interest in St. Luke's!! St. Luke's University Health Network is an Equal Opportunity Employer.
RN Utilization Review Full-time
CVS Health

Utilization Management Nurse Consultant

CVS Health KS
$26.01 - $56.14 / hour
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours. Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function. Typical office working environment with productivity and quality expectations. Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor. Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment. Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding. Effective communication skills, both verbal and written Required Qualifications - 2+ years of experience as a Registered Nurse in adult acute care/critical care setting - Must have active current and unrestricted RN licensure in state of residence - Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours Preferred Qualifications - 2+ years of clinical experience required in med surg or specialty area - Managed Care experience preferred, especially Utilization Management - Preference for those residing in Central Time zones Education Associates Degree required BSN preferred Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $26.01 - $56.14 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan . No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 03/27/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
RN Utilization Review Full-time
Bryan Health

Utilization Management RN

Bryan Health Grand Island, NE
Summary GENERAL SUMMARY: Conducts day-to-day activities for the clinical, financial and utilization coordination of the patient’s hospital experience. Proactively consults with the interdisciplinary team which includes, but is not limited to, hospital patient care staff, physicians, patient support and family to ensure the patient’s hospital stay meets medical necessity and insurance authorizations are obtained in order to facilitate the patient’s and hospitals financial well-being. PRINCIPAL JOB FUNCTIONS: 1. *Commits to the mission, vision, beliefs and consistently demonstrates our core values. 2. *Performs utilization review activities, including concurrent and retrospective reviews as required. 3. *Determines the medical necessity of request by performing first level reviews, using approved evidence based guidelines/criteria. 4. *Collaborates with the patient’s provider and other healthcare team members in managing the patient’s length of stay and determining the continuing medical necessity of continued stays. 5. *Refers cases to reviewing physician when the treatment request does not meet criteria per appropriate algorithm. 6. *Participates in concurrent and retrospective denials and appeals process by researching issues surrounding the denial, participating in all levels of the appeal and process follow-up. 7. *Serves as an internal and external resource regarding appropriate level of care; admission status/classification; Medicare/Medicaid rules, regulations, and policies; 3rd party and managed care contracts; discharge planning; and length of stay. 8. Ensures appropriate resource utilization relevant to the financial, regulatory and clinical aspects of care; proposes alternative treatment to ensure a cost effective and efficient plan of care. 9. *Maintains awareness of financial reimbursement methodology, utilization management, payer/reimbursement practices and regulations and participates in resource stewardship. 10. *Promotes quality improvement initiatives and health care outcomes based on currently accepted clinical practice guidelines and total quality improvement initiatives. 11. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise. 12. Participates in meetings, committees and department projects as assigned. 13. Performs other related projects and duties as assigned. REQUIRED KNOWLEDGE, SKILLS AND ABILITIES: 1. Maintains clinical competency as required for the unit including but not limited to age-specific competencies relative to patient’s growth and developmental needs, annual skill competency verification and mandatory education and competencies. 2. Knowledge of governmental and third party payer regulations and requirements related to patient hospitalization and acute rehabilitation admission, stay and discharge activities, i.e., CMS, CARF, FIM (TM). 3. Knowledge of computer hardware equipment and software applications relevant to work functions. 4. Skill in conflict diffusion and resolution. 5. Ability to communicate effectively both verbally and in writing. 6. Ability to perform crucial conversations with desired outcomes. 7. Ability to establish and maintain effective working relationships with all levels of personnel and medical staff. 8. Ability to problem solve and engage independent critical thinking skills. 9. Ability to maintain confidentiality relevant to sensitive information. 10. Ability to prioritize work demands and work with minimal supervision. 11. Ability to perform crucial conversations with desired outcomes. 12. Ability to maintain regular and punctual attendance. EDUCATION AND EXPERIENCE: Current Registered Nurse licensure from the State of Nebraska or approved compact state of residence as defined by the Nebraska Nurse Practice Act. Minimum of two (2) years recent clinical experience required. Prior care coordination and/or utilization management experience preferred. OTHER CREDENTIALS / CERTIFICATIONS: Basic Life Support (CPR) certification required. Bryan Health recognizes American Heart Association (for healthcare professionals), American Red Cross (for healthcare professionals) and the Military Training Network.
NP Utilization Review Full-time
Queen's Health System

Medical Staff Peer Review and Performance Improvement Specialist (Full-Time, 40, Day Shift)

Queen's Health System Honolulu, HI
RESPONSIBILITIES I. JOB SUMMARY/RESPONSIBILITIES: • Facilitates peer review and performance improvement activities (case review, professionalism review, practitioner health, OPPE reports) for the Medical Staff in accordance with the mission of The Queen’s Health System (QHS). • Produces reports for the medical staff reappointment process. • Facilitates activities of the Professional Practice Evaluation Committee (PPEC) and Leadership Council. • Meets requirements of regulatory and accreditation agencies. II. TYPICAL PHYSICAL DEMANDS: • Essential: seeing, hearing, speaking. • Constant: sitting. • Occasional: standing, walking, finger dexterity. • Infrequent: kneeling, climbing stairs, stooping/bending, lifting, pushing/pulling and carrying usual weight of 10 pounds, reaching above, at and below shoulder level. • Operates computer, copier, facsimile, and telephone. III. TYPICAL WORKING CONDITIONS: • Not substantially subjected to adverse environmental conditions. • Work environment may be stressful due to workload. IV. MINIMUM QUALIFICATIONS: A. EDUCATION/CERTIFICATION AND LICENSURE: • Bachelor's degree in health care related field. B. EXPERIENCE: • One (1) year medical staff peer review and performance improvement experience in a healthcare facility; or two (2) years clinical experience with competency in summarizing patient’s medical history. • Knowledge of regulatory and licensing agency standards, medical staff bylaws, and rules/regulations. Ability to interpret and apply guidelines and procedures. • Knowledge and skill in data collection, data entry, data analysis, data presentation and reporting. • Skill in establishing and maintaining effective working relationships with staff, physicians, consultants, hospital committees, administrators, and staff. • Ability to communicate effectively both orally and in writing with all levels throughout the organization. • Proficiency with Microsoft office applications, i.e. Word, Excel, Outlook, etc. • Prior experience in medical staff credentialing/reappointment preferred. Equal Opportunity Employer/Disability/Vet
RN Utilization Review Full-time
Molina Healthcare

Care Review Clinician (RN)

Molina Healthcare Long Beach, CA
$30.37 - $59.21 / hour
JOB DESCRIPTION Job SummaryProvides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care. Must be licensed in CA. 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: $30.37 - $59.21 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
RN Utilization Review Full-time
Molina Healthcare

Care Review Clinician (RN)

Molina Healthcare Long Beach, CA
$30.37 - $59.21 / hour
JOB DESCRIPTION Job SummaryProvides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care. Must be licensed in CA. 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: $30.37 - $59.21 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
RN Utilization Review Full-time
Freeman Health System

RN - QUALITY REVIEW COORDINATOR

Freeman Health System MO
Our Mission To improve the health of the communities we serve through contemporary, innovative, quality healthcare solutions. Schedule : Monday - Friday (40hrs/week) About Us – Physician Reimbursement Center (PRC) Located inside the Freeman Business Center Vital part of our revenue cycle Our team consists of over eighty professionals that assure reimbursement for the valued services our clinicians provide What You’ll Do Performs a variety of duties in support of the quality assurance and compliance function of the Physician Reimbursement Center. Performs prospective chart reviews to ensure medical record accurately reflects the patient’s level of service, severity of illness and risk of mortality. Works closely with Medical Staff to clarify, assist and educate with documentation of evaluation and management coding. Requirements Minimum of 3 years of clinical experience in an acute care setting, (ICU, Medical/Surgical or Emergency Department nursing preferred). If homebound, must reside in one of the following states: Arkansas, Kansas, Missouri or Oklahoma. Current Missouri Registered Nurse license or current Registered Nurse license from a compact state. If a compact license is held, it must be in the nurse state of residence. Experience and skills in coding, billing and compliance. Preferred Requirements COSC Certification Freeman Perks and Programs For eligible full time and part time employees Freeman offers a wide variety of career opportunities, a great work culture and generous benefits, most starting day one! Health, vision, dental insurance Retirement with employer match Wellness program with discounts to Health Insurance or Cash Bonus with Participation Milestone payments with longevity of employment Paid Time Off (PTO) or Flex time off (FTO) Extended sick pay Learning Center designated only for Freeman Family members Payroll deduction at different locations such as The Daily Grind, Freeman Gift Shop, Cafeteria, etc
RN Utilization Review Full-time
L.A. Care Health Plan

