As a utilization review (UR) nurse, you help ensure that patients are receiving the appropriate level of care while being mindful of expenditures to your employer, whether you work for a hospital, managed care facility, or insurance company.
Wondering where you might work in this role? The federal government requires that organizations participating in Medicare and Medicaid conduct utilization reviews. This means that you’ll find a variety of workplace options for UR nurse jobs.
Education and Certifications for Utilization Review Nursing Jobs
Before you can work in utilization review, you must complete a nursing program from an approved institution. Once you pass the NCLEX and receive your license, you’ll want to gain clinical experience in direct patient care. Registered nurses may also want to pursue experience as an RN case manager.
While likely not required for most jobs, specialty certification can increase both your knowledge and also your leverage when it comes time to look for a new utilization review nurse job. Certifications include:
Health Utilization Management Certification (HUMC)
Put some effort into customizing your utilization review nurse resume to each job posting. For instance, if an employer is seeking a candidate “proficient in insurance prior authorizations and medical necessity criteria for different payers,” include that phrase in your resume. This helps demonstrate that your skills are a good fit for the job.
In your UR nurse cover letter, explain a bit about what drew you to this particular position. Remember, you don’t want just any old job — you want this job. To reinforce this sentiment as you apply to UR nurse jobs, search the employer’s website for their mission statement and see where your values overlap.
Interviewing for a Utilization Review Nurse Job
A job interview has the potential to determine whether or not you’ll get a job offer. Need some pointers? Review our nursing interview tips in advance to help you formulate smart answers to common questions and boost your confidence.
Learn how to answer interview questions about your strengths as a nurse:
Utilization Review Nurse Salary
The average annual salary for a UR nurse is around $91,600 for a registered nurse. Your location, level of education and experience, and employer can impact this number. For a more accurate picture of utilization review nurse jobs’ salary estimates in your area, explore the current UR nursing jobs on IntelyCare.
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Pay Range: Pay Range:$41.66 - $58.69 As part of a consortium-wide team, support and manage patient progression of care in the hospital setting, promote evidence-based protocols, ensure the appropriateness of interventions, assess patient psycho-social needs, and expedite care delivery for patients. SEARHC is a non-profit health consortium which serves the health interests of the residents of Southeast Alaska. We see our employees as our strongest assets. It is our priority to further their development and our organization by aiding in their professional advancement. Working at SEARHC is more than a job, it’s a fulfilling career. We offer generous benefits, including retirement, paid time off, paid parental leave, health insurance, dental, and vision benefits, life insurance and long and short-term disability, and more. ********************************************************* $25K Sign On and $10K Relocation for qualified hire! ************************************************************ Key Essential Functions and Accountabilities of the Job Works collaboratively with consortium wide team supporting inpatient Care Coordination and Utilization Management Coordinate local CAH Swing Bed/Transitional Care program. Lead local CAH Inpatient interdisciplinary team meeting. Reviews all admissions to develop personalized treatment plans that are clinically appropriate, match the patients care needs and are consistent with patient choice and available resources while ensuring a timely and appropriate discharge. Collaborate with providers, leadership, and clinical support team to ensure treatment plan is based upon patient need and meets criteria approved by consortium and regulatory agencies/payors. Ensure ongoing documentation supports Utilization Management functions and communicate with payors appropriately. Provide appropriate information to educate patients/families regarding healthcare benefits and treatment plan. Assess patient to obtain relevant psycho-social information, make interventions and professional support referrals as needed. Develop and communicate discharge plan with the care team and patient/family, ensuring safe and well-coordinated transition of care. Support Peer Review process as part of consortium plan. Education, Certifications, and Licenses Required Current full, unrestricted Registered Nursing license in Alaska or other U.S. state required. Bachelor’s preferred. Direct Hire must have applied for an Alaska nursing license before start date. Agency staff must have an active Alaska license. Case Management certification by recognized certifying organization within 24 months of hire. BLS. ACLS. PALS preferred. High school diploma or equivalent required. Clinical Competency required within 3 months of hire and every three years High Risk Competency required within 3 months of hire and every year Experience Required 5 years clinical nursing experience 1 year experience with chart review, risk management, or related quality service preferred. Knowledge of Medical record review, medical necessity/insurance guidelines, and regulatory compliance. Skills in Communication, both verbal and written Strong organizational skills Ability to Work collaboratively as part of an interdisciplinary team. Build relationships with colleagues, community partners, and consumers. Physical Demands: While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to stand; walk; sit; use hands to finger, handle or feel and reach with hands and arms. The employee is occasionally required to climb or balance; stoop, kneel, crouch or crawl. The employee must lift and/or move 50 lbs. Required Certifications : Advanced Cardiovascular Life Support (ACLS) - American Heart Association, Basic Life Support (BLS) - American Heart Association, Case Manager Certification - Commission for Case Manager Certification, Clinical Competency Assessment - SEARHC, High Risk Competency - SEARHC, Registered Nurse License - State of Alaska - Alaska State Board of Nursing If you like wild growth and working with happy, enthusiastic over-achievers, you'll enjoy your career with us!
Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job Summary The Utilization Management Nurse Specialist RN II facilitates, coordinates, and approves medically necessary referrals that meet established criteria. Assures timely and accurate determination and notification of referrals and reconsiderations based on the referral determination status. Generates approval, modification and denial communications, to include member and provider notification of referral determination. Actively monitors for admissions in any inpatient setting. Performs telephonic and/or onsite admission and concurrent review, and collaborates with onsite staff, physicians, providers, member/family interaction to develop and implement a successful discharge plan. Works with the UM Manager and Physician Advisor on case reviews for pre-service, concurrent, post-service and retrospective claims medical review. Monitors and oversees the collection and transfer of data (medical records) and referral requests by Providers. Acts as a department resource for medical service requests /referral management and processes. Receives incoming calls from providers, professionally handles complex calls, researches to identify timely and accurate resolution steps. Follows up with caller to provide response or resolution steps. Answers all inquiries in a professional and courteous manner. Duties Promote and support team engagements, programs and activities to create and ensure a positive and productive workplace environment. Perform telephonic and/or onsite admission and concurrent review, and collaborates with onsite staff, physicians, providers, the member and significant others to develop and implement a successful discharge plan. Process, finalize and facilitate inbound requests that are received from providers. Generate appropriate member and provider communication for all determinations within the required timelines as defined by the most current department policy. Facilitate/review requests for Higher level of care or skilled nursing/discharge planning needs. Research for appropriate facilities, specialty providers and ancillary providers to utilize for all lines of business. Identification of potential areas of improvement within the provider network. Identify and initiate referrals for appropriate members to the various L.A. Care programs/processes and external community based programs or Linked and Carve Out Services (e.g. DDS/CCS/MH). Potential quality of care/potential fraud issues are identified and documented per L.A. Care policy. High risk/high cost cases and reports are maintained and referred to the Physician Advisor/UM Director. Document in platform/system of record. Utilize designated software system to document reviews and/or notes. Receive incoming calls from providers, professionally handle complex calls, research to identify timely and accurate resolution steps. Follow up with caller to provide response or resolution steps. Answer all inquiries in a professional and courteous manner. Perform other duties as assigned. Duties Continued Education Required Associate's Degree in Nursing Education Preferred Bachelor's Degree in Nursing Experience Required: At least 5 years of varied RN clinical experience in an acute hospital setting. At least 2 years of Utilization Management/Case Management experience in a hospital or HMO setting . Preferred: Managed Care experience performing UM and CM at a medical group or management services organization. Experience with Managed Medi-Cal, Medicare, and commercial lines of business. Skills Required: Must be computer literate, with expertise in Outlook, Word, Excel, PowerPoint. Effectively utilizes computer and appropriate software and interacts as needed with L.A. Care Information System. Knowledge of personal computer, keyboarding, and appropriate software to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment. Prepare clear, comprehensive written and oral reports and materials. Provision of excellent customer service required due to frequent communication with providers and other members of the interdisciplinary team Excellent time management and priority-setting skills. Maintains strict member confidentiality and complies with all HIPAA requirements. Strong verbal and written communication skills. Preferred: Knowledge of National Committee for Quality Assurance (NCQA) requirements for Utilization Management or Care Management (CM). Knowledge of Department of Health Care Services (DHCS) or Centers for Medicare and Medicaid Services(CMS) requirements for health plan compliance with UM or CM. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California License Licenses/Certifications Preferred Certified Case Manager (CCM) Required Training Physical Requirements Light Additional Information May work on occasional weekends and some holidays depending on business needs. Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. L.A. Care offers a wide range of benefits including Paid Time Off (PTO) Tuition Reimbursement Retirement Plans Medical, Dental and Vision Wellness Program Volunteer Time Off (VTO)
Salary: 74,431.50-111,637.50 USD Facility: Kenmore Mercy Hospital Shift: Shift 1 Status: Full Time FTE: 1.000000 Bargaining Unit: ACE Associates Exempt from Overtime: Exempt: Yes Work Schedule: Days with Weekend and Holiday Rotation Hours: 8 am- 4 pm Summary: The Registered Nurse (RN), Utilization Review, as an active member of the Middle Revenue Cycle and interdisciplinary care team, provides comprehensive Utilization Review to patients and families in the hospital setting. Utilizing foundational nursing clinical skills Utilization Review nurse collaborates with the interdisciplinary team to maintain appropriate levels of care and to facilitate movement of the patient through the continuum. The Utilization Review RN identifies and removes barriers for delays of treatment. This individual also works to maintain third-party payer relationships related to Utilization Review Activities. This includes, but is not limited to, concurrent review, responding to inquiries, complaints, and other correspondence, and may include setting up discussions between parties. Knowledge of state and federal laws relating to contracts and utilization review process processes is vital. Responsibilities: EDUCATION BSN degree or RN with a BS in health-related field and working knowledge/experience in documentation utilization review in an acute care/inpatient setting Unrestricted NYS RN license Holds, or will obtain within one year of hire, Certified Case Manager (CCM) Certification in a Nationally Recognized Utilization Review Criteria set is preferred At least 1 year of experience in working with third party payers strongly preferred EXPERIENCE Minimum of three (3) years of experience working in an Acute Care Hospital Setting Proficiency in utilization management and regulatory requirements preferred Experience in working with people who are geographically dispersed preferred Experience in working with third party payers strongly preferred KNOWLEDGE, SKILL AND ABILITY Strong clinical assessment skills and ability to articulate findings in a fast-paced environment. Possess the ability to make independent decisions within the professional scope of practice Possess ability to educate, inform, advocate, promote and facilitate health care options, and demonstrate the willingness to work harmoniously with a team approach Possesses ability to effectively and efficiently utilize technology within daily work with the care team and ability to quickly learn and adapt to new technology tools and software Extensive knowledge of third-party payer guidelines, accreditation and regulatory requirements preferred Knowledge of Managed Care Organization contracts/agreements preferred WORKING CONDITIONS: Willingness to work beyond normal working hours, and in other positions temporarily, and/or at other locations when necessary Variable schedule which may include weekends and holidays. May be requested to travel to multiple hospital and community sites ENVIRONMENT Normal heat, light space, and safe working environment; typical of most office jobs Occasional exposure to one or more mildly unpleasant physical conditions Minimum physical effort required, typical of most office work Significant amount of walking within the acute care facility
Overview CentraState Healthcare System, headquartered in Freehold, New Jersey, is a leading nonprofit healthcare provider dedicated to serving the community. Its comprehensive network includes CentraState Medical Center, a community-focused hospital, along with an ambulatory campus, two senior living facilities, three free-standing community health pavilions, and a charitable foundation. As the third-largest employer in Monmouth County, CentraState has earned repeated recognition as a Great Place to Work-Certified™ company, reinforcing its reputation as an exceptional workplace. CentraState Medical Center has an employment opportunity available for a Utilization Review Nurse . The Utilization Review RN (UR RN) applies professional nursing judgment and critical thinking skills to assess patients for appropriate levels of care and to mitigate potential denials. This role requires a strong knowledge of evidence-based clinical criteria and federal and state utilization management requirements. The UR RN identifies key clinical information to support hospital admissions and continued stays, collaborates with the care management team to optimize resource utilization, and secures payer approvals. The UR RN also reviews escalated cases that do not meet medical necessity prior to initiating secondary review. Responsibilities Responsibilities include, but are not limited to: Provides timely and thorough clinical information to insurance companies and other intermediaries to secure payer authorizations and avoid denials or reduction in level of care. Performs daily surveillance of observation cases and works with APNs and PA discussing any barriers to progression of care or discharge. Intervenes proactively to avoid denials or delays in authorization. Actively communicates information to other CM team members and interdisciplinary teams regarding progress or payer issues related to continued hospitalization and post-acute service associated with the patients discharge plan. Refers cases and issues to Physician Advisors or Designees in compliance with department procedures with timely follow up as indicated. Assists in identification and collection of avoidable days and management of the expected discharge date. Coordinates with the CM RN and/or CMA to identify and complete the process for CMS required patient notices. Completes and documents utilization reviews, physician advisor referrals and other communications related to assigned cases in accordance with department policy and procedure. Complies with the Condition of Code 44 process, CMS required patient notices and other regulatory requirements within the utilization management process. Maintains proficiency in the application of organization selected clinical review criteria sets evidenced through IRR testing Assists in facilitating and coordinating clinical progression of assigned patients Other duties as assigned by management Qualifications BSN or Bachelor’s Degree in related field or current enrollment in BSN or related Bachelor’s Degree program required. Prior clinical experience in care and management of hospitalized patients. Experience in acute care case management, preferred. Utilization review or case management training from a professional Case Management organization, preferred. RN license required/NJ. Case Management certification preferred. Excellent communication, negotiation, and conflict resolution skills Data and computer skills Knowledge of relevant and state utilization review and appeals requirements Rapid cycle change or clinical performance improvement expertise About Us CentraState Healthcare System, in partnership with Atlantic Health System, is a fully accredited, not-for-profit, community-based health system dedicated to providing comprehensive health services in central New Jersey. Beyond offering a wide range of advanced diagnostic and treatment options, CentraState is committed to being a valuable health partner, focusing on disease prevention, promoting healthy behaviors, and helping individuals of all ages live well. Located in Freehold, CentraState includes a 284-bed acute-care hospital, a dynamic health and wellness campus, two award-winning senior living communities, a charitable foundation, and convenient satellite health pavilions. These pavilions offer primary care, specialty physician practices, and access to outpatient services such as lab work and physical therapy. CentraState is proud to be among the less than two percent of hospitals nationwide to earn Magnet® designation for nursing excellence five times. Additionally, it has been recognized as a Great Place to Work-Certified™ Company by Great Place to Work® for four consecutive years. Joining CentraState means becoming part of a pioneering healthcare facility committed to high-quality, patient-focused care. We invite you to make a difference in our community and advance your career with us. We support our employees with work/life balance initiatives, tuition assistance, career advancement opportunities, and more. Discover why our employees love their jobs and being part of the CentraState family! CentraState Health System offers a competitive and comprehensive Total Rewards package that supports the health, financial security, and well-being of all team members. What We Offer: Medical, Dental, Vision, Prescription Coverage (30 hours per week or above for full-time and part-time team members) Life & AD&D Insurance Long-Term Disability (with options to supplement) 403(b) Retirement Plan with employer match 401(a) Retirement Plan with employer contribution PTO Tuition Reimbursement Well-Being Rewards Employee Assistance Program (EAP) Fertility Coverage, Healthy Pregnancy Program Flexible Spending & Commuter Accounts Pet, Home & Auto, Identity Theft and Legal Insurance Growth Opportunity and Workforce Development Initiatives Continuing Education / Onsite Training A warm, welcoming company culture based upon mutual respect and a collaborative goal of providing excellent patient care Concierge Services with Work & Family Benefits Magnet recognized healthcare facility Compensation Range: $93,600 - $159,120 annually The compensation above reflects the established range from CentraState Healthcare System (CSHS) for this position at the time the job was posted. CSHS considers many factors to determine compensation, including education, experience, skills, licenses, certification, and training. As such, team member compensation may fall outside this range. Additionally, the compensation range reflects base salary and does not include extra shift rates or incentives tied to quality, productivity, etc., as applicable. The benefits outlined also reflect CSHS’ policy at the time of posting. Benefits as are made available to other similarly situated team members of CSHS, although participation is at all times in accordance with and subject to the eligibility and other provisions of such plans and programs. CSHS may modify its benefits plans or programs at any time. CSHS is proud to comply with all pay equity and pay transparency laws.
Position Summary The Peer Review QNS works closely with medical staff leaders to organize and conduct all Professional Practice Evaluation (PPE) activities, which include Focused Professional Practice Evaluation (FPPE) for initial and additional privileges, Peer Review of clinical activity, professionalism and behavior, and Ongoing Professional Practice Evaluation (OPPE). Responsibilities Synthesize information from relevant resources to demonstrate current practice and identify opportunities for improvement. Identify sources of valid and reliable information and metrics to monitor performance trends. Analyze information from disparate sources. Analyze comparative data, benchmarks, and evidence-based practices for possible adaptation into the organization. Use valid and reliable data to support opportunity recommendations and illuminate key trends for stakeholders. Demonstrate expertise in the use of analytical and statistical tools and techniques including understanding of how process goals are established, measured and monitored; apply techniques and tools to identify variation and its causes; analyze input variable to identify critical factors that must be addressed to achieve optimal process performance. Communicate improvement priorities and results using narrative and visual tools by create graphs and charts that accurately reflect valid interpretation of findings; develop dashboards and scorecards to depict internal metrics and benchmark comparisons; create written and verbal communication to tell a story appropriate to the audience. Design and develop project plans including providing project coordination using project management tools, measurement plans, estimates costs to determine budget, incorporates evidence-based guidelines. Uses change management principles. Communicates project progress to all stakeholders through the project. Promote a safety culture and infrastructure by engaging stakeholders to understand all perspectives when addressing patient safety issues; model behaviors that promotes a safety culture; educate staff; support adoption of high reliability principles; design sustainable actions to improve patient safety. Minimum Requirements Bachelor's degree in applicable field or higher is required. Active RN license 3 years or more experience in healthcare field Certification in specialty preferred within 3 years and maintained thereafter. ECU Health About ECU Health Medical Center ECU Health Medical Center, one of four academic medical centers in North Carolina, is the 974-bed flagship hospital for ECU Health and serves as the primary teaching hospital for The Brody School of Medicine at East Carolina University. ECU Health Medical Center has achieved Magnet® designation twice and provides acute and intermediate care, rehabilitation and outpatient health services to a 29-county region that is home to more than 1.4 million people. General Statement It is the goal of ECU Health and its entities to employ the most qualified individual who best matches the requirements for the vacant position. Offers of employment are subject to successful completion of all pre-employment screenings, which may include an occupational health screening, criminal record check, education, reference, and licensure verification. We value diversity and are proud to be an equal opportunity employer. Decisions of employment are made based on business needs, job requirements and applicant’s qualifications without regard to race, color, religion, gender, national origin, disability status, protected veteran status, genetic information and testing, family and medical leave, sexual orientation, gender identity or expression or any other status protected by law. We prohibit retaliation against individuals who bring forth any complaint, orally or in writing, to the employer, or against any individuals who assist or participate in the investigation of any complaint.
Division: Eskenazi Health Sub-Division: Hospital Req ID: 24795 Schedule : Full Time Shift : Days Salary Range: Eskenazi Health serves as the public hospital division of the Health & Hospital Corporation of Marion County. Physicians provide a comprehensive range of primary and specialty care services at the 327-bed hospital and outpatient facilities both on and off of the Eskenazi Health downtown campus as well as at 10 Eskenazi Health Center sites located throughout Indianapolis. FLSA Status Exempt Job Role Summary The Utilization Payor Specialist, RN is responsible for working behind the scenes to maximize the quality and cost of efficiency of health services. This position coordinates pre-certifications, re-certifications, the denial management and appeals process, and initial and concurrent reviews. Through regular reviews and audits, the Utilization Payor Specialist ensures that patients receive the care needed without burdening the health care system with unnecessary procedures, ineffective treatments or lengthy hospital stays. #EXPRN Essential Functions and Responsibilities Communicates secondary review decisions determining appropriate patient status provided by secondary reviewer process Communicates and negotiates with payers to obtain approvals for the appropriate care level Serves as a resource on payor requirements for severity and intensity of service determinations for outpatient and acute inpatient admissions Provides timely payor feedback to Case Managers and Social Workers; notifies the Case Manager when additional clinical information may be required that is not currently identified within the electronic medical record or bedside documentation to ensure that services will be approved at the acute level of care as required by the payor Ensures pre-certification/authorizations for post-acute services, initial, concurrent reviews, authorizations not obtained by Patient Registration/Admitting or the doctor's office and clinics for direct admissions and procedures Reviews patient admission for appropriateness and type; refers case to Medical Director/department leadership for review and course of action when case fails to meet admission standards Coordinates and facilitates the most accurate and appropriate patient status for care across the continuum Actively communicates and documents payor issues and concerns regarding the initial level of care, continued stay, denials and discharge plans to the Medical Director/department leadership as appropriate Supports the denial management process and participates in tracking and reporting denials Ensures payor and customer satisfaction through effective communication with the Interdisciplinary Team Obtains payor certification for unplanned admissions, homecare and post-acute services as required Initiates contact with payers for continued stay; reviews utilizing clinical information; pursues additional information as needed Utilizes conflict resolution, critical thinking, and negotiation skills as necessary to ensure timely resolution of issues Identifies concurrent third-party payers denials and notifies Case Managers for immediate intervention and escalation to the Medical Director/department leadership Coordinates denial and appeals process and responds to all third-party payer denials Applies appropriate clinical criteria to complete initial reviews within 24-48 hours of patient presentation Facilitates tracking and payment approval processes for the outpatient parenteral antimicrobial therapy program (OPAT) Assists with coordination, data entry and needed follow up support to the OPAT program Provides post-hospitalization telephonic follow up for OPAT patients in the community for care coordination regarding care outcomes that support the OPAT program Facilitates tracking and payment approval processes for Eskenazi Health inpatient overlaps receiving services at IUH Facilitates tracking and payment approval processes for Eskenazi Health Cardiac send-out receiving services at IUH Reviews claims for both inpatient overlaps and cardiac send-outs and verifies dates of service; provides to Revenue Cycle for adjudication and payment Facilitates tracking and payment approval processes for vendor picc lines to include charge reconciliation in EPIC Provides oversight and maintains readmission initiatives directly related to Target Diagnosis, Bedside education, follow-ups for vendor-automated calls Provides assistance for complex discharge planning placement and programs, departmental projects, authorizations and accounts payable Facilitates referral, tracking and payment approval processes for Eskenazi Health requiring home wound-vac services provided by in-network vendors for specialty clinics and patients discharging home Job Requirements Current Indiana RN nursing license required Four years of clinical nursing experience required Two or more years of Utilization Review experience strongly preferred Knowledge, Skills & Abilities Must demonstrate knowledge of the Utilization Management managed care processes Must demonstrate knowledge of levels of care of Inpatient and Outpatient status Excellent interpersonal, written and verbal communication, and negotiation skills Demonstrated ability to be diplomatic and flexible, and demonstrates a high level of professionalism Ability to cohesively network with the Interdisciplinary Team Accredited by The Joint Commission and named one of the nation’s 150 best places to work by Becker’s Hospital Review for four consecutive years and Forbes list of best places to work for women, and Forbes list of America’s best midsize employers’ Eskenazi Health’s programs have received national recognition while also offering new health care opportunities to the local community. As the sponsoring hospital for Indianapolis Emergency Medical Services, the city’s primary EMS provider, Eskenazi Health is also home to the first adult Level I trauma center in Indiana, the only verified adult burn center in Indiana, the first community mental health center in Indiana and the Eskenazi Health Center Primary Care – Center of Excellence in Women’s Health, just to name a few.