Utilization Management Nurse Specialist RN II

L.A. Care Health Plan Los Angeles, CA
$88,854 - $142,166 / year
Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job Summary The Utilization Management Nurse Specialist RN II facilitates, coordinates, and approves medically necessary referrals that meet established criteria. Assures timely and accurate determination and notification of referrals and reconsiderations based on the referral determination status. Generates approval, modification and denial communications, to include member and provider notification of referral determination. Actively monitors for admissions in any inpatient setting. Performs telephonic and/or onsite admission and concurrent review, and collaborates with onsite staff, physicians, providers, member/family interaction to develop and implement a successful discharge plan. Works with the UM Manager and Physician Advisor on case reviews for pre-service, concurrent, post-service and retrospective claims medical review. Monitors and oversees the collection and transfer of data (medical records) and referral requests by Providers. Acts as a department resource for medical service requests /referral management and processes. Receives incoming calls from providers, professionally handles complex calls, researches to identify timely and accurate resolution steps. Follows up with caller to provide response or resolution steps. Answers all inquiries in a professional and courteous manner. Duties Promote and support team engagements, programs and activities to create and ensure a positive and productive workplace environment. Perform telephonic and/or onsite admission and concurrent review, and collaborates with onsite staff, physicians, providers, the member and significant others to develop and implement a successful discharge plan. Process, finalize and facilitate inbound requests that are received from providers. Generate appropriate member and provider communication for all determinations within the required timelines as defined by the most current department policy. Facilitate/review requests for Higher level of care or skilled nursing/discharge planning needs. Research for appropriate facilities, specialty providers and ancillary providers to utilize for all lines of business. Identification of potential areas of improvement within the provider network. Identify and initiate referrals for appropriate members to the various L.A. Care programs/processes and external community based programs or Linked and Carve Out Services (e.g. DDS/CCS/MH). Potential quality of care/potential fraud issues are identified and documented per L.A. Care policy. High risk/high cost cases and reports are maintained and referred to the Physician Advisor/UM Director. Document in platform/system of record. Utilize designated software system to document reviews and/or notes. Receive incoming calls from providers, professionally handle complex calls, research to identify timely and accurate resolution steps. Follow up with caller to provide response or resolution steps. Answer all inquiries in a professional and courteous manner. Perform other duties as assigned. Duties Continued Education Required Associate's Degree in Nursing Education Preferred Bachelor's Degree in Nursing Experience Required: At least 5 years of varied RN clinical experience in an acute hospital setting. At least 2 years of Utilization Management/Case Management experience in a hospital or HMO setting . Preferred: Managed Care experience performing UM and CM at a medical group or management services organization. Experience with Managed Medi-Cal, Medicare, and commercial lines of business. Skills Required: Must be computer literate, with expertise in Outlook, Word, Excel, PowerPoint. Effectively utilizes computer and appropriate software and interacts as needed with L.A. Care Information System. Knowledge of personal computer, keyboarding, and appropriate software to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment. Prepare clear, comprehensive written and oral reports and materials. Provision of excellent customer service required due to frequent communication with providers and other members of the interdisciplinary team Excellent time management and priority-setting skills. Maintains strict member confidentiality and complies with all HIPAA requirements. Strong verbal and written communication skills. Preferred: Knowledge of National Committee for Quality Assurance (NCQA) requirements for Utilization Management or Care Management (CM). Knowledge of Department of Health Care Services (DHCS) or Centers for Medicare and Medicaid Services(CMS) requirements for health plan compliance with UM or CM. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California License Licenses/Certifications Preferred Certified Case Manager (CCM) Required Training Physical Requirements Light Additional Information May work on occasional weekends and some holidays depending on business needs. Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. L.A. Care offers a wide range of benefits including Paid Time Off (PTO) Tuition Reimbursement Retirement Plans Medical, Dental and Vision Wellness Program Volunteer Time Off (VTO)
RN Utilization Review Full-time
CareSource

Clinical Care Reviewer II-BH - MSL - Must be RN

CareSource OH
$62,700 - $100,400 / year
Job Summary: Clinical Care Reviewer II – Behavioral Health is responsible for processing medical necessity reviews for appropriateness of authorization for behavioral health care services, assisting with discharge planning activities (i.e. outpatient services, home health services) and care coordination for members. Essential Functions: Complete prospective, concurrent and retrospective review of Behavioral Health services Identify, document, communication and coordinate care engaging collaborative care partners to facilitation transition to an appropriate level of care Engage with medical director when additional clinical expertise if needed Maintain knowledge of state and federal regulations, including State Contracts and Provider Agreements, benefits, and accreditation standards Identify and refer quality issues to Quality Improvement Identify and refer appropriate members for Care Management Provide guidance to non-clinical staff Provide guidance and support to LPN staff Attend medical advisement and State Hearing meetings, as requested Assist Team Leader with special projects or research, as requested Perform any other job related duties as requested. Education and Experience: Associates of Science (A.S) in Nursing required or Bachelor of Science (B.S) in Social Work required Three (3) years clinical experience required Utilization Management/Utilization Review experience preferred Medicaid/Medicare/Commercial experience preferred Competencies, Knowledge and Skills: Proficient data entry skills and ability to navigate clinical platforms successfully Working knowledge of Microsoft Outlook, Word, and Excel Effective oral and written communication skills Ability to work independently and within a team environment Attention to detail Proper grammar usage and phone etiquette Time management and prioritization skills Customer service oriented Decision making/problem solving skills Strong organizational skills Change resiliency Licensure and Certification: Current, unrestricted Registered Nurse (RN) Licensure or Licensed Social Worker (LSW) required MCG Certification is required or must be obtained within six (6) months of hire required Working Conditions: General office environment; may be required to sit or stand for extended periods of time Travel is not typically required Compensation Range: $62,700.00 - $100,400.00 CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package. Compensation Type (hourly/salary): Hourly Organization Level Competencies Fostering a Collaborative Workplace Culture Cultivate Partnerships Develop Self and Others Drive Execution Influence Others Pursue Personal Excellence Understand the Business This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds. #LI-JM1
RN Utilization Review Wound Care Full-time
Elevance Health

Wound Care Utilization Management RN

Elevance Health Mile Square, IN
$39.34 - $67.44 / hour
Anticipated End Date: 2026-03-31 Position Title: Wound Care Utilization Management RN Job Description: Wound Care Utilization Management RN Carelon, a proud member of the Elevance Health family of companies, is a healthcare services organization that takes a whole-health approach to making care more integrated, personalized, and affordable. We put people at the center—connecting physical, behavioral, social, and pharmacy services, along with clinical expertise, research, operations, and advanced technology to help care work better, together. Among us are specialty-care physicians, nurse practitioners, pharmacists, engineers, data scientists, and other dedicated and caring health professionals. While our roles may differ, our purpose is shared: to make a positive impact on whole health. Virtual - This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Alternate locations may be considered. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. Work Shift Hours: Monday through Friday, 8:00AM to 4:30PM (CST). The Wound Care UM RN is responsible for performing pre-certification certification and/or authorization activities for Home Health Services for members with wound care needs included as contracted services that meet eligibility and benefits coverage. Oversees members who have complex wound needs to determine if the member has the appropriate wound care for the type of wound. Identifies and monitors delivery of home-based services responds to a members total health needs and ensures the highest quality of continuity of care. How you will make an impact: Develops coordinated collaborative care plans with all involved providers. Reviews Home based services for clinical appropriateness of the continued care. Performs reviews telephonically using the members medical records discussion with the members physician and/or discussion with Home health agency staff. Contacts the home care agency and ordering physician to discuss changing the member plan of care for wound care. Promotes healing and decrease home care utilization. Responsible for certification determinations and sending written authorizations to referring physician and home health care provider. Requests additional clinical information from members care providers as necessary. Facilitates timely discharges and transfers based on individual needs and care requirements. Educates patients to help them understand their health choices and assists them in making informed decisions about their health care. Serves as an information resource to patients health care professionals facilities health plan representatives care givers and family members. Monitors cost-effective use of resources and uses clinical expertise to make recommendations for alternate resources as needed. Refers requests that do not meet coverage guidelines criteria to Physician for review. Uses clinical judgment in authorizations that fall outside of guideline parameters. Minimum Requirements: Requires a HS diploma or equivalent and a minimum of 5 years of experience in a variety of health care settings; or any combination of education and experience which provides an equivalent background. Current active valid unrestricted RN license to practice as a health professional within the scope of practice in applicable state(s) or territory of the United States required. Certifications relevant to wound care such as WOCN or CWS required. For the Wound Care Connect program, in addition to Wound Care Certification requirements above, Ostomy training through accredited program such as WOCN or ABWM and ostomy experience is also required. Preferred Skills, Capabilities and Experiences: WOCNCB certification preferred. Home health experience preferred. 1 year of Utilization Management experience preferred. Compact license would be preferred but not required for consideration. Prior Home Health experience preferred. Intermediate knowledge of MS Office Suite products preferred. For candidates working in person or virtually in the below location(s), the salary* range for this specific position is $39.34/hr. to $67.44/hr. Locations: California, District of Columbia (Washington, DC); Illinois, New Jersey, Massachusetts and Nevada. In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws . * The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law. Job Level: Non-Management Non-Exempt Workshift: 1st Shift (United States of America) Job Family: MED > Licensed Nurse Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health. Who We Are Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. How We Work At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business. We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few. Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws. Elevance Health is an Equal Employment Opportunity employer, and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act. Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration .
RN Utilization Review Full-time
Montage Health