Summary Samaritan Health Plans (SHP) provides health insurance options to Samaritan employees, community employers, and Medicare and Medicaid members. SHP operates a portfolio of health plan products under several different legal structures: InterCommunityHealth Plans, Inc. (IHN) is designated as a regional Coordinated Care Organization (CCO) for Medicaid beneficiaries; Samaritan Health Plans, Inc. offers Medicare Advantage, Commercial Large Group, and Commercial Large Group PPO and EPO plans; SHP is also the third-party administrator for Samaritan Health Services’ self-funded employee health benefit plan. As part of an Integrated Delivery System, Samaritan Health Plans is strategically and operationally aligned with Samaritan Health Services’ mission of Building Healthier Communities Together. This is a remote position in which we are able to employ in the following states: Arizona, Arkansas, Connecticut, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Mexico, North Carolina, Oklahoma, Oregon, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, or Wisconsin Occasionally JOB SUMMARY/PURPOSE The Clinical Program Manager RN serves as the cornerstone of SHP’s regulatory infrastructure within the utilization management department. This role is responsible for the development, testing, and validation of complex report queries that support federal and state regulatory deliverables. It also oversees the creation and maintenance of policies, procedures, work instructions, and audit tools, while ensuring staff are adequately trained on these materials. The Clinical Program Manager leads all aspects of program development and execution, collaborates with internal teams and external partners, and serves as a subject matter expert across the organization. The position will also oversee and partner other health plan functions such non-emergency medical transport and delegation audits. EXPERIENCE/EDUCATION/QUALIFICATIONS Current unencumbered Oregon RN License required within 90 days of hire. BSN preferred. Master's degree in a related field preferred. One (1) year clinical nursing experience plus four (4) years health plan, case management and/or utilization management experience required. Experience or training in the following required: Health care delivery systems and/or managed care patients. Computer applications including electronic documentation (e.g., MS Office, EPIC, Clinical Care Advanced). Experience in the following preferred: Team leadership. Case management. Medicare and Medicaid rules and regulations and health plan benefit structure and policy. KNOWLEDGE/SKILLS/ABILITIES Leadership - Inspires, motivates, and guides others toward accomplishing goals. Achieves desired results through effective people management. Conflict resolution - Influences others to build consensus and gain cooperation. Proactively resolves conflicts in a positive and constructive manner. Critical thinking - Identifies complex problems. Involves key parties, gathers pertinent data and considers various options in decision making process. Develops, evaluates and implements effective solutions. Communication and team building - Lead effectively with excellent verbal and written communication. Delegates and initiates/manage cross-functional teams and multi-disciplinary projects. PHYSICAL DEMANDS Rarely (1 - 10% of the time) (11 - 33% of the time) Frequently (34 - 66% of the time) Continually (67 - 100% of the time) CLIMB - STAIRS LIFT (Floor to Waist: 0"-36") 0 - 20 Lbs LIFT (Knee to chest: 24"-54") 0 - 20 Lbs LIFT (Waist to Eye: up to 54") 0 - 20 Lbs CARRY 1-handed, 0 - 20 pounds BEND FORWARD at waist KNEEL (on knees) STAND WALK - LEVEL SURFACE ROTATE TRUNK Standing REACH - Upward PUSH (0 - 20 pounds force) PULL (0 - 20 pounds force) SIT CARRY 2-handed, 0 - 20 pounds ROTATE TRUNK Sitting REACH - Forward MANUAL DEXTERITY Hands/wrists FINGER DEXTERITY PINCH Fingers GRASP Hand/Fist
Description Introduction This Work from Home position requires that you live and will perform the duties of the position; within 60 miles of an HCA Healthcare Hospital (Our hospitals are located in the following states: FL, GA, ID, KS, KY, MO, NV, NH, NC, SC, TN, TX, UT, VA). Do you want to join an organization that invests in you as an Inpatient Authorization Review Services Registered Nurse or Licensed Practical Nurse -NICU (Code Pink)? At Parallon, you come first. HCA Healthcare has committed up to 300 million in programs to support our incredible team members over the course of three years. Benefits Parallon offers a total rewards package that supports the health, life, career and retirement of our colleagues. The available plans and programs include: Comprehensive medical coverage that covers many common services at no cost or for a low copay. Plans include prescription drug and behavioral health coverage as well as free telemedicine services and free AirMed medical transportation. Additional options for dental and vision benefits, life and disability coverage, flexible spending accounts, supplemental health protection plans (accident, critical illness, hospital indemnity), auto and home insurance, identity theft protection, legal counseling, long-term care coverage, moving assistance, pet insurance and more. Free counseling services and resources for emotional, physical and financial wellbeing 401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service) Employee Stock Purchase Plan with 10% off HCA Healthcare stock Family support through fertility and family building benefits with Progyny and adoption assistance. Referral services for child, elder and pet care, home and auto repair, event planning and more Consumer discounts through Abenity and Consumer Discounts Retirement readiness, rollover assistance services and preferred banking partnerships Education assistance (tuition, student loan, certification support, dependent scholarships) Colleague recognition program Time Away From Work Program (paid time off, paid family leave, long- and short-term disability coverage and leaves of absence) Employee Health Assistance Fund that offers free employee-only coverage to full-time and part-time colleagues based on income. Learn more about Employee Benefits Note: Eligibility for benefits may vary by location. You contribute to our success. Every role has an impact on our patients’ lives and you have the opportunity to make a difference. We are looking for a dedicated Inpatient Authorization Review Services Registered Nurse or Licensed Practical Nurse -NICU (Code Pink) like you to be a part of our team. Job Summary and Qualifications The Inpatient Authorization Review Services Registered Nurse or Licensed Practical Nurse NICU (Code Pink) will review post discharge, prebill accounts that do not have authorization on file, ALOS versus days authorized variances, and/or other account discrepancies identified that will result in the account being denied by the payor that require clinical expertise. Communicates with third party payors to resolve discrepancies prior to billing. Accurately and concisely documents all communications and action taken on the account in accordance with policies and procedures. Escalate medical review request and /or denial activities to management as needed. What you will do in this role: Work post discharge, prebill accounts efficiently and effectively daily to resolve accounts with “no auth numbers, ALOS vs. authorized days or other discrepancies. Evaluates clinical documentation on multiple patient accounts and escalates issues through the established channels. Perform accurate and timely documentation of all review activities based on policy and procedure. Demonstrates a working knowledge of managed care agreements based on available resources which may include and not be limited to payer UM Manual, policy and procedure, facility contract information. Escalates variations timely. Work assigned accounts in eRequest to resolve outstanding issues. Report insurance denial trends identified during daily operational assignments. Contact facilities, physicians’ offices and/or insurance companies to resolve denials/appeals if needed. Demonstrates knowledge of regulatory requirements, Ethics and Compliance policies, and quality initiatives; monitors self-compliance and implements process changes to ensure compliance to such regulations and quality initiatives. Assess CPT code(s) for outpatient accounts that require authorization when accounts have not been coded. Qualifications that you will need: Registered Nursing degree and current licensure or Vocational nursing degree required. Healthcare experience in an acute care hospital. Utilization Review, appeals, denials, managed care contracting, experienced preferred. Currently licensed as a registered nurse (RN) in the state(s) of practice and/or has an active compact license, in accordance with law and regulation or Licensed Practical Nurse -Currently licensed as a licensed practical nurse in the state in which he or she resides and practices, in accordance with law and regulation. Multi-state nursing licensure for compact states Parallon provides full-service revenue cycle management, or total patient account resolution, for HCA Healthcare. Our services include scheduling, registration, insurance verification, hospital billing, revenue integrity, collections, payment compliance, credentialing, health information management, customer service, payroll and physician billing. We also provide full-service revenue cycle management as well as targeted solutions, such as Medicaid Eligibility, for external clients across the country. Parallon has over 17,000 colleagues, and serves close to 1,000 hospitals and 3,000 physician practices, all making an impact on patients, providers and their communities. HCA Healthcare has been recognized as one of the World’s Most Ethical Companies® by the Ethisphere Institute more than ten times. In recent years, HCA Healthcare spent an estimated 3.7 billion in cost for the delivery of charitable care, uninsured discounts, and other uncompensated expenses. "Good people beget good people." - Dr. Thomas Frist, Sr. HCA Healthcare Co-Founder We are a family 270,000 dedicated professionals! Our Talent Acquisition team is reviewing applications for our Inpatient Auth Review Services RN or LPN -NICU opening. Qualified candidates will be contacted for interviews. Submit your resume today to join our community of caring! We are an equal opportunity employer. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.
Overview About us: Fallon Health is a company that cares. We prioritize our members—always—making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, Fallon Health delivers equitable, high-quality, coordinated care and is continually rated among the nation’s top health plans for member experience, service, and clinical quality. We believe our individual differences, life experiences, knowledge, self-expression, and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status, and other characteristics that make people unique. Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs—including Medicare, Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)— in the region. Learn more at fallonhealth.org or follow us on Facebook, Twitter and LinkedIn. Brief summary of purpose: With the general direction from the VP Sr. Medical Director Clinical Management and SVP/Chief Medical Officer will provide strategic leadership and oversight responsibility for the clinical and operational utilization management activities for all inpatient and outpatient care, and staff across all product lines. Responsibilities Utilization Management: Oversees all administrative, operational and clinical functions related to outpatient and inpatient, utilization management operations, including but not limited to prior authorization, concurrent review and discharge planning. Ensures that members get the appropriate care that is medically necessary and meets the benefit coverage criteria. Ensures that all reviews meet the appropriate regulatory and accreditation requirements including turnaround times and communication. Ensures program compliance with all federal regulatory and state mandates, Division of Insurance, National Committee for Quality Assurance standards, Centers for Medicare and Medicaid guidance and requirements, MassHealth (Medicaid contractual agreements). Responsible for hiring appropriate non-physician clinical and non-clinical personnel to review medical cases and determine if requests for services meet medical necessities and criteria for coverage. Oversight of UM by delegated organizations and ensure regulatory and accreditation compliance, Monitors and analysis of operational and outcome data related to all utilization management activities. Recommends and implements innovative process improvements for the prior authorization and utilization management processes Develops and implements the Utilization Management Program Description and annually evaluate the effectiveness of the program. Represents the UM Department in Program Audits across all LOBs, including information gathering, research, presenting, and development of Corrective Action Plans (if applicable) Key Contact for RFP responses related to UM Functions and department organization structure/staffing. Works with VP/Medical Director to identify and prioritize the cost of care opportunities related to Utilization Management. Works with VP/ Medical Director to set agenda related to UM and represent the plan at clinical joint operating committees to support collaborative Fallon/provider group relationship. Manages data, predictive analytics to improve efficiency of prior authorization and utilization management Works with and represents Care Services for utilization management on the different product line task forces at Fallon. Serves as SME and Point of Contact for internal committees including but not limited to Delegation Oversight Committee (DOC), Payment Policy, Mental Health Parity, Medical Directors monthly meeting, and TruCare Insights/upgrade meetings. Represents the Vice President and Senior Medical Director of Clinical Management at internal and external senior level meetings. Budget creation and management of annual budget. Clinical Integration Support: Provides UM expertise to Clinical Integration leadership to ensure seamless integrated member care within Care Services as well as other departments by involving inpatient case management with out-patient case management and utilization management to optimize post-acute care. Manage and develop staff: Ensures objectives defined across a broader group are integrated and supportive where necessary. Defines roles and accountabilities for staff, within the group and in the context of the broader process/operation in support of cross-functional efforts. Hires for, develops and recognizes the experience and knowledge/skills/abilities required for a successful team. Provides for the orientation and welcome of new staff. Defines performance expectations and goals for staff. Trains and mentors’ staff on the application of policy and procedures, use of supporting systems/applications, appropriate soft skills: time management, etc. Monitors work of individual staff for efficiency, effectiveness and quality. Provide ongoing constructive feedback and guidance to staff. Evaluates staff on achievement of goals and deliverables and assessment of competencies. Helps staff progress in their careers to the benefit of the department and broader organization. Manages the resolution of performance issues in consultation with Human Resources as appropriate. Qualifications Education: Master’s degree in health administration or business preferred. Bachelor’s degree in nursing or related health field required. License/Certifications: Massachusetts Nursing Licensure Experience: Broad experience in managed care and /or integrated delivery systems, either payer or provider. Significant experience in regulatory and accreditation compliance requirements for Medicare, Medicaid and the division of insurance support all Fallon Health Products Experience in managing health care and support personnel, as well as managing health care personnel and external relationships. A comprehensive knowledge of utilization management strategies to manage utilization and costs. Minimum of ten years clinical experience, at least five in managed care or ambulatory clinical operations. Pay Range Disclosure: In accordance with the Massachusetts Wage Transparency Act, the pay range for this position is $155,000 - 175,000 per year, which reflects what we reasonably and in good faith expect to pay at the time of posting. Final compensation will depend on the candidate’s experience, skills, and fit with the role’s responsibilities. Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. #P01
Overview Works with physicians and multidisciplinary team members to develop a plan of care for assigned patients. Ensures patient is progressing towards desired outcomes by monitoring care through assessments and/or patient records. Identifies and resolves barriers that hinder effective patient care. Actively involved in discharge planning process. **UR specific experience preferred Responsibilities Works with Medical Director and appropriate physician(s) to establish Dartmouth-Hitchcock (D-H) ambulatory and inpatient procedure list, updates and maintains list. Reviews reservation forms and the log of emergent and urgent admissions daily. Identifies areas that require intervention and education around the use of definitions. Reviews “one day stays” to assess appropriate use of level of care (LOC) determinations. Works with individual physicians and office staff when they are experiencing discrepancies with pre-certifications. Assumes responsibility for the oversight of inpatient denials, including, but not limited to, reviewing denial letters, collaborating with the Medical Director and appropriate physicians to determine the decision to appeal or accept, assisting in the response to Health Plan, etc. Develops and implements communication strategies to keep clinicians and staff informed of changes and current practice. Works closely with others to transition level of care determinations. Provides information to departmental leadership that reflects trends and practices that may need organization, intervention, and change. Collaborates with Health Plans to understand their definitions, articulates the definitions of D-H, and assists in the development of strategies for resolution of differences. Benchmarks with other facilities concerning admission and denial experience and policies. Performs other duties as required or assigned. Qualifications Graduate from an accredited Nursing Program required. Bachelor of Science Degree in Nursing (BSN) with 3 years of experience. Masters of Science Degree in Nursing (MSN) preferred. Strong leadership, communication and computer skills desired. Required Licensure/Certifications Licensed Registered nurse with NH eligibility
Department/Unit: Care Management/Social Work Work Shift: Day (United States of America) Salary Range: $71,612.39 - $110,999.20 Responsible for Utilization Management, Quality Screening and Delay Management for assigned patients. • Completes Utilization Management and Quality Screening for assigned patients. • Applies MCG criteria to monitor appropriateness of admissions and continued stays, and documents findings based on Departmental standards. • While performing utilization review identifies areas for clinical documentation improvement and contacts appropriate department. • Identifies at-risk populations using approved screening tool and follows established reporting procedures. • Monitors LOS and ancillary resource use on an ongoing basis. Takes actions to achieve continuous improvement in both areas. • Refers cases and issues to Medical Director and Triad Team in compliance with Department procedures and follows up as indicated. • Communicates covered day reimbursement certification for assigned patients. • Discusses payor criteria and issues and a case-by-case basis with clinical staff and follows up to resolve problems with payors as needed. • Uses quality screens to identify potential issues and forwards information to the Quality Department. • Demonstrates proper use of MCG and documentation requirements through case review and inter-rater reliability studies. • Facilitates removal of delays and documents delays when they exist. Reports internal and external delays to the Triad Team. • Collaborates with the health care team and appropriate department in the management of care across the continuum of care by assuring communication with Triad Team and health care team. Minimum Qualifications: • Registered nurse with a New York State current license. • Bachelor's degree preferred. • Minimum of three years clinical experience in an assigned service. • Recent experience in case management, utilization management and/or discharge planning/home care in a high volume, acute care hospital preferred. PRI and • Case Management certification preferred. • Assertive and creative in problem solving, critical thinking skills, systems planning and patient care management. • Self-directed with the ability to adapt in a changing environment. • Basic knowledge of computer systems with skills applicable to utilization review process. • Excellent written and verbal communication skills. • Working knowledge of MCG criteria and ability to implement and utilize. • Understanding of Inpatient versus Outpatient surgery and ICD10-Coding (preferred) and Observation status qualifications. • Ability to work independently and demonstrate organizational and time management skills. • Strong analytic, data management and PC skills. • Working knowledge of Medicare regulatory requirements, Managed Care Plans Thank you for your interest in Albany Medical Center! Albany Medical is an equal opportunity employer. This role may require access to information considered sensitive to Albany Medical Center, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that: Access to information is based on a “need to know” and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Med Center policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification.
Interested in a career with both meaning and growth? Whether your abilities are in direct patient care or one of the many other areas of healthcare administration and support, everyone at Parkland works together to fulfill our mission: the health and well-being of individuals and communities entrusted to our care. By joining Parkland, you become part of a diverse healthcare legacy that’s served our community for more than 125 years. Put your skills to work with us, seek opportunities to learn and join a talented team where patient care is more than a job. It’s our passion. Primary Purpose Parkland Community Health Plan's (PCHP's) Utilization Management (UM) Clinician is responsible for processing authorization requests for members requiring physical and/or behavioral healthcare for outpatient and inpatient service. UM responsibilities include but are not limited to processing of prior and concurrent review authorizations, discharge planning and transitions of care. Oversees the application of clinical guidelines in determining appropriateness of requested and continued healthcare services. Ensures that all clinical decisions are completed according to evidence based best practice guidelines and meets regulatory requirements. Seeks Medical Director review of cases not meeting criteria and monitors time frames for decision making and notifications of decision. Minimum Specifications Education Bachelor's degree in Nursing; or Master's Degree in Social Work or a related field required. If serving physical health populations, graduation from an accredited school of nursing is required. Experience 3+ years of acute clinical nursing or medical management experience required. If serving behavioral health populations, at least three 3+ years of clinical social work or behavioral health experience required. 3+ years of experience in Texas Medicaid, Medicaid, or a Medicaid managed care organization or health plan preferred. 1+ year experience with the implementation of utilization management policies, procedures, and protocols for physical health and/or behavioral health services and knowledge of utilization management and case management principles is preferred. Experience managing pediatric population with complex PH/BH conditions preferred. Experience in Texas Medicaid and NCQA is preferred. Certification/Registration/Licensure If primarily serving members with physical health needs, current and unrestricted licensure as a RN in the State of Texas required. If primarily serving members with behavioral health needs, must have and maintain an unrestricted license such as a RN, LPC, LMFT, or LCSW in the State of Texas. Skills or Special Abilities Knowledge of community resources, local service systems including indigent physical health and/or behavioral health systems. Knowledge of utilization management and case management principles. Understanding of utilization management principles, objectives, standards and methods, and of program policies and procedures. For those reviewing BH authorizations, demonstrate knowledge and utilization of evidence-based practices relevant to population served (persons who have experienced trauma, members with substance use disorder, members with serious mental illness or serious emotional disturbance). Competency in prior and concurrent review authorization functions including application of criteria and timelines. Demonstrated ability to analyze clinical information and accurately apply clinical criteria. Excellent verbal and written communication skills including the ability to communicate effectively and professionally across disciplines. Ability to communicate complex information in understandable terms. Proven history of effective communication and counseling skills Strong interpersonal and conflict resolution skills with the ability to establish and maintain effective working relationships across and beyond the organization. Excellent analytical and problem-solving skills. Strong time management and organizational skills with the ability to manage multiple demands and respond to rapidly changing priorities. Ability to write clearly and succinctly with a high level of attention to detail. Proficient computer and Microsoft Office skills. Ability to learn new software programs. Knowledge of Texas Medicaid, National Committee for Quality Assurance (NCQA), the Uniformed Managed Care Contract, and the Uniform Managed Care Manual. - Familiar with InterQual and Texas Medicaid Provider Procedures Manual and utilization guidelines. Solid understanding of managed care and medical terminology. Knowledge of and competence in use of UM software. Foster strong, positive, and effective working relationships with inter-system and intra-system team members, encouraging and supporting interaction among various team members across organizational lines. Responsibilities Care Coordination and Clinical Review Performs clinical utilization reviews of pre-authorization, concurrent and retrospective requests per clinical information submitted by providers using clinical criteria for medical necessity and appropriateness of care. Approves services or forwards requests to the appropriate medical director for further review, as appropriate. Performs utilization management functions competently and adheres to the guidelines for authorization turn-around times. Reviews clinical service requests from members or providers using evidence based clinical guidelines, analyzes clinical information and correctly applies clinical criteria. Requests additional information from members or providers in a timely manner and makes referrals to other clinical programs as needed. Identifies members that are high risk or who have conditions that may need service coordination or disease management and facilitates appropriate referrals. Works collaboratively with provider network and health services team to coordinate member care. Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services. Answers utilization management directed telephone calls, managing them in a professional and competent manner. Conducts ongoing availability, monitoring, and oversight of non-clinical staff activities. Uses effective relationship management, coordination of services, resource management, education, patient advocacy and related interventions to assure appropriate levels of care are received by members. Identifies and utilizes appropriate alternative and non-traditional available resources in managing cases. Documentation Provides accurate and complete documentation along with an explanation of the rationale that was used to approve requests. Documents and maintains clinical information in health management systems ensuring all pertinent information is entered in a timely manner and in accordance with department guidelines. Performs medical necessity documentation to expedite approvals and ensure that appropriate follow up is performed. Regulatory Ensures work is carried out in compliance with regulatory and/or accreditation standards as well as contractual requirements. Professional Accountability Promotes and supports a culturally welcoming and inclusive work environment. Acts with the highest integrity and ethical standards while adhering to Parkland's Mission, Vision, and Values. Adheres to organizational policies, procedures, and guidelines. Completes assigned training, self-appraisal, and annual health requirements timely. Adheres to hybrid work schedule requirements. Attends required meetings and town halls. Recognizes and communicates ethical and legal concerns through the established channels of communication. Demonstrates accountability and responsibility by independently completing work, including projects and assignments on time, and providing timely responses to requests for information. Maintains confidentiality at all times. Performs other work as requested that is reasonably related to the employee's position, qualifications, and competencies. Parkland Health and Hospital System prohibits discrimination based on age (40 or over), race, color, religion, sex (including pregnancy), sexual orientation, gender identity, gender expression, genetic information, disability, national origin, marital status, political belief, or veteran status. As part of our commitment to our patients and employees’ wellness, Parkland Health is a tobacco and smoke-free campus.