Utilization Review Nurse - Care Coordination Services

Montage Health Monterey, CA
$71.69 - $95.88 / hour
Welcome to Montage Health’s application process! Job Description: Under the leadership of the department director the Utilization Review Nurse facilitates quality care by screening the admission and continued stay of patients utilizing Intensity of Service/Severity of Illness criteria. The Utilization Nurse complies with regulatory requirements and supports systems and processes to meet regulations. Important dimensions of this position consist of quality, professional commitment, teamwork, interpersonal skills, safety, good public/customer relations and a broad clinical knowledge. Experience Must have 5 years current acute care hospital experience. Broad clinical expertise to evaluate patient diagnosis and treatment plan and outcomes utilizing established criteria. Effective communication and public relations skills. Ability to work as an integral member of the interdisciplinary assessment team. Strong organization skills. Knowledge of financial reimbursement — state, federal and commercial insurance requirements preferred. Knowledge of Government programs, rules and regulations, and commercial insurance requirements preferred. Education Bachelor’s degree in nursing preferred. Licensure/Certifications State of California RN license required. Equal Opportunity Employer #LI-AC1 Assigned Work Hours: Full time (On-site) Position Type: Regular Pay Range (based on years of applicable experience): $71.69 to $95.88 The hours employees work determine when a shift differential is paid. Hourly Evening Shift Differential: $5.50 Hourly Night Shift Differential: $8.00
RN Utilization Review Full-time
JPS Health Network

Nurse Case Manager - Inpatient

JPS Health Network Fort Worth, TX
Description: The Nurse Case Manager - Inpatient is responsible for coordinating the care and service of assigned patients with physicians, nurses, social workers and other members of the healthcare team to facilitate the progression of care from hospital admission through discharge. The Nurse Case Manager- Inpatient is also responsible for ensuring that the patient is placed in the appropriate level of care while monitoring the utilization of healthcare resources and discharge planning to achieve the desired clinical, financial, and resource utilization outcomes. Typical Duties: Provides an assessment for all observation status patients prior to observation placement. The patient is to be assessed throughout the shift to determine discharge readiness or the need to convert to an inpatient status by using the approved medical appropriateness criteria and all third-party payer regulatory requirement. Performs initial status review and level of care placement on all patients in an inpatient status using approved medical appropriate criteria in addition to third-party payer regulatory requirements. Conducts an initial clinical assessment on assigned patients as well as discharge planning assessment prior to admission, at the time of admission, or at discharge. Meets directly with the patient, family, and/or representative to assess needs and develop an individualized discharge plan based on the patient’s medical diagnosis, treatment plan, financial resources, and psychosocial issues, etc. Reassesses the discharge plan throughout the patient’s hospitalization with input from the healthcare team and patient, family, and/or representative and modifying as needed. Collaborates with the multi-disciplinary care team to ensure all needed clinical information is provided to the appropriate entities for the assigned level of care and supports the concurrent appeal process for any reduction in level of care or denial as requested. Maintains active communication with the patient, family, and/or representative, physicians, nursing and other members of the multi-disciplinary care team to effect timely, appropriate patient management; documents each component of the case management process and related activities. Identifies appropriate services not related to admission and assists in arrangement of services on an outpatient basis. Leads the Unit’s daily interdisciplinary rounds to ensure a comprehensive plan of care is developed, including identification of patient needs, assignment of tasks to resolve clinical issues, review of discharge barriers, and identification of discharge planning options. Generates referrals to the Case Management Physician Advisor according to departmental policies. Serves as an educational resource for physician, nursing staff and others concerning case management strategies essential in meeting the organization’s quality, utilization, financial and customer satisfaction objectives. Performs other related job duties as assigned.
RN Utilization Review Full-time
Capital Health

Utilization Review RN - FT - Day - Utilization Resource Management Trenton NJ

Capital Health Ashland, VA
$39.40 - $59.19 / hour
Capital Health is the region's leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advanced technology. Capital Health is a five-time Magnet-Recognized health system for nursing excellence and is comprised of 2 hospitals. Capital Health Medical Group is made up of more than 250 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region. Capital Health recognizes that attracting the best talent is key to our strategy and success as an organization. As a result, we aim for flexibility in structuring competitive compensation offers to ensure we can attract the best candidates. The listed pay range or pay rate reflects compensation for a full-time equivalent (1.0 FTE) position. Actual compensation may differ depending on assigned hours and position status (e.g., part-time). Pay Range: $39.40 - $59.19 Scheduled Weekly Hours: 40 Position Overview Shift: Fri, Sat, Sun or Sat, Sun, Mon (8:00am-8:00pm) Performs chart review of identified patients to identify quality, timeliness and appropriateness of patient care. Conducts admission reviews for Medicare, Medicaid beneficiaries, as well as private insurers and self pay patients, based on appropriate guidelines. Uses these criteria guidelines to screen for appropriateness for inpatient level of care or observation services based on physician certification (physicians H&P, treatment plan, potential risks and basis for expectation of a 2 midnight stay). Refers cases as appropriate, to the UR physician advisor for review and determination. Gathers clinical information to conduct continued stay utilization review activities with payers on a daily basis. Performs concurrent and retrospective clinical reviews with various payers, utilizing the appropriate guidelines as demonstrated by compliance with all applicable regulations, policies and timelines. Adheres to CMS guidelines for utilization reviews as evidenced by utilization of the relevant guidelines and appropriate referrals to the physician advisor and the UR Committee. Identifies, develops and implements strategies to reduce length of stay and resource consumption. . Confers proactively with admitting physician to provide coaching on accurate level of care determinations at point of hospital entry. Keeps current on all regulatory changes that affect delivery or reimbursement of acute care services. Uses knowledge of national and local coverage determinations to appropriately advise physicians. Understands and applies federal law regarding the use of Hospital Initiated Notice of Non-Coverage (HINN) and Lifetime Reserve Days letters. Identifies and records consistently any information on any progression of care or patient flow barriers using the Avoidable Days tool in the Utilization software program. Consults with medical staff, care team and case managers as necessary to resolve immediate progression of care barriers through appropriate administrative and medical channels. Engages care team colleagues in collaborative problem solving regarding appropriate utilization of resources. Recognizes and responds appropriately to patient safety and risk factors. Represents Utilization Management at various committees, professional organizations an physician groups as needed. Promotes the use of evidence based protocols and or order sets to influence high quality and cost effective care. Identifies, develops and implements strategies to reduce lengths of stay and resource consumption in the patient population. Participates in performance improvement activities. Promotes medical documentation that accurately reflects findings and interventions, presence of complication or comorbidities, and patient's need for continued stay. Identifies and records episodes of preventable delays or avoidable days due to failure of progression of care processes. Maintains appropriate documentation in the Utilization software system on each patient to include specific information of all resource utilization activities. Participates actively in daily huddles, patient care conferences, and hospitalist or nurse handoff reports to maintain knowledge about intensity of services and the progression of care. Identifies potentially wasteful or misused resources and recommends alternatives if appropriate by analyzing clinical protocols. Maintains related continuing education credits = 15 per calendar year. MINIMUM REQUIREMENTS Education: Minimum of Associate's degree in Nursing. Graduate of an accredited school of nursing. CPHQ, CCM or CPUR preferred. Experience: Three years of clinical nursing or two years quality management, utilization review or discharge planning experience. Other Credentials: Registered Nurse - NJ Knowledge and Skills: Three years of clinical nursing or two years quality management, utilization review or discharge planning experience. CPHQ, CCM or CPUR preferred. Special Training: Basic computer skills including the working knowledge of Microsoft Office, UR software and EMR. Possesses familiarity with MCG guidelines. Mental, Behavioral and Emotional Abilities: Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form. Usual Work Day: 8 Hours PHYSICAL DEMANDS AND WORK ENVIRONMENT Frequent physical demands include: Sitting , Standing , Walking Occasional physical demands include: Climbing (e.g., stairs or ladders) , Carry objects , Push/Pull , Twisting , Bending , Reaching forward , Reaching overhead , Keyboard use/repetitive motion , Talk or Hear Continuous physical demands include: Lifting Floor to Waist 10 lbs. Lifting Waist Level and Above 5 lbs. Sensory Requirements include: Accurate Near Vision, Accurate Far Vision, Accurate Color Discrimination, Accurate Depth Perception, Accurate Hearing Anticipated Occupational Exposure Risks Include the following: N/A This position is eligible for the following benefits: Medical Plan Prescription drug coverage & In-House Employee Pharmacy Dental Plan Vision Plan Flexible Spending Account (FSA) - Healthcare FSA - Dependent Care FSA Retirement Savings and Investment Plan Basic Group Term Life and Accidental Death & Dismemberment (AD&D) Insurance Supplemental Group Term Life & Accidental Death & Dismemberment Insurance Disability Benefits – Long Term Disability (LTD) Disability Benefits – Short Term Disability (STD) Employee Assistance Program Commuter Transit Commuter Parking Supplemental Life Insurance - Voluntary Life Spouse - Voluntary Life Employee - Voluntary Life Child Voluntary Legal Services Voluntary Accident, Critical Illness and Hospital Indemnity Insurance Voluntary Identity Theft Insurance Voluntary Pet Insurance Paid Time-Off Program The pay range listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future. When determining base salary and/or rate, several factors may be considered including, but not limited to location, years of relevant experience, education, credentials, negotiated contracts, budget, market data, and internal equity. Bonus and/or incentive eligibility are determined by role and level. The salary applies specifically to the position being advertised and does not include potential bonuses, incentive compensation, differential pay or other forms of compensation, compensation allowance, or benefits health or welfare. Actual total compensation may vary based on factors such as experience, skills, qualifications, and other relevant criteria.
RN Utilization Review Full-time
Astrana Health

UM Review Nurse

Astrana Health Monterey Park, CA
$30 - $34 / hour
UM Review Nurse Department: HS - UM Employment Type: Full Time Location: 1600 Corporate Center Dr., Monterey Park, CA 91754 Reporting To: Sandra Castellon Compensation: $30.00 - $34.00 / hour Description Astrana Health is looking for a CA-licensed Utilization Review Nurse to assist our Health Services Department. In this position, you will utilize your clinical judgement to approve or deny outpatient medical services for patients based on Medical Necessity Criteria, respective to various Health Plans. This position requires open availability between Monday through Sunday, 8 A - 8 P. You would be scheduled for 5 shifts per week. This is a hybrid position where you will work at-home and in our Monterey Park office on a weekly basis. We are open to nurses without prior UM experience! Our Values: Put Patients First Empower Entrepreneurial Provider and Care Teams Operate with Integrity & Excellence Be Innovative Work As One Team What You'll Do Complete prior authorization/retrospective review of elective inpatient admissions, outpatient procedures, post-homecare services, and durable medical equipment Refer cases to Medical Directors as needed/appropriate Maintain knowledge of state and federal regulations and accreditation standards Comply with internal policies and procedures Perform any other job duties as requested Qualifications Active and unrestricted LVN license in CA. Experience with Microsoft applications such as Word, Excel, and Outlook You’ll be Great for this Role If: Two (2) years of health plan, IPA or MSO experience Strong interpersonal skills Ability to collaborate with co-workers, senior leadership, and other management Experience educating and training staff Environmental Job Requirements and Working Conditions This is a hybrid position. Our office is located at 1600 Corporate Center Drive in Monterey Park, CA. Typical business hours are Monday - Friday from 8:30 AM to 5 PM, however, this position requires open availability between 8 AM - 8 PM PST, M-Su. Your schedule will be compromised of 5 shifts per week. Nurses rotate weekend and holiday coverage. Overtime is required in this position. The national target pay range for this role is $30.00 - $34.00 per hour. Actual compensation will be based on geographic location (current or future), experience, and other job-related factors. Astrana Health is proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based on race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. All employment is decided based on qualifications, merit, and business need. If you require assistance in applying for open positions due to a disability, please email us at humanresourcesdept@astranahealth.com to request an accommodation. Additional Information: The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.
RN Utilization Review Full-time
Conway Regional Health System

Case Manager / Utilization Review Nurse

Conway Regional Health System Conway, AR
Overview Provides discharge planning and utilization review services in compliance with patient’s discharge planning needs and the hospital’s utilization review program. SAFETY SENSITIVE POSITION: This position is a designated as “Safety Sensitive Position” under Act 593 of the State of Arkansas. An employee who is under the influence of Marijuana constitutes a threat to patients/customers which Conway Regional is responsible for in providing and supporting the delivery health care related services. Responsibilities Demonstrates initiative and pursues activities which contribute to the accomplishment of goals and objectives Appropriately utilizes organizational resources to achieve the goals and objectives Considers cost implications in all decision making Promotes efficiency enhancements; actively identifies and implements cost savings/containment initiatives Apply clinical knowledge to determine appropriate acuity levels and utilization through chart review Effectively organizes workflow to consistently complete assignments in a timely manner Demonstrates ability to access and effectively utilize primary sources of data Obtains and maintains medical records in conformance with Medical Information policies Communicates with co-workers in a manner that is conducive to positive and effective working relationships. Demonstrates respect, honesty and integrity when working with other service providers Demonstrates compliance with all relevant hospital, state and federal requirements related to maintenance of confidentiality of persons, data and information systems Takes advantage of opportunities made available through CRHS and other professional organizations for continued professional growth and development Responsible for analysis of patient information for determination of necessity of admission or continuation of stay Review for medical necessity of admission on the first working day after admission using approved review criteria Reviews inpatient procedures to determine appropriate utilization and acuity level. Reviews potential for outpatient setting or swing bed utilization Reviews all patients for medical necessity of continued stay, or before the next review date, using approved review criteria Performs retroactive reviews, as necessary, and responds to the appropriate review agency or third-party payor Researches denials issued by review agencies and third-party payors and responds within the specified time frames for appeal Works with others on healthcare team to coordinate for patients discharge needs Establishes an effective utilization review process and maintains an active, effective utilization review file system. Recommends, develops and revises policies related to the utilization review process Works collaboratively with physicians, Case Management, the discharge planning process, Admissions, Central Scheduling and other CRHS associates Educates staff, physicians and other personnel regarding medical necessity requirements as defined by approved review criteria Attends 75% of staff meetings Participates in committees which promote staff and medical center facility growth as directed by Director/Manager and/or CRMC policy Attends mandatory in-services and committee meetings as assigned Adheres to dress code, conduct and attendance policies Participate in activities that promote personal development Must maintain all organizational education and work requirements (i.e., Annual Mandatory Education, Competencies, BLS Provider, etc.) Other duties as assigned by management Qualifications Registered Nurse or Licensed Practical Nurse with current, active license to practice in Arkansas, required Proof of the highest level of nursing education achieved, required At least one-year experience in the area of case management/utilization review, preferred
RN Utilization Review Full-time
Baptist Health South Florida

Utilization Review Registered Nurse, Care Coordination, Bethesda East, FT, 01P-11:30P Local REMOTE

Baptist Health South Florida Boynton Beach, FL
$73,860.80 - $96,019.04 / year
Baptist Health is the region’s largest not-for-profit healthcare organization, with 12 hospitals, over 28,000 employees, 4,500 physicians and 200 outpatient centers, urgent care facilities and physician practices across Miami-Dade, Monroe, Broward and Palm Beach counties. With internationally renowned centers of excellence in cancer, cardiovascular care, orthopedics and sports medicine, and neurosciences, Baptist Health is supported by philanthropy and driven by its faith-based mission of medical excellence. For 25 years, we’ve been named one of Fortune’s 100 Best Companies to Work For, and in the 2024-2025 U.S. News & World Report Best Hospital Rankings, Baptist Health was the most awarded healthcare system in South Florida, earning 45 high-performing honors. What truly sets us apart is our people. At Baptist Health, we create personal connections with our colleagues that go beyond the workplace, and we form meaningful relationships with patients and their families that extend beyond delivering care. Many of us have walked in our patients’ shoes ourselves and that shared experience fuels out commitment to compassion and quality. Our culture is rooted in purpose, and every team member plays a part in making a positive impact – because when it comes to caring for people, we’re all in. Description: Increases patient throughput to the most appropriate level of care while facilitating interdisciplinary care across the continuum while maintaining regularity compliance. The role Integrates, coordinates care facilitation throughput while working in partnership with the healthcare team. Is accountable for prioritizing, reviewing cases to determine the appropriateness of pre-admission, admission utilizing payer established criteria Assisting in identifying appropriate patient status and level of care. Identify readmissions managing per policy. Identify possible inappropriate hospitalizations and collaborate with the healthcare team to facilitate alternate Level of Care. Assist in identifying physician and staff documentation opportunities to support Quality and Pay for Performance indicators. Estimated salary range for this position is $73860.80 - $96019.04 / year depending on experience. Qualifications: Degrees: Associates. Licenses & Certifications: ACMA ACM Certification. CDMS Certified Disability Management Specialist. ACMA Case Management Administrator Certification. NACCM Care Manager Certified. ABMCM Certified Managed Care Nurse. RNCB Certified Rehabilitation Registered Nurse. ANCC Nursing Case Management. NBCC Certification in Continuity of Care, Advanced. Registered Nurse. CCMC Case Manager. Additional Qualifications: RNs hired prior to 10/1/2017 with an Associate Degree are not required to have a BSN to continue their non-leadership role as an RN, however, they are required to complete the BSN within 3 years of job entry date. A Case Management Certification required within 12 months of hire. 3 years of hospital clinical experience with a minimum of 1-3 years of hospital or payor Case management or Utilization management review experience preferred. Excellent interpersonal communication and negotiation skills. Strong analytical, data management and computer skills. Current working knowledge of discharge planning, utilization management, case management and performance improvement preferred. Understanding of pre-acute and post-acute venues of care and post-community resources preferred. Strong organizational and time management skills. Ability to work independently and exercise sound judgment. Ability to prioritize and manage multiple high-risk, complex patients. Ability to work with multiple members of a care team and maintain positive working relationships. Demonstrate the ability to solve problems in a fast-paced environment. Minimum Required Experience: BSN Required 3 Years of acute care experience required 1 year of Utilization Review experience required EOE, including disability/vets
RN Utilization Review Full-time
Cape Fear Valley Health