Department/Unit: Care Management/Social Work Work Shift: Day (United States of America) Salary Range: $71,612.39 - $110,999.20 Responsible for Utilization Management, Quality Screening and Delay Management for assigned patients. • Completes Utilization Management and Quality Screening for assigned patients. • Applies MCG criteria to monitor appropriateness of admissions and continued stays, and documents findings based on Departmental standards. • While performing utilization review identifies areas for clinical documentation improvement and contacts appropriate department. • Identifies at-risk populations using approved screening tool and follows established reporting procedures. • Monitors LOS and ancillary resource use on an ongoing basis. Takes actions to achieve continuous improvement in both areas. • Refers cases and issues to Medical Director and Triad Team in compliance with Department procedures and follows up as indicated. • Communicates covered day reimbursement certification for assigned patients. • Discusses payor criteria and issues and a case-by-case basis with clinical staff and follows up to resolve problems with payors as needed. • Uses quality screens to identify potential issues and forwards information to the Quality Department. • Demonstrates proper use of MCG and documentation requirements through case review and inter-rater reliability studies. • Facilitates removal of delays and documents delays when they exist. Reports internal and external delays to the Triad Team. • Collaborates with the health care team and appropriate department in the management of care across the continuum of care by assuring communication with Triad Team and health care team. Minimum Qualifications: • Registered nurse with a New York State current license. • Bachelor's degree preferred. • Minimum of three years clinical experience in an assigned service. • Recent experience in case management, utilization management and/or discharge planning/home care in a high volume, acute care hospital preferred. PRI and • Case Management certification preferred. • Assertive and creative in problem solving, critical thinking skills, systems planning and patient care management. • Self-directed with the ability to adapt in a changing environment. • Basic knowledge of computer systems with skills applicable to utilization review process. • Excellent written and verbal communication skills. • Working knowledge of MCG criteria and ability to implement and utilize. • Understanding of Inpatient versus Outpatient surgery and ICD10-Coding (preferred) and Observation status qualifications. • Ability to work independently and demonstrate organizational and time management skills. • Strong analytic, data management and PC skills. • Working knowledge of Medicare regulatory requirements, Managed Care Plans Thank you for your interest in Albany Medical Center! Albany Medical is an equal opportunity employer. This role may require access to information considered sensitive to Albany Medical Center, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that: Access to information is based on a “need to know” and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Med Center policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification.
Summary GENERAL SUMMARY: Conducts day-to-day activities for the clinical, financial and utilization coordination of the patient’s hospital experience. Proactively consults with the interdisciplinary team which includes, but is not limited to, hospital patient care staff, physicians, patient support and family to ensure the patient’s hospital stay meets medical necessity and insurance authorizations are obtained in order to facilitate the patient’s and hospitals financial well-being. PRINCIPAL JOB FUNCTIONS: 1. *Commits to the mission, vision, beliefs and consistently demonstrates our core values. 2. *Performs utilization review activities, including concurrent and retrospective reviews as required. 3. *Determines the medical necessity of request by performing first level reviews, using approved evidence based guidelines/criteria. 4. *Collaborates with the patient’s provider and other healthcare team members in managing the patient’s length of stay and determining the continuing medical necessity of continued stays. 5. *Refers cases to reviewing physician when the treatment request does not meet criteria per appropriate algorithm. 6. *Participates in concurrent and retrospective denials and appeals process by researching issues surrounding the denial, participating in all levels of the appeal and process follow-up. 7. *Serves as an internal and external resource regarding appropriate level of care; admission status/classification; Medicare/Medicaid rules, regulations, and policies; 3rd party and managed care contracts; discharge planning; and length of stay. 8. Ensures appropriate resource utilization relevant to the financial, regulatory and clinical aspects of care; proposes alternative treatment to ensure a cost effective and efficient plan of care. 9. *Maintains awareness of financial reimbursement methodology, utilization management, payer/reimbursement practices and regulations and participates in resource stewardship. 10. *Promotes quality improvement initiatives and health care outcomes based on currently accepted clinical practice guidelines and total quality improvement initiatives. 11. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise. 12. Participates in meetings, committees and department projects as assigned. 13. Performs other related projects and duties as assigned. (Essential Job functions are marked with an asterisk “*”. Refer to the Job Description Guide for the definition of essential and non-essential job functions.) Attach Addendum for positions with slightly different roles or work-specific differences as needed. REQUIRED KNOWLEDGE, SKILLS AND ABILITIES: 1. Maintains clinical competency as required for the unit including but not limited to age-specific competencies relative to patient’s growth and developmental needs, annual skill competency verification and mandatory education and competencies. 2. Knowledge of governmental and third party payer regulations and requirements related to patient hospitalization and acute rehabilitation admission, stay and discharge activities, i.e., CMS, CARF, FIM (TM). 3. Knowledge of computer hardware equipment and software applications relevant to work functions. 4. Skill in conflict diffusion and resolution. 5. Ability to communicate effectively both verbally and in writing. 6. Ability to perform crucial conversations with desired outcomes. 7. Ability to establish and maintain effective working relationships with all levels of personnel and medical staff. 8. Ability to problem solve and engage independent critical thinking skills. 9. Ability to maintain confidentiality relevant to sensitive information. 10. Ability to prioritize work demands and work with minimal supervision. 11. Ability to perform crucial conversations with desired outcomes. 12. Ability to maintain regular and punctual attendance. EDUCATION AND EXPERIENCE: Current Registered Nurse licensure from the State of Nebraska or approved compact state of residence as defined by the Nebraska Nurse Practice Act. Minimum of two (2) years recent clinical experience required. Prior care coordination and/or utilization management experience preferred. OTHER CREDENTIALS / CERTIFICATIONS: Basic Life Support (CPR) certification required. Bryan Health recognizes American Heart Association (for healthcare professionals), American Red Cross (for healthcare professionals) and the Military Training Network. PHYSICAL REQUIREMENTS: (Physical Requirements are based on federal criteria and assigned by Human Resources upon review of the Principal Job Functions.) (DOT) – Characterized as sedentary work requiring exertion up to 10 pounds of force occasionally and/or a negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects, including the human body.
Health and Hospital Corporation is an organization that celebrates diversity, and seeks to employ a diverse workforce. We actively encourage all individuals to apply for employment and to seek advancement opportunities. Health and Hospital Corporation also provides reasonable accommodations to qualified individuals with disabilities as required by law. For additional questions please contact us at: hrmail@hhcorp.org. Job Role Summary Assists the Long Term Care department in the review and analysis of care and services provided by HHC owned nursing homes and licensed residential facilities. Performs on site, overnight as needed, and office review of various clinical resident care services and management operations at HHC affiliated long term care facilities and participates in the preparation of related reports for the long term care department, individual facilities and the contract management company. Assists in the analysis of various aspects of nursing home operations using professional standards of practice and industry benchmarks. This position is responsible for promoting health and wellbeing of long term care residents of Health & Hospital Corporation Marion County nursing facilities by promoting preventive, therapeutic, and supportive care based on standards of practice and in compliance with all applicable regulatory requirements with an emphasis on resident behavior health needs including dementia, addiction and current DSM manual (DSM-5-TR). Essential Duties Responsibility 1: 70% • Performs quality review oversight, including overnight as directed, visits to HHC owned nursing homes and retirement communities as assigned. May serve as a member of a quality review team or at times may visit assigned facilities as the sole representative from the HHC Long Term Care Department. Maintains a professional and supportive role when interacting with the nursing home and licensed residential facility staff providing helpful observations and suggestions. • Performs various auditing/review activities during the site visits including but not limited to: meal service observations, resident care observations, resident and family interviews, staff interviews, clinical record reviews and review of facility management records. At times may assist the other members of the quality review team to complete their assigned tasks. • Performs various auditing/review activities during the site visits including but not limited to: observations of resident behavioral interaction/intervention, medication administration, wound care, personal care services, meal service, clinical record reviews and review of nursing management records. • Participates in the exit conferences held with facility management and the quality reviewers and provides summary information regarding significant observations during the facility visit including specific resident and employee identification when possible. • Prepares a written site visit report following each facility visit in cooperation with other quality review team members who participated in the facility visit. Reviews report for accuracy, and clarity. Distributes reports in a confidential manner to all parties and maintains HHC records. • Assures the retention and confidentiality of all data materials from facility visits and forwards to the department Executive Assistant for proper storage/retention. Responsibility 2: 30% • Participates in the compilation and completion of quarterly and other reports prepared for the HHC Board of Trustees’. • Accepts phone calls from residents, family members and interested parties in the absence of other Long Term Care Department staff or as assigned. Receives concerns or information in a manner that reflects good customer service practices and prepares detailed written information for the Vice President’s review and processing. • Attends community and professional association functions and meetings representing HHC Long Term Care division, as requested. • Follows departmental travel policy for travel arrangements/reservations for out of town facility site visits. Qualifications • Registered nurse with four or more years experience including two or more years of behavioral health background. Licenses/Certifications Required Registered Nurse (RN) Knowledge, Skills & Abilities • Good judgment and discretion in communication (written, verbal and non-verbal).Must be able to prioritize work, meet deadlines, and work well under pressure. • Flexibility to adjust to changing program/department needs and activities. • Excellent verbal and written skills. • Must be proficient with Microsoft Office, Word, Internet Explorer, and all usual and customary office equipment. • Must possess the ability to work independently, and as part of a team. Working Environment Unconfined sitting 75% Confined sitting 15% Standing or walking 10% (50% - on site visit days) Steady use of hands or fingers – Typing and filing 85% Lift, carry, etc. with arms and legs – 15% Ability to perform driving functions in normal course of workday with confined sitting for several hours at times All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.