Registered Nurse-Utilization Management, Full Time Days

Cape Fear Valley Health Coffeyville, KS
$20,000 BONUS, PLUS RELOCATION ASSISTANCE!! Facility Cape Fear Valley Medical Center Location Fayetteville, North Carolina Department Coordination of Care Job Family Nursing Work Shift Days (United States of America) Summary Responsible for performing the initial and concurrent Utilization Review determination on all patients admitted or placed in observation (Outpatient with Observation Services). Direct discussion with the physicians and advanced practice providers to determine medical necessity for admission and establish appropriate status and level of care requirements. Facilitates clinical guidelines and achievement of desired treatment outcomes in the most appropriate setting and the most cost-effective manner. Analyzes patient records to determine appropriateness of admission, treatment, and length of stay in a health care facility to comply with regulatory and payor reimbursement policies. Maintain compliance with regulatory changes affecting utilization management and performs utilization review in accordance with all state and federally mandated regulations. Works collaboratively with the Utilization Management Manager and payors to ensure that denials and appeals are tracked and responded to in a timely and appropriate manner. Major Job Functions The following is a summary of the major essential functions of this job. The incumbent may perform other duties, both major and minor, that are not mentioned below. In addition, specific functions may change from time to time: Performs initial admission reviews on all patients within one day of bedding, using the appropriate InterQual guidelines or in accordance with CMS rules and regulations for admission and medical necessity Reviews physician orders for level of care status against patient status in the hospital registration system to ensure accuracy Ensures the chart coincides with the review or CMS rules and regulations for appropriate level of care and status on all patients Adheres to Medicare Condition Code 44 process Issues Medicare Outpatient Observation Notice (MOON) promptly to ensure timely notification to patients Coordinates with registration/bed placement departments and physician’s office to assure pre-certification authorizations and supporting documents are obtained when required Reviews patient medical records for third party payors and provides clinical information to support admission and continued stay review Send billing communication to the designated PFS and HIM team members to ensure accurate billing designation Assesses and evaluates the medical necessity and appropriateness of ancillary testing, medications, treatment, and plan of care, discussing concerns with the involved case manager Representative and point of contact for the Medicare Appeal process Adheres to mandates, standards and policies and procedures as determined at the federal, state, health system and department level Promotes positive customer service and service orientation in the performance of position duties and responsibilities and interactions with patients, hospital staff and visitors Participate in quality improvement activities in the direction of the Leadership Team to improve processes and promote evidence-based practice Other duties as assigned Minimum Qualifications The following qualifications, or equivalents, are the minimum requirements necessary to perform the essential functions of this job: Education and Formal Training : Associate’s degree in nursing required Bachelor’s degree in nursing preferred Registered Nurse with active North Carolina License or Compact State Licensure preferred Professional certification in Case Management or Utilization Management preferred Work Experience : 3 years’ experience in Acute Care Setting preferred Medical/Surgical and/or ICU experience preferred Case Management experience preferred Additional one year in managed care claims/reimbursement or other healthcare field preferred Knowledge, Skills, and Abilities Required : Critical thinking and clinical competence demonstrated at an above average level Excellent interpersonal communication and negotiation skills Self-motivated, proven written, telephonic, and electronic communication skills, assertive and persuasive in interactions with customers, peers, management, and core staff served Ability to discuss a patient’s clinical, socio-economic, and financial issues with physicians and patient and/or patient representatives Strong organizational and time management skills Proficiency with various computer programs, including Microsoft Office, Allscripts, InterQual, Valley Link, eHIM, Teletracking, Form Fast and SMS Ability to transition to EPIC system, for Utilization Management processes. Ability to be flexible, open-minded, and adaptable to change Ability to analyze related information, plan effective actions and follow through reliably Ability to work collaboratively with department staff, physicians, and healthcare professionals at all levels to achieve established goals Physical Requirements : Some light carrying and lifting may be required Occasional walking may be required to access all areas of the Medical Center Near visual acuity to proofread hand and typewritten materials Manual ability to use telephones and computer keyboards Position involves sitting for extended periods of time performing data entry into the computer Must be able to lift 35 pounds Required Licenses and Certifications RN - Board Of Nursing Cape Fear Valley Health System is an Equal Opportunity Employer M/F/Disability/Veteran/Sexual Orientation/Gender Identity
RN Utilization Review Full-time
Phelps Health

Cardiac Cath Lab Nurse Reviewer - Quality | M-F

Phelps Health Rolla, MO
Phelps Health is a 2000-employee-strong hospital and healthcare system serving the heart of small-town Missouri. No matter where you start with us, we’re committed to taking our team to the top. If you’re ready for the challenge of providing life-saving care or supporting those who do, read on to find your fit in the Phelps Health family. General Summary The Cardiac Cath Lab Nurse Reviewer (CCLNR) collects and submits reliable data to the NCDR program by performing high-quality clinical screening, data compilation, documentation and entry into the database of all eligible procedures, in both inpatient and outpatient settings, for Phelps Health. The CCLNR works closely with the members of the Department of Clinical Quality and Measurement to identify opportunities for clinical quality improvement and other special projects as may be identified. Essential Duties and Responsibilities Ensures the reliable, accurate and timely collection of data components for the program through effective utilization of the Electronic Medical Record (EMR). Identifies cath lab patients for inclusion in the program registry through the application of strict program inclusion/exclusion criteria. Demonstrates applicability of the methodology and the reliability of definitions utilized by reviewers within the program. Identifies areas for streamlining and process improvement in the data collection and cardiac cath lab process. Maintains compliance with federal, state and regulatory body laws and regulations. Monitors other quality indicators and efficiency measures identified outside what is required for NCDR. Education Graduate of an accredited school of nursing required. Bachelor’s in Nursing preferred. Work Experience Three (3) years’ experience in inpatient cath lab nursing preferred. Quality improvement and patient safety knowledge is preferred. Certification/License Current RN license in the State of Missouri or Compact Licensure. Mental/Physical Requirements Considerable mental concentration for sustained periods of time with frequent interruptions. Light lifting (15 lbs.) required. Standing, sitting and walking required. Working Conditions Typical office conditions with noise and distractions. Possible eye strain or other discomfort from constant use of computer screens. At Phelps Health, we think we have a better team, benefits, and opportunities for growth than anyone else around, and we invite you to see for yourself! Apply now to join us on our mission in health care.
RN Utilization Review Full-time
Memorial Health (OH)

Utilization Review Case Manager, RN | Case Management, Full-Time, 1st Shift (Includes every other weekend rotation)

Memorial Health (OH) Marysville, OH
We are looking for a Utilization Review Case Manager to join our collaborative team at Memorial Health! What You'll Do: Clinical/Technical Recognizes, interprets, documents, and communicates information necessary for quality patient care and related patient information. Always maintains confidentiality to protect patient’s privacy and maintains Health Insurance Portability and Accountability Act (HIPAA) privacy and security regulations. Carries out the hospital utilization review plan. Collaborates with the interdisciplinary team and asks clarifying questions regarding documentation, hospital course, and expected date of discharge. Provides clinical information to the payer as requested to obtain admission authorization and to support level of care. Communicates payer resources available for discharge planning to Case Management Team. Understands in-network coverage and out of network insurance coverage and impact on patients served. Communicates information to patient upon request. Coordinates with Patient Financial Services on all patients, including those without insurance coverage to obtain Hospital Care Assurance Program (HCAP) and Medicaid eligibility. Daily Responsibilities: Reviews charts for medical necessity and assists on the level of care and status determinations. Utilizes Evidenced Based Criteria Set (Interqual, Milliman, etc) to assess medical necessity, appropriateness of admission, level of care, length of stay, need for continued stay, and avoidable days or delays in patient care. Will provide suggestions to the ED provider and Admitting Hospitalist of the most appropriate admission status based on the patient’s expected length of stay, application of standard of care criteria, patient presentation and treatment plan of care. Will assist providers to clearly and completely document for the purpose of accurately representing the acuity of the patient. Formulates and documents clinical review and submits clinical information to payer as required per departmental policy. Has knowledge of expected length of stay based on established criteria, ensures payer response to authorization requests are obtained for hospital services and documents authorization in auth/cert fields in Epic based on payer responses. Accesses payer portals daily to submit clinical review, appeal letters and obtain authorization numbers. Documents activity in Epic UR comment and communication field. Utilizes physician advisor services in accordance with hospital/department policy for secondary review consideration. Collaborates with presurgical scheduler to monitor the surgery schedule daily for prior authorization of inpatient procedures and monitoring for Medicare FFS inpatient only procedure status confirmation. Assumes responsibility for the oversight of inpatient medical necessity denials: track, monitor, investigate, and report denials and outcomes through participation in the Denials Management Committee and per request investigate root cause analysis or other information. Appropriately document and generate timely appeal letters and submit to payers for denial reconsideration. Manage work queues as assigned by Director or Supervisor. Including tracking and tending results. Calls payer UR nurse and requests reconsideration of a potential concurrent denial via conversation with insurance UR nurse reviewer prior to accepting a concurrent denial. Generates timely and thorough appeal letters in response to an inpatient denial and submits via the payer requested methodology. Manage the workflow through the appropriate work queues and determines case review based on timeliness of the appeal and high dollar amount. Facilitates the Peer-to-Peer denial/appeal process and proactively communicate with payer for denials mitigation and prevention. Appropriately monitor the outcome and document the process in Epic. Provides written notices (following the documentation retention policy) to the Medicare Beneficiary, including but not limited to: Hospital-Issued Notice of Non-Coverage (HINN) Detailed Notice of Discharge Advance Beneficiary Notices Denial letters if applicable Coordinates with Livanta, Permideon (or other organizations) and medical team for patient denials and requests for additional information for inpatient stays. Follows policy/procedure maintaining regulatory compliance and documentation retention requirements. Maintains a current knowledge of rules and regulations surrounding utilization management; observation management, and payer methodologies including approvals, denials, and appeal processes. Maintains a current knowledge of revised rule/regulatory changes pertaining to utilization review, strategies to reduce and combat denials, and effective care transitions management. Collects and interprets data as designated by the Utilization Review Committee, Denials Committee, and the department Key Results Measures including, but not limited to outlier review, readmission analysis, observation management, extended stay reviews, denials root cause analysis, and other reporting as assigned. Acts as a resource for staff; including Providers, agency and contingent personnel. Interpersonal Communicates in order to educate patients/ family; provides kindness and consideration in meeting the emotional needs of patients; confers with Providers and Case Management Team, interacts with ancillary staff. Provides excellent customer service, facilitates quality care delivery and fosters an atmosphere of understanding cultural diversity. Communicates and assists providers as indicated. Must have excellent written, verbal and telephone communication skills. All interactions are conducted in a professional manner. Demonstrates a positive attitude. Resolves conflict through one-on-one negotiation or with the assistance of Director or designee. Demonstrates the philosophy of team concept. Participates in unit projects, attends committees as assigned, and attends monthly staff meetings. Communicates dissatisfaction with issues to Director; actively contributes to the solution of problems and refrains from promoting dissatisfaction among co-workers. Critical Thinking Actively looks for and creates opportunities to improve the department, staff, and personal development. Develops and demonstrates knowledge of current developments in field to maintain professional competency. Compliant with CMS, DNV, Federal, State, hospital and departmental policies and procedures. Follows the Ohio Nurse Practice Act Understand the importance of Utilization Review and how job functions, impacts the revenue cycle, compliance, patient finances, and patient satisfaction. Documentation Maintains accurate data collection and timely documentation. Documentation retention practices are followed per hospital and department policy. Refrains from using unaccepted abbreviation in written documentation. When necessary, follows department downtime procedures Maintains license Enters and retrieves information from computer; demonstrated competence in the electronic medical record, Microsoft/Outlook/Word/Excel, other software tools and portals as assigned. Unit Financial Accountability Understands and is accountable to hospital goals and benchmarks for financial viability Is accountable for productivity and time management Maintains appropriateness of supplies Education Completes all mandatory education and in services required for the facility Completes an initial orientation and competencies per Human Resources established guidelines Completes annual competencies and unit specific competencies per Human Resources established guidelines Maintains professional competency; actively contributes to the solution of problems; deals with problems involving several variables within familiar context Responsible and accountable for maintaining own state board required CEU’s per licensing board requirements. Has knowledge of HIPAA privacy regulation and related procedures Has knowledge of Centers for Medicare and Medicaid Services and third party in network payer updates on benefit coverage and acute care policies Reviews Case management literature as distributed by director or designee Maintains bi-annual BLS certification. Completes mandatory health requirements (e.g. annual TB testing, Fit testing and physicals as indicated.) Attendance Demonstrates regular and predictable attendance Work scheduled holidays and weekends Overtime to be pre-approved per Director Requested schedule time off to be pre-approved by Director or designee Other Exhibits behaviors reflective of Memorial’s core values: Compassion, Accountability, Respect, Excellence, and Service Attends all mandatory education and in-services (i.e., team training, safety, infection control, etc.); completes mandatory health requirements. Employee performs within the prescribed limits of the hospital’s and department’s Ethics and Compliance program and is responsible to detect, observe and report compliance variances to their immediate supervisor, or upward through the chain of command, the Compliance Officer, or the hospital hotline. Works assigned shift hours, may be asked to rotate hours or shifts if needed or upon the Director's request/discretion, to maintain adequate department coverage including weekend and holiday rotation. Performs reviews as assigned across multiple access points into the hospital and manages both inpatient and outpatient care areas as they relate to the UR function. Performs other duties as assigned. Requirements Completion of an accredited school of nursing with current active registration in the State of Ohio as an RN or LPN in good standing. Must have at least two years of clinical nursing or case management experience. Completes the required 24 contact hours of approved CE during each two year renewal period consistent with the Ohio Board of Nursing requirements. Maintains continuous certification in American Heart Association’s BLS. Shift 1st (Includes every other weekend rotation) Hours 80 per pay (Every two weeks) Benefits • Medical Insurance • Dental Insurance • Vision Insurance • Life Insurance • Flexible Spending Account Time Off • Vacation • Sick Leave • 11 Paid Holidays • Personal Day Retirement • Ohio Public Employee Retirement System • Deferred Compensation Other • Tuition Reimbursement • Kidzlink Daycare Center • Employee Recognition • Free Parking • Wellness Center • Competitive Salaries • Community/Family Atmosphere We look forward to seeing your application! It is our commitment to inclusivity and diversity and our ongoing determination to provide a welcoming and inclusive environment for all staff and guests of the Hospital, regardless of age, color, disability, gender, gender expression or gender identity, genetic information, national origin, race, religion, sexual orientation, or veteran status. For any questions or needed accommodations, please contact Memorial Health Human Resources at 937.578.2701.
RN Utilization Review Full-time
Baptist Health South Florida

Utilization Review Registered Nurse, Case Management, PT, 08A-4:30P Local Remote

Baptist Health South Florida Boca Raton, FL
$35.51 - $46.16 / hour
Baptist Health is the region’s largest not-for-profit healthcare organization, with 12 hospitals, over 28,000 employees, 4,500 physicians and 200 outpatient centers, urgent care facilities and physician practices across Miami-Dade, Monroe, Broward and Palm Beach counties. With internationally renowned centers of excellence in cancer, cardiovascular care, orthopedics and sports medicine, and neurosciences, Baptist Health is supported by philanthropy and driven by its faith-based mission of medical excellence. For 25 years, we’ve been named one of Fortune’s 100 Best Companies to Work For, and in the 2024-2025 U.S. News & World Report Best Hospital Rankings, Baptist Health was the most awarded healthcare system in South Florida, earning 45 high-performing honors. What truly sets us apart is our people. At Baptist Health, we create personal connections with our colleagues that go beyond the workplace, and we form meaningful relationships with patients and their families that extend beyond delivering care. Many of us have walked in our patients’ shoes ourselves and that shared experience fuels out commitment to compassion and quality. Our culture is rooted in purpose, and every team member plays a part in making a positive impact – because when it comes to caring for people, we’re all in. Description: The purpose of this position is to conduct initial, concurrent, retrospective chart review for clinical financial resource utilization. Coordinates with healthcare team for optimal/efficient patient outcomes, while decreasing length of stay (LOS) and avoid delays and denied days. They are accountable for a designated patient caseload and provides intervention, coordination to decrease avoidable delays, denial of reimbursement. Specific functions within this role include: Screens pre-admission, admission process using established criteria for all points of entry. Facilitates communication between payers, review agencies, healthcare team. Identify delays in treatment or inappropriate utilization and serves as a resource. Coordinates communication with physicians. Identify opportunities for expedited appeals and collaborates to resolve payer issues. Ensures/Maintains effective communication with Revenue Cycle Departments. Estimated salary range for this position is $35.51 - $46.16 / hr depending on experience. Qualifications: Degrees: Associates. Licenses & Certifications: MCG Care Guidelines Specialist. Registered Nurse. Additional Qualifications: RNs hired prior to 2-2012 (10/1/2017 at Bethesda or 7/1/2019 at BRRH) with an Associates Degree in Nursing are not required to have a BSN to continue their non-leadership role as an RN. however, they are required to complete the BSN within 3 years of job entry date. MCG Specialist Certification ISC/HRC required within 12 months of job entry date. 3 years of Nursing experience preferred. Excellent written, interpersonal communication and negotiation skills. Strong critical thinking skills and the ability to perform clinical/chart review abstract information efficiently. Strong analytical, data management and computer skills. Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components. Current working knowledge of payer and managed care reimbursement preferred. Ability to work independently and exercise sound judgment in interactions with the health care team and patients/families. Knowledgeable in local, state, and federal legislation and regulations. Ability to tolerate high volume production standards. Minimum Required Experience: 3 Years of Nursing experience required EOE, including disability/vets
RN Utilization Review Part-time
Temple Health