Capital Health is the region's leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advanced technology. Capital Health is a five-time Magnet-Recognized health system for nursing excellence and is comprised of 2 hospitals. Capital Health Medical Group is made up of more than 250 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region. Capital Health recognizes that attracting the best talent is key to our strategy and success as an organization. As a result, we aim for flexibility in structuring competitive compensation offers to ensure we can attract the best candidates. Pay Range: $39.40 - $59.19 Scheduled Weekly Hours: 40 Position Overview Performs chart review of identified patients to identify quality, timeliness and appropriateness of patient care. Conducts admission reviews for Medicare, Medicaid beneficiaries, as well as private insurers and self pay patients, based on appropriate guidelines. Uses these criteria guidelines to screen for appropriateness for inpatient level of care or observation services based on physician certification (physicians H&P, treatment plan, potential risks and basis for expectation of a 2 midnight stay). Refers cases as appropriate, to the UR physician advisor for review and determination. Gathers clinical information to conduct continued stay utilization review activities with payers on a daily basis. Performs concurrent and retrospective clinical reviews with various payers, utilizing the appropriate guidelines as demonstrated by compliance with all applicable regulations, policies and timelines. Adheres to CMS guidelines for utilization reviews as evidenced by utilization of the relevant guidelines and appropriate referrals to the physician advisor and the UR Committee. Identifies, develops and implements strategies to reduce length of stay and resource consumption. . Confers proactively with admitting physician to provide coaching on accurate level of care determinations at point of hospital entry. Keeps current on all regulatory changes that affect delivery or reimbursement of acute care services. Uses knowledge of national and local coverage determinations to appropriately advise physicians. Understands and applies federal law regarding the use of Hospital Initiated Notice of Non-Coverage (HINN) and Lifetime Reserve Days letters. Identifies and records consistently any information on any progression of care or patient flow barriers using the Avoidable Days tool in the Utilization software program. Consults with medical staff, care team and case managers as necessary to resolve immediate progression of care barriers through appropriate administrative and medical channels. Engages care team colleagues in collaborative problem solving regarding appropriate utilization of resources. Recognizes and responds appropriately to patient safety and risk factors. Represents Utilization Management at various committees, professional organizations an physician groups as needed. Promotes the use of evidence based protocols and or order sets to influence high quality and cost effective care. Identifies, develops and implements strategies to reduce lengths of stay and resource consumption in the patient population. Participates in performance improvement activities. Promotes medical documentation that accurately reflects findings and interventions, presence of complication or comorbidities, and patient's need for continued stay. Identifies and records episodes of preventable delays or avoidable days due to failure of progression of care processes. Maintains appropriate documentation in the Utilization software system on each patient to include specific information of all resource utilization activities. Participates actively in daily huddles, patient care conferences, and hospitalist or nurse handoff reports to maintain knowledge about intensity of services and the progression of care. Identifies potentially wasteful or misused resources and recommends alternatives if appropriate by analyzing clinical protocols. Maintains related continuing education credits = 15 per calendar year. MINIMUM REQUIREMENTS Education: Minimum of Associate's degree in Nursing. Graduate of an accredited school of nursing. CPHQ, CCM or CPUR preferred. Experience: Three years of clinical nursing or two years quality management, utilization review or discharge planning experience. Other Credentials: Registered Nurse - NJ Knowledge and Skills: Three years of clinical nursing or two years quality management, utilization review or discharge planning experience. CPHQ, CCM or CPUR preferred. Special Training: Basic computer skills including the working knowledge of Microsoft Office, UR software and EMR. Possesses familiarity with MCG guidelines. Mental, Behavioral and Emotional Abilities: Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form. Usual Work Day: 8 Hours PHYSICAL DEMANDS AND WORK ENVIRONMENT Frequent physical demands include: Sitting , Standing , Walking Occasional physical demands include: Climbing (e.g., stairs or ladders) , Carry objects , Push/Pull , Twisting , Bending , Reaching forward , Reaching overhead , Keyboard use/repetitive motion , Talk or Hear Continuous physical demands include: Lifting Floor to Waist 10 lbs. Lifting Waist Level and Above 5 lbs. Sensory Requirements include: Accurate Near Vision, Accurate Far Vision, Accurate Color Discrimination, Accurate Depth Perception, Accurate Hearing Anticipated Occupational Exposure Risks Include the following: N/A This position is eligible for the following benefits: Medical Plan Prescription drug coverage & In-House Employee Pharmacy Dental Plan Vision Plan Flexible Spending Account (FSA) - Healthcare FSA - Dependent Care FSA Retirement Savings and Investment Plan Basic Group Term Life and Accidental Death & Dismemberment (AD&D) Insurance Supplemental Group Term Life & Accidental Death & Dismemberment Insurance Disability Benefits – Long Term Disability (LTD) Disability Benefits – Short Term Disability (STD) Employee Assistance Program Commuter Transit Commuter Parking Supplemental Life Insurance - Voluntary Life Spouse - Voluntary Life Employee - Voluntary Life Child Voluntary Legal Services Voluntary Accident, Critical Illness and Hospital Indemnity Insurance Voluntary Identity Theft Insurance Voluntary Pet Insurance Paid Time-Off Program The pay range listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future. When determining base salary and/or rate, several factors may be considered including, but not limited to location, years of relevant experience, education, credentials, negotiated contracts, budget, market data, and internal equity. Bonus and/or incentive eligibility are determined by role and level. The salary applies specifically to the position being advertised and does not include potential bonuses, incentive compensation, differential pay or other forms of compensation, compensation allowance, or benefits health or welfare. Actual total compensation may vary based on factors such as experience, skills, qualifications, and other relevant criteria.
It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you’ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development. Summary We are seeking a skilled Utilization Review Nurse to conduct prior authorization, prospective, concurrent, and retrospective reviews for medical necessity and appropriateness of services, following clinical criteria, coverage policies, and contract guidelines. This involves reviewing medical documentation, accurately documenting findings, and ensuring policy compliance. Your role in our mission Review admissions, procedures, services, and supplies for medical necessity and appropriateness, meeting quality and production goals. Use clinical criteria for decision-making, referring complex cases to Medical Directors when needed. Engage with providers to gather clinical information, apply guidelines, and make determinations. Document findings and rationale in medical management systems. Assist in training new nurses, provide feedback, and stay updated on clinical guidelines. Maintain RN license and meet continuing education requirements. What we're looking for Active RN license. 3+ years of inpatient clinical experience. 1+ year in prior authorization reviews using InterQual or MCG. Strong written communication skills in a fast-paced setting. Proficient in Microsoft Office and other computer applications. What you should expect in this role Home-based position. High-speed internet and a distraction-free workspace required. Core hours: 8:00 AM - 6:00 PM ET, with potential for extended hours. Occasional travel (up to 10%) based on business needs. This position is for pipeline purposes, and we welcome applications on an ongoing basis. #LI-AC1 #LI-REMOTE The pay range for this position is $65,000.00 - $78,000.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits , and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities. We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings. Gainwell Technologies is an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics.
Hello, Thank you for your interest in career opportunities with the University of Mississippi Medical Center. Please review the following instructions prior to submitting your job application: Provide all of your employment history, education, and licenses/certifications/registrations. You will be unable to modify your application after you have submitted it. You must meet all of the job requirements at the time of submitting the application. You can only apply one time to a job requisition. Once you start the application process you cannot save your work. Please ensure you have all required attachment(s) available to complete your application before you begin the process. Applications must be submitted prior to the close of the recruitment. Once recruitment has closed, applications will no longer be accepted. After you apply, we will review your qualifications and contact you if your application is among the most highly qualified. Due to the large volume of applications, we are unable to individually respond to all applicants. You may check the status of your application via your Candidate Profile. Thank you, Human Resources Important Applications Instructions: Please complete this application in entirety by providing all of your work experience, education and certifications/ license. You will be unable to edit/add/change your application once it is submitted. Job Requisition ID: R00046700 Job Category: Nursing Organization: Utilization Review Location/s: Main Campus Jackson Job Title: RN - Utilization Reviewer - Coordinated Care Job Summary: Accountable to perform utilization management services for designated patient case load, including prospective, concurrent, retrospective, and denial management reviews by applying clinical protocols and review medical necessity criteria. Reports quality of care issues identified during the um process to the appropriate manager. To perform job duties in accordance with the medical center's purpose. Education & Experience Four (4) years RN experience, one (1) year of which must have been in performance improvement, utilization review, or case management. CERTIFICATIONS, LICENSES OR REGISTRATION REQUIRED: Valid RN license. CPUM (certified professional in utilization management), ACM (accredited case manager), or CCM (certified case manager) preferred. Knowledge, Skills & Abilities Knowledge of the aspects of utilization review. Excellent interpersonal verbal and written communication and negotiation skills. Skills in the use of personal computers and related software applications. Ability to gather data, compile information, and prepare reports. Ability to identify process improvements. Good working knowledge of and understanding of medical procedures and diagnoses, procedure codes, including ICD-10, CPT, and DSM-IV codes. Current working knowledge of discharge planning, utilization management, case management, performance improvement and managed care reimbursement. Ability to work independently and exercise sound judgement in interactions with physicians, payers, and patients and their families. Demonstrate commitment to the organIzation’s mission and the behavioral expectations in all interactions and in performing all job duties. Performs duties in a manner to promote quality patient care and customer service/satisfaction, while promoting safety, cost efficiency, and commitment to continuous quality improvement (CQI) process. Independent, focused and follow written instructions. Ability to use medical necessity guidelines with minimal supervision. Equipped to work remotely to include hardware with high speed internet via cable and Windows 10 RESPONSIBILITIES: Performs all aspects of prospective, concurrent, retrospective and denials review for individual cases to include benefit coverage issues, medical necessity appropriate level of care (setting) and mandated services. Assists in the collection and reporting of financial indicators including case mix, los, cost per case, excess days, resource utilization, readmission rates, denials and appeals. Uses data to drive decisions and plan/implement performance improvement strategies related to case management for assigned patients, including fiscal, clinical and patient satisfaction. Collects, analyzes and addresses variances from the plan of care path with physician and/or other members of the healthcare team. Uses concurrent variance data to drive practice changes and positively impact outcomes. Collects delay and other data for specific performance and/or outcome indicators as determined by administrator - resource management. Documents key clinical path variances and outcomes which relate to areas of direct responsibility (e.g., discharge planning, care transitions and care coordination). Uses pathway data in collaboration with other disciplines to ensure effective patient management concurrently. Applies approved clinical appropriateness criteria to monitor appropriateness of admissions, and continued stays, and documents findings based on department standards. Identifies at-risk populations using approved screening tool and follows established reporting procedures. Refers cases and issues to care management physician advisor in compliance with department procedures and follows up as indicated. Communicates with third party payers to facilitate covered day reimbursement certification for assigned patients. Discusses payor criteria and issues on a case-by-case basis with clinical staff and follows up to resolve problems with payers as needed. Uses quality screens to identify potential issues and forwards information to clinical quality review department. Completes utilization management and quality screening for assigned patients. Works collaboratively and maintains active communication with physicians, nursing, and other members of the inter-disciplinary care team to effect timely, appropriate patient management and eliminate barriers to efficient delivery of care in the appropriate setting. Addresses/resolves system problems impeding diagnostic or treatment progress. Proactively identifies and resolves delays and obstacles to discharge. Utilizes conflict resolution skills as necessary to ensure timely resolution of issues. Collaborates with physicians and all members of the multidisciplinary team to facilitate care for designated case load; monitors the patient’s progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective; facilitates the following on a timely basis: completion and reporting diagnostic testing; completion of treatment plan and discharge plan; modification of plan of care, as necessary, to meet the ongoing needs of the patient; communication to third party payers and other relevant information to the care team; assignment of appropriate levels of care; completion of all required documentation in epic screens and patient records. Ensures safe care to patients adhering to policies, procedures, and standards, within budgetary specifications, including time management, supply management, productivity, and accuracy of practice. Promotes individual professional growth and development by meeting requirements for mandatory/ continuing education, skills competency, supports department- based goals which contribute to the success of the organization; serves as preceptor, mentor, and resource to less experienced staff. Actively participates in clinical performance improvement activities The duties listed are general in nature and are examples of the duties and responsibilities performed and are not meant to be construed as exclusive or all-inclusive. Management retains the right to add or change duties at any time. Environmental and Physical Demands: Requires occasional exposure to unpleasant or disagreeable physical environment such as high noise level and exposure to heat and cold, no handling or working with potentially dangerous equipment, occasional working hours beyond regularly scheduled hours, occasional travelling to offsite locations, occasional activities subject to significant volume changes of a seasonal/clinical nature, occasional work produced is subject to precise measures of quantity and quality, occasional bending, occasional lifting/carrying up to 10 pounds, occasional lifting/carrying up to 25 pounds, no lifting/carrying up to 50 pounds, no lifting/carrying up to 75 pounds, no lifting/carrying up to100 pounds, no lifting/carrying 100 pounds or more, no climbing, no crawling, occasional crouching/stooping, no driving, occasional kneeling,occasional pushing/pulling, occasional reaching, frequent sitting,occasional standing,occasional twisting, and frequent walking. (Occasional-up to 20%, frequent-from 21% to 50%, constant-51% or more) Time Type: Part time FLSA Designation/Job Exempt: No Pay Class: Hourly FTE %: 100 Work Shift: Benefits Eligibility: Grant Funded: Job Posting Date: 11/5/2025 Job Closing Date (open until filled if no date specified):
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 (UM) Admissions Liaison RN II is primarily responsible for receiving/reviewing admission requests and higher level of care (HLOC) transfer requests from inpatient facilities within regular timelines. Reviews clinical data in real-time and post admission to issue a determination based on clinical criteria for medical necessity. Assures timely, accurate determination and notification of admission and inter-facility transfer requests. Generates approval, modification, and denial communications for inpatient admission requests. Actively monitors for appropriate level of care (inpatient vs. observation) admission in the acute setting. Works with UM leadership, including the Utilization Management Medical Director, on requests where determination requires extended review. Collaborates with the inpatient care team for facilitation/coordination of patient transfers between acute care facilities. Acts as a department resource for medical service requests/referral management and processes. Actively participates in the discharge planning process, including providing clinical review and authorization for alternate levels of care, home health, durable medical equipment, and other discharge needs. Provides support to the inpatient review team as necessary to ensure timely processing of concurrent reviews. Duties Provides the primary clinical point of contact for inpatient acute care hospitals requesting Inpatient care/post-stabilization admission requests, Higher level of care transfers and other emergent transfers or needs. Ensures appropriate determination for admission requests/HLOC transfers based on clinical data presented and established criteria/guidelines, escalating to the medical director if needed. Triages and assesses members for admission needs, including, but not limited to, bed and accepting physician availability. (40%) Establishes and maintains ongoing communication with internal stakeholders and external customers while securing the L.A. Care member's admission or inter-facility transfer. Interfaces with physicians, house supervisors, and other hospital delegates to ensure that telephone triage results in appropriate patient placement. (10%) Applies clinical expertise and the nursing process to triage and prioritize admission acuity, servicing as an expert clinical resource for patient placement while utilizing medical knowledge and experience to facilitate consensus-building and development of satisfactory outcomes (10%) Continually seeks new ways to improve processes and increase efficiencies. Takes the initiative to communicate recommendations to UM Leadership. (5%) Completes all inpatient and discharge planning requests appropriately and timely including, but not limited to: Skilled nursing facility, outpatient needs (home health, physical therapy, infusion), and case management referrals (5%) Performs prospective, concurrent, post-service, and retrospective claim medical review processes. Utilizes clinical judgement, independent analysis, critical-thinking skills, detailed knowledge of medical policies, clinical guidelines and benefit plans to complete reviews and determinations within required turnaround times specific to the case type. Identifies requests needing medical director review or input and presents for second level review (20%) Performs other duties as assigned. (10%) Duties Continued Education Required Associate's Degree in Nursing Education Preferred Bachelor's Degree in Nursing Experience Required: Minimum of 7 years of clinical experience in an acute hospital setting. Previous experience to have a strong understanding of Utilization Management/Case Management practices including, but not limited to, placement (with level of care) criteria (MCG, InterQual), concurrent review, and discharge planning. Preferred: Consistent Critical Care experience (Emergency Department, Intensive Care, Labor & Delivery) background highly desirable. Experience in bed placement decision-making highly desirable. Skills Required: Must be computer literate, with expertise in Outlook, Word, Excel, PowerPoint. Provision of excellent customer service required due to frequent communication with providers and other members of the interdisciplinary team 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. 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 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) American Case Management Association (ACM) Required Training Physical Requirements Light Additional Information Required: Attend mandatory department trainings as scheduled Financial Impact: Management of all medical services has a tremendous potential impact on the cost of health care and budget. This position manages determinations to ensure services requested are medically appropriate and provided in the most cost effective manner without compromising quality healthcare delivery. Types of Shift: Day (7:00am - 3:30pm), Evening (3:00pm -11:30 pm), Night (11:00pm -7:30am). Float (Varies)* *All possible shifts. 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)
It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you’ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development. Summary We are seeking a talented individual for a Nurse Reviewer (RN) to support our Massachusetts contract. Due to recent turnover, there is an immediate need for nurses who hold an active Massachusetts RN license. This role involves performing clinical reviews to determine if the medical record documentation supports the need for the service based on clinical criteria, coverage policies, and utilization and practice guidelines as defined by review methodologies specific to the contract. Responsibilities include accessing proprietary systems to audit medical records, documenting findings accurately, and providing policy and regulatory support for determinations. This position is intended for pipelining, and applications will be accepted on an ongoing basis. Summary Your role in our mission Your role in our mission Reviews and interprets medical records against criteria to assess appropriateness and reasonableness of care; applies critical thinking to ensure documentation supports medical necessity while meeting production and quality goals. Documents decisions and rationale clearly to support findings or no findings. Determines approvals or refers cases to physician consultants; processes consultant decisions and ensures denial reasons are detailed and completed within deadlines. Performs prior authorization, precertification, and retrospective reviews; prepares decision letters as required. Assists management in training new Nurse Reviewers, including daily monitoring, mentoring, feedback, and education. Maintains current knowledge of clinical criteria guidelines and completes CEUs to maintain RN licensure. Attends trainings and meetings to stay current on clinical policies, procedures, rules, and regulations. Cross-trains to review multiple claim types to maintain workforce flexibility. Recommends and helps implement process improvements, new audit concepts, and technology solutions to enhance production, quality, and client satisfaction. Reviews and interprets medical records against criteria to assess appropriateness and reasonableness of care; applies critical thinking to ensure documentation supports medical necessity while meeting production and quality goals. Reviews and interprets medical records against criteria to assess appropriateness and reasonableness of care; applies critical thinking to ensure documentation supports medical necessity while meeting production and quality goals. Documents decisions and rationale clearly to support findings or no findings. Documents decisions and rationale clearly to support findings or no findings. Determines approvals or refers cases to physician consultants; processes consultant decisions and ensures denial reasons are detailed and completed within deadlines. Determines approvals or refers cases to physician consultants; processes consultant decisions and ensures denial reasons are detailed and completed within deadlines. Performs prior authorization, precertification, and retrospective reviews; prepares decision letters as required. Performs prior authorization, precertification, and retrospective reviews; prepares decision letters as required. Assists management in training new Nurse Reviewers, including daily monitoring, mentoring, feedback, and education. Assists management in training new Nurse Reviewers, including daily monitoring, mentoring, feedback, and education. Maintains current knowledge of clinical criteria guidelines and completes CEUs to maintain RN licensure. Maintains current knowledge of clinical criteria guidelines and completes CEUs to maintain RN licensure. Attends trainings and meetings to stay current on clinical policies, procedures, rules, and regulations. Attends trainings and meetings to stay current on clinical policies, procedures, rules, and regulations. Cross-trains to review multiple claim types to maintain workforce flexibility. Cross-trains to review multiple claim types to maintain workforce flexibility. Recommends and helps implement process improvements, new audit concepts, and technology solutions to enhance production, quality, and client satisfaction. Recommends and helps implement process improvements, new audit concepts, and technology solutions to enhance production, quality, and client satisfaction. What we're looking for What we're looking for Proficient in computer and typing skills, including Microsoft Windows, Outlook, Excel, Word, PowerPoint, and internet browsers. Active, unrestricted RN licensure in Massachusetts required; compact multistate RN license strongly preferred. Verification will occur during post-offer background check. Minimum of 5+ years clinical experience in an inpatient hospital setting required. Minimum of 2+ years utilization review or claims auditing experience required. Experience with Milliman or InterQual criteria required. Ability to work standard business hours with frequent interactions across teams and departments. Flexibility to work extended hours when needed to support business demands. Proficient in computer and typing skills, including Microsoft Windows, Outlook, Excel, Word, PowerPoint, and internet browsers. Proficient in computer and typing skills, including Microsoft Windows, Outlook, Excel, Word, PowerPoint, and internet browsers. Active, unrestricted RN licensure in Massachusetts required; compact multistate RN license strongly preferred. Verification will occur during post-offer background check. Active, unrestricted RN licensure in Massachusetts required; compact multistate RN license strongly preferred. Verification will occur during post-offer background check. Minimum of 5+ years clinical experience in an inpatient hospital setting required. Minimum of 5+ years clinical experience in an inpatient hospital setting required. Minimum of 2+ years utilization review or claims auditing experience required. Minimum of 2+ years utilization review or claims auditing experience required. Experience with Milliman or InterQual criteria required. Experience with Milliman or InterQual criteria required. Ability to work standard business hours with frequent interactions across teams and departments. Ability to work standard business hours with frequent interactions across teams and departments. Flexibility to work extended hours when needed to support business demands. Flexibility to work extended hours when needed to support business demands. What you should expect in this role What you should expect in this role This is a fully remote position. Candidates may reside anywhere within the United States but must hold and maintain an active Massachusetts RN license. Full-time, permanent salaried (W-2) employee position, not a contract or short-term role. Health benefits (medical, dental, vision) and paid time off begin on the first day of employment. Standard Monday through Friday work schedule. Remote position; employees must be located within the continental U.S. while working. Work environment must be private, free of distractions, loud noises, and recording devices. May require up to 10% travel depending on business needs. This is a fully remote position. Candidates may reside anywhere within the United States but must hold and maintain an active Massachusetts RN license. Full-time, permanent salaried (W-2) employee position, not a contract or short-term role. Full-time, permanent salaried (W-2) employee position, not a contract or short-term role. Health benefits (medical, dental, vision) and paid time off begin on the first day of employment. Health benefits (medical, dental, vision) and paid time off begin on the first day of employment. Standard Monday through Friday work schedule. Standard Monday through Friday work schedule. Remote position; employees must be located within the continental U.S. while working. Remote position; employees must be located within the continental U.S. while working. Work environment must be private, free of distractions, loud noises, and recording devices. Work environment must be private, free of distractions, loud noises, and recording devices. May require up to 10% travel depending on business needs. May require up to 10% travel depending on business needs. #LI-AC1 #LI-REMOTE The pay range for this position is $78,000.00 - $85,000.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits , and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities. We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings. Gainwell Technologies is an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. Gainwell Technologies is an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics.