RN- Utilization Review- Part-time Weekends (Temple Hospital)

Temple Health Philadelphia, PA
Utilizing InterQual and other appropriate criteria, responsible for reviewing all admissions and continued stay of patients in conformance with the established criteria set forth in the hospital's utilization management and quality assurance plan. Will determine the medical necessity for admission and continued stays for patients within department's scope of service and to meet the hospital's objectives for assuring a high quality of patient care as well as assuring the effective and efficient utilization of available health services. Identifies appropriate level of care for inpatients and outpatients requiring overnight care. Education Other Graduate Of An Accredited School Of Nursing Required Bachelor's Degree BSN Required Experience 1 year experience of recent Utilization Review in acute care or in insurance company setting. Required 1 Year Experience In Medical-surgical Setting. Required 1 year experience in working with competency utilizing InterQual criteria. Required General Experience In Working With Utilization Review Standards Required Licenses PA Registered Nurse License Required Certified Case Manager Preferred Multi State Compact RN License Required Or
RN Pediatric Utilization Review Full-time
Cook Children's Health Care System

UM/ECM - RN Reviewer HP

Cook Children's Health Care System Fort Worth, TX
Location: Calmont Operations Building Department: Utilization Shift: First Shift (United States of America) Standard Weekly Hours: 40 Summary: Responsible for the coordination and efficient utilization of health care resources for Cook Childrens Health Plan (CCHP) members. Works with the Department Manager and Team Lead to assure the timely provision of quality care throughout the continuum of care. The Registered Nurse Utilization Management/Episodic Case Manager (UM/ECM - RN) Reviewer facilitates clinically appropriate and fiscally responsible care through communication with the providers and health plan medical directors. The UM/ECM - RN Reviewer assesses and identifies the members clinical information and determines, in conjunction with the Medical Director, medical necessity and appropriateness of requested services. Utilizes Medical Management Committee (MMC) approved clinical criteria to authorize requested services for the member. The UM/ECM - RN Reviewer communicates with providers of care/services to facilitate appropriate care transitions. The UM/ECM - RN Reviewer assures adherence to regulatory/contractually required timeliness standards for authorization request processing, associated communications and notice of adverse determinations are met for CCHP. Additional Information: Responsible for the coordination and efficient utilization of health care resources for Cook Childrens Health Plan (CCHP) members. Works with the Department Manager and Team Lead to assure the timely provision of quality care throughout the continuum of care. The Registered Nurse Utilization Management/Episodic Case Manager (UM/ECM - RN) Reviewer facilitates clinically appropriate and fiscally responsible care through communication with the providers and health plan medical directors. The UM/ECM - RN Reviewer assesses and identifies the members clinical information and determines, in conjunction with the Medical Director, medical necessity and appropriateness of requested services. Utilizes Medical Management Committee (MMC) approved clinical criteria to authorize requested services for the member. The UM/ECM - RN Reviewer communicates with providers of care/services to facilitate appropriate care transitions. The UM/ECM - RN Reviewer assures adherence to regulatory/contractually required timeliness standards for authorization request processing, associated communications and notice of adverse determinations are met for CCHP. Qualifications: Registered Nurse, BSN preferred. Minimum of five (5) years clinical experience. 2 years utilization management or case management experience required. Strong skills in the following area s: Oral and written communication. Critical thinking. Organization and time management. Customer service. Certification/Licensure: Current unrestricted Registered Nurse licensure in the State of Texas. About Us: Cook Children's Health Plan Cook Children's Health Plan provides vital coverage to nearly 120,000 people in low-income families who qualify for government-sponsored programs in our six county service region. Cook Children's Health Plan provides health coverage for CHIP, CHIP Perinatal, STAR (Medicaid) and STAR Kids Members in the Tarrant county service area. The counties we serve includes Tarrant, Johnson, Denton, Parker, Hood and Wise. Cook Children’s is an equal opportunity employer. As such, Cook Children’s offers equal employment opportunities without regard to race, color, religion, sex, age, national origin, physical or mental disability, pregnancy, protected veteran status, genetic information, or any other protected class in accordance with applicable federal laws. These opportunities include terms, conditions and privileges of employment, including but not limited to hiring, job placement, training, compensation, discipline, advancement and termination.
RN Utilization Review Full-time
University of Miami Health System

Case Manager RN - Utilization Review

University of Miami Health System Miami, FL
Current Employees: If you are a current Staff, Faculty or Temporary employee at the University of Miami, please click here to log in to Workday to use the internal application process. To learn how to apply for a faculty or staff position, please review this tip sheet . The purpose of the Utilization Case Manager RN is to conduct initial chart reviews for medical necessity and identify the need for authorization. The Utilization Case Manager RN coordinates with the healthcare team for optimal and efficient patient outcomes, while avoiding potential treatment delays and authorization denials. They are accountable for a designated patient caseload and provide intervention and coordination to decrease avoidable delays. At all times they provide communication of progress and or determination to the clinical team and or the patient as it pertains to treatment or treatment barriers. The nurse serves as the subject matter expert to her team, providing support and education. Work Location : UHealth Tower CORE JOB FUNCTIONS 1. Adhere and perform timely prospective reviews for services requiring prior authorization. 2. Follows the authorization process using established criteria as set forth by the payer or clinical guidelines. 3. Accurate review of coverage benefits and payer policy limitations to determine appropriateness of requested services. 4. Refers to the treatment plan for clinical reviews in accordance with established criteria in recommended compendia and or guidelines. 5. Serves as a resource to provide education regarding payer policies and facilitates coordination of alternative treatment options. 6. Ensures and maintains effective communication regarding prior authorization status and determination to the clinical team and on occasion the patient. 7. Facilitates interdepartmental communication regarding authorization status in advance of the patient’s appointment. 8. Identifies potential delays in treatment by reviewing the treatment plan and proactively communicates with the healthcare team and or patient regarding the potential treatment barrier. 9. Maintains knowledge regarding payer reimbursement policies and clinical guidelines. 10. Adheres to University and department level policies and procedures and safeguards University assets. This list of duties and responsibilities is not intended to be all-inclusive and may be expanded to include other duties or responsibilities as necessary. CORE QUALIFICATIONS Education: Graduate from an accredited school of nursing, Bachelor’s degree (BSN). Certification and Licensing: Valid State of Florida RN license required Basic Life Support Certification (BLS) from the American Heart Association required. Experience: Minimum 2 years of relevant experience required. Minimum of one 1 year in Hospital Case Management/nursing. Working knowledge of patient assessment, and medical terminology. Knowledge, Skills and Attitudes: · Learning Agility: Ability to learn new procedures, technologies, and protocols, and adapt to changing priorities and work demands. · Teamwork: Ability to work collaboratively with others and contribute to a team environment. · Technical Proficiency: Skilled in using office software, technology, and relevant computer applications. · Communication: Strong and clear written and verbal communication skills for interacting with colleagues and stakeholders. The University of Miami offers competitive salaries and a comprehensive benefits package including medical, dental, tuition remission and more. UHealth-University of Miami Health System, South Florida's only university-based health system, provides leading-edge patient care powered by the ground breaking research and medical education at the Miller School of Medicine. As an academic medical center, we are proud to serve South Florida, Latin America and the Caribbean. Our physicians represent more than 100 specialties and sub-specialties, and have more than one million patient encounters each year. Our tradition of excellence has earned worldwide recognition for outstanding teaching, research and patient care. We're the challenge you've been looking for. The University of Miami is an Equal Opportunity Employer. Applicants and employees are protected from discrimination based on certain categories protected by Federal law. Job Status: Full time Employee Type: Staff
RN Utilization Review Per Diem
UNC Health

RN Utilization Manager (Per Diem)- Rex Case Management

UNC Health Raleigh, NC
$35.87 - $51.57 / hour
Description Per diem Weekend Utilization Manager Become part of an inclusive organization with over 40,000 teammates, whose mission is to improve the health and well-being of the unique communities we serve. Summary: Works in collaboration with the patient/family, and interdisciplinary team (including physicians, other care providers, and payors), and assesses the patient care progression from acute care episode through post discharge for quality, efficiency, and effectiveness. The Utilization Manager works collaboratively with other Clinical Care Management staff to ensure patient needs are met and care delivery is coordinated across the continuum. The Utilization Manager completes admission, continued stay, and discharge reviews in accordance with federal regulations & the Hospitals? Utilization Management Plan. In addition, the Utilization Manager is responsible for revenue protection by reconciling physician orders, bed billing type, and medical necessity. This may include delivering notifications to patients directly. Interface is completed verbally, via email, data base tasks, or other electronic communication and via telephone. Responsibilities: 1. Clinical Review Process - Uses approved criteria and conducts admission review/status change review within 24 hours of patient admission to the hospital to ensure appropriateness of the setting and timely implementation of the plan of care. Identifies and obtains observation status as appropriate. Partners with physicians, nursing, and other care providers to help ensure timely and accurate documentation of patient data and treatments. Communicates daily with the Case Manager to manage level of care transitions & appropriate utilization of services. Coordinates with the support center to assure third party payor pre-certification and/or re-certifications when required. Utilizes high risk screening criteria to make appropriate referrals to Manager. 2. Discharge Facilitation - Identifies patient/families with the complex psychosocial, on-going medical discharge planning issues, continuing care needs by initiating appropriate case management referrals. Initiates appropriate social work referrals. 3. Utilization Management Process - Performs utilization management assessments and interventions, using collaboration with interdisciplinary team approach, on assigned patients as appropriate to ensure optimal patient outcomes. Using approved criteria, conducts continued stay and quality reviews to monitor the patient's progress along the continuum of care and intervenes as necessary to ensure appropriateness of setting and that the services provided are quality-driven, efficient, and effective. Enters all pertinent review data into the correct computer system in a timely manner. Consults with Physician Advisor as necessary to resolve barriers through appropriate administrative and medical channels. 4. Utilization Outcomes Management - Monitors and guides to trend interdisciplinary documentation and guides medical staff in documentation that will assist in coding accuracy, enhance quality of care, reflect accurate severity of illness and appropriate reimbursement. Facilitates patient movement to appropriate (acuity) level of care including observation status issues through collaboration with patient/family, multidisciplinary team, third party payors and resource center. Provides information regarding denials and approvals to designated entities. Assists in coordination of practice parameter development with the assigned departments/sections/specialties of Medical Staff. Oversees collection and analysis of patient care and financial data relevant to the target case types. Directs delivery of notifications to patients (includes traveling to hospital(s) to deliver notifications. Other Information Other information: Education Requirements: ● Graduation from a state-accredited school of professional nursing ● If hired after October 1, 2015, must be enrolled in an accredited program within four years of employment, and obtain a Bachelor's degree with a major in Nursing or a Master's degree with a major in Nursing within seven years of employment date. Licensure/Certification Requirements: ● Licensed to practice as a Registered Nurse in the state of North Carolina. Professional Experience Requirements: ● Two (2) years of clinical experience in a medical facility and/or comparable Utilization Management experience. Knowledge/Skills/and Abilities Requirements: Job Details Legal Employer: NCHEALTH Entity: UNC REX Healthcare Organization Unit: Rex Case Management Services Work Type: Per Diem Standard Hours Per Week: 4.00 Salary Range: $35.87 - $51.57 per hour (Hiring Range) Pay offers are determined by experience and internal equity Work Assignment Type: Onsite Work Schedule: Weekend Location of Job: US:NC:Raleigh Exempt From Overtime: Exempt: Yes This position is employed by NC Health (Rex Healthcare, Inc., d/b/a NC Health), a private, fully-owned subsidiary of UNC Heath Care System. This is not a State employed position. Qualified applicants will be considered without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, status as a protected veteran or political affiliation. UNC Health makes reasonable accommodations for applicants' and employees' religious practices and beliefs, as well as applicants and employees with disabilities. All interested applicants are invited to apply for career opportunities. Please email applicant.accommodations@unchealth.unc.edu if you need a reasonable accommodation to search and/or to apply for a career opportunity.
RN Utilization Review Full-time
UNC Health

RN Utilization Manager - Rex Case Management

UNC Health Raleigh, NC
$35.87 - $51.57 / hour
Description Full time Utilization Manager to cover Medical Surgical ICU, Neuro ICU, and Acute Care Neuroscience Become part of an inclusive organization with over 40,000 teammates, whose mission is to improve the health and well-being of the unique communities we serve. Summary: Works in collaboration with the patient/family, and interdisciplinary team (including physicians, other care providers, and payors), and assesses the patient care progression from acute care episode through post discharge for quality, efficiency, and effectiveness. The Utilization Manager works collaboratively with other Clinical Care Management staff to ensure patient needs are met and care delivery is coordinated across the continuum. The Utilization Manager completes admission, continued stay, and discharge reviews in accordance with federal regulations & the Hospitals? Utilization Management Plan. In addition, the Utilization Manager is responsible for revenue protection by reconciling physician orders, bed billing type, and medical necessity. This may include delivering notifications to patients directly. Interface is completed verbally, via email, data base tasks, or other electronic communication and via telephone. Responsibilities: 1. Clinical Review Process - Uses approved criteria and conducts admission review/status change review within 24 hours of patient admission to the hospital to ensure appropriateness of the setting and timely implementation of the plan of care. Identifies and obtains observation status as appropriate. Partners with physicians, nursing, and other care providers to help ensure timely and accurate documentation of patient data and treatments. Communicates daily with the Case Manager to manage level of care transitions & appropriate utilization of services. Coordinates with the support center to assure third party payor pre-certification and/or re-certifications when required. Utilizes high risk screening criteria to make appropriate referrals to Manager. 2. Discharge Facilitation - Identifies patient/families with the complex psychosocial, on-going medical discharge planning issues, continuing care needs by initiating appropriate case management referrals. Initiates appropriate social work referrals. 3. Utilization Management Process - Performs utilization management assessments and interventions, using collaboration with interdisciplinary team approach, on assigned patients as appropriate to ensure optimal patient outcomes. Using approved criteria, conducts continued stay and quality reviews to monitor the patient's progress along the continuum of care and intervenes as necessary to ensure appropriateness of setting and that the services provided are quality-driven, efficient, and effective. Enters all pertinent review data into the correct computer system in a timely manner. Consults with Physician Advisor as necessary to resolve barriers through appropriate administrative and medical channels. 4. Utilization Outcomes Management - Monitors and guides to trend interdisciplinary documentation and guides medical staff in documentation that will assist in coding accuracy, enhance quality of care, reflect accurate severity of illness and appropriate reimbursement. Facilitates patient movement to appropriate (acuity) level of care including observation status issues through collaboration with patient/family, multidisciplinary team, third party payors and resource center. Provides information regarding denials and approvals to designated entities. Assists in coordination of practice parameter development with the assigned departments/sections/specialties of Medical Staff. Oversees collection and analysis of patient care and financial data relevant to the target case types. Directs delivery of notifications to patients (includes traveling to hospital(s) to deliver notifications. Other Information Other information: Education Requirements: ● Graduation from a state-accredited school of professional nursing ● If hired after October 1, 2015, must be enrolled in an accredited program within four years of employment, and obtain a Bachelor's degree with a major in Nursing or a Master's degree with a major in Nursing within seven years of employment date. Licensure/Certification Requirements: ● Licensed to practice as a Registered Nurse in the state of North Carolina. Professional Experience Requirements: ● Two (2) years of clinical experience in a medical facility and/or comparable Utilization Management experience. Knowledge/Skills/and Abilities Requirements: Job Details Legal Employer: NCHEALTH Entity: UNC REX Healthcare Organization Unit: Rex Case Management Services Work Type: Full Time Standard Hours Per Week: 32.00 Salary Range: $35.87 - $51.57 per hour (Hiring Range) Pay offers are determined by experience and internal equity Work Assignment Type: Onsite Work Schedule: Day Job Location of Job: US:NC:Raleigh Exempt From Overtime: Exempt: Yes This position is employed by NC Health (Rex Healthcare, Inc., d/b/a NC Health), a private, fully-owned subsidiary of UNC Heath Care System. This is not a State employed position. Qualified applicants will be considered without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, status as a protected veteran or political affiliation. UNC Health makes reasonable accommodations for applicants' and employees' religious practices and beliefs, as well as applicants and employees with disabilities. All interested applicants are invited to apply for career opportunities. Please email applicant.accommodations@unchealth.unc.edu if you need a reasonable accommodation to search and/or to apply for a career opportunity.