It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you’ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development. Summary We are seeking a skilled Utilization Review Nurse to conduct prior authorization, prospective, concurrent, and retrospective reviews for medical necessity and appropriateness of services, following clinical criteria, coverage policies, and contract guidelines. This involves reviewing medical documentation, accurately documenting findings, and ensuring policy compliance. Your role in our mission Review admissions, procedures, services, and supplies for medical necessity and appropriateness, meeting quality and production goals. Use clinical criteria for decision-making, referring complex cases to Medical Directors when needed. Engage with providers to gather clinical information, apply guidelines, and make determinations. Document findings and rationale in medical management systems. Assist in training new nurses, provide feedback, and stay updated on clinical guidelines. Maintain RN license and meet continuing education requirements. What we're looking for Active RN license. 3+ years of inpatient clinical experience. 1+ year in prior authorization reviews using InterQual or MCG. Strong written communication skills in a fast-paced setting. Proficient in Microsoft Office and other computer applications. What you should expect in this role Home-based position. High-speed internet and a distraction-free workspace required. Core hours: 8:00 AM - 6:00 PM ET, with potential for extended hours. Occasional travel (up to 10%) based on business needs. #LI-AC1 #LI-REMOTE The pay range for this position is $65,000.00 - $78,000.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits , and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities. We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings. Gainwell Technologies is an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics.
It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you’ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development. Summary We are seeking a talented individual for a Nurse Reviewer (RN) who will be responsible for performing clinical reviews to determine if the medical record documentation supports the need for the service based on clinical criteria, coverage policies, and utilization and practice guidelines as defined by review methodologies specific to the contract for which services are being provided. This involves accessing proprietary systems to audit medical records, accurately documenting findings, and providing policy/regulatory support for determinations. This position is intended for pipelining. We will accept applications on an ongoing basis. Your role in our mission Review and interpret medical records and compare them against criteria to determine appropriateness and reasonableness of care. Apply critical thinking and decision-making skills to assess if the documentation supports the need for the service, while maintaining production goals and quality standards. Document decisions and rationale to justify review findings or no findings. Determine approval or initiate a referral to the physician consultant, and process physician consultant decisions—ensuring the denial rationale is clearly detailed and completed within the contractual deadline. Perform prior authorization, precertification, and retrospective reviews; prepare decision letters as needed in support of the utilization review contract. Assist management with training new Nurse Reviewers, including daily monitoring, mentoring, feedback, and education. Maintain up-to-date knowledge of clinical criteria guidelines and complete required CEUs to maintain RN licensure. Attend training and scheduled meetings to strengthen working knowledge of clinical policies, procedures, rules, and regulations. Cross-train to perform reviews of multiple claim types to ensure workforce flexibility and meet client needs. Recommend, test, and help implement process improvements, audit concepts, and technology enhancements that increase productivity, quality, and client satisfaction. What we're looking for Proficiency in computer and typing skills (e.g., Microsoft Windows, Outlook, Excel, Word, PowerPoint, and internet browsers). Active, unrestricted RN license from the United States and in the state of primary home residency. An active compact multistate unrestricted RN license (as defined by the Nurse Licensure Compact – NLC) is required and will be verified during the post-offer background check. Minimum of 5 years clinical experience in an inpatient hospital setting. At least 2 years of utilization review or claims auditing experience. Experience using Milliman or InterQual criteria is required. Ability to work standard business hours, as this role involves regular interactions with internal teams and other departments. May occasionally require extended hours to meet business needs. What you should expect in this role This is a full-time job. Health benefits (medical, dental, vision) and paid time off begin on Day 1 of employment. Company-provided computer. Remote/work-from-home role; employees must be located within the continental U.S. Home workspace must be quiet, secure, free from distractions and recording devices. May require up to 10% travel, depending on business needs. #LI-AC1 #LI-REMOTE The pay range for this position is $65,000 - $75,000 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits , and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities. We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings. Gainwell Technologies is an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics.
Navajo Preference Employment Act In accordance with Navajo Nation and federal law, TCRHCC has implemented an Affirmative Action Plan pursuant to the Navajo Preference in Employment Act. Pursuant to this Plan and corresponding TCRHCC Policy, applicants who meet the necessary qualifications for this position and (1) are enrolled members of the Navajo Nation, Hopi Tribe, or San Juan Southern Paiute Tribe will be given preference in hiring and employment for this position, (2) are legally married to enrolled members of the Navajo Nation, Hopi Tribe, or San Juan Southern Paiute Tribe and meet residency requirements will be given secondary preference, and (3) are enrolled members of other federally-recognized American Indian Tribes will be given tertiary preference. Overview POSITION SUMMARY This position facilitates the analysis of medical staff quality and performance data for the organization through coordination of information including data collection, analysis and trending of required medical staff quality and peer review activities, and other select clinical outcome measurements. This position serves as assisting the medical staff with practitioner specific quality monitoring and reporting. This position manages issues that are brought up regarding the quality of practice by providers, evaluates and investigates quality issues. Responsible for managing Ongoing Professional Practice Evaluations/Focused Professional Practice Evaluations. Supporting the Peer Review Committee and other Quality related projects. This Registered Nurses will be evaluating the quality and appropriateness of care provided by their peers, aiming to improve patient safety and practice standards through a non-punitive, continuous learning process. The role of the Case Review RN is to establish, promote and monitor seamless care for TCRHCC patients. Qualifications NECESSARY QUALIFICATIONS Education: Bachelor’s degree in nursing and Master’s Degree in Business Administration or other Master’s degree in healthcare. License: A valid, current, full and unrestricted Professional Nursing License to practice nursing in any state of the United States of America, The Commonwealth of Puerto Rico, or a territory of the United States Experience: Five (5) years of supervisory experience in discharge planning, case management, or utilization review in an acute-care health care setting or related healthcare clinical leadership Other Skills and Abilities: A record of satisfactory performance in all prior and current employment as evidenced by positive employment references from previous and current employers. All employment references must address and indicate success in each one of the following areas: Accessing community resources for patient referrals Elimination of potential conflicts of interest including professional, organizational, and/or personal bias inherent to review programs performed or supported with internal review. Providing a systematic and scalable approach ensuring review criteria and results are accurate, reliable which reduces risk by identifying trends and potential issues of clinical staff performance, deficiencies, and errors. Knowledge of diagnosis related groups (DRG) and documentation requirements Positive working relationships with others Possession of high ethical standards and no history of complaints Reliable and dependable; reports to work as scheduled without excessive absences Ability to sense varying skill levels and direct instruction accordingly Detail oriented, well organized, and applies critical thinking, reasoning, deduction, and inference skills Knowledge of report writing, graphical analysis, and working with computer spreadsheets and database programs Completion of and above-satisfactory scores on all job interviews, demonstrating to the satisfaction of the interviewees and TCRHCC that the applicant can perform the essential functions of the job Successful completion of and positive results from all background and reference checks, including positive employment references from authorized representatives of past and current employers demonstrating to the satisfaction of TCRHCC a record of satisfactory performance and that the applicant can perform the essential functions of the job Successful completion of fingerprint clearance requirements, physical examinations, and other screenings indicating that the applicant is qualified to be employed by TCRHCC and demonstrating to the satisfaction of TCRHCC that the applicant can perform the essential functions of the job Submission of all required employment-related documents, applications, resumes, references, and other required information free of false, misleading or incomplete information, as determined by TCRHCC MENTAL AND PHYSICAL EFFORT The physical and mental demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform essential functions. Physical: The work involves prolonged periods of sitting in an office setting operating a personal computer, walking throughout the hospital to obtain and review medical records, and standing while inquiring with providers and clinical staff. The Incumbent may occasionally need to drive, bend, climb, kneel, crouch, twist, maintain balance, and reach. There may be times of distant travel for ongoing and advanced training. Occasional travel to the satellite health centers for on-site reviews. The Incumbent will frequently need to be able to lift, pull, and push up to 10 pounds. This position requires the sensory ability for frequent use of far vision, near vision, color vision, depth perception, seeing fine details, hearing normal speech, telephone use, and hearing overhead pages over a loudspeaker. The incumbent must be able to utilize hand manipulation to do simple grasping and use of keyboard for prolonged time during work day. The position requires frequent firm grasping and fine manipulation. Mental: The work requires the ability to deal relatively independently with the interrelated elements that affect data analyzing and reporting, to resolve complications and controversial matters. This position requires the mental & emotional requirement ability to cope with high levels of stress; make decisions under high pressure; copy with anger/fear/hostility of others in a calm way; manage altercations; concentrate; handle a high degree of flexibility; handle multiple priorities in a stressful situation; work alone; demonstrate a high degree of patience; and work in areas that are close and crowded. May occasionally be required to adapt to shift work. Environmental: The incumbent may be exposed to the following environmental situations: Infectious Diseases, chemical agents, dust, fumes, gases, extremes in temperature or humidity, hazardous or moving equipment, unprotected heights, and loud noises. Responsibilities ESSENTIAL FUNCTIONS: Reviews patient records and clinical documentation to assess the appropriateness and necessity of healthcare services, ensuring quality and cost-effectiveness of care Resolves informal/formal complaints and grievances within jurisdiction and refers appropriately to a higher level of management if needed. As appropriate, refers instances of inappropriate patient care, discharge delays, and so on to the Risk Manager and /or Clinical Division. Review patient records, thoroughly examine patient charts, clinical documentation, and billing information to assess the appropriateness and necessity of services provided. Perform chart reviews to identify quality, timeliness, and appropriateness of patient care. Refer cases as appropriate to physician advisors for review and determination. Requires experience in performance improvement methodologies; quality measurement; and data analysis using statistical principles. Prior experience in hospital or clinical management preferred. Requires computer knowledge. Windows application: Skilled in the use of select Microsoft Office Applications, e.g. Word; Excel and PowerPoint or other database management applications. Requires strong written and verbal communication skills and the ability to work effectively with all levels of the organization and with members of the medical staff. Requires strong public speaking skills and the ability to deliver effective presentations and education to large groups of physicians and staff. Requires ability to prioritize multiple projects and the flexibility to accommodate changing priorities. Effectively communicates and coordinates processes to assure the continuity of patient care to outside providers and promote patient advocacy among Navajo Area Indian Health Services/Service Units, and Federal and State entities. Develops and implements policies and procedures regarding case management eligibility, alternate resource programs, referral/notification process, interdepartmental relationship and responsibilities; promote patient access to the appropriate level of care, prevent over or under utilization of resources, maximize the use of alternate resources, and supports continuity of care. Assists with review, research, and decision of first level appeal process with Purchase Referred Care Provides clinical expertise, skills, and behaviors appropriate to the population(s), served, and based on specific criteria and/or age-specific considerations. Supports, educates, and oversees the overall quality and completeness of clinical documentation by performing admission/continued stay reviews using clinical documentation enhancement guidelines for selected patient populations. Collaborates with the Physician Advisor or designee in leading and facilitating the Utilization Review Committee, develops and interprets reports (i.e. statistical, financial, trends), provides data for the PI Committee and submits reports, as required, on outcomes, clinical quality documentation and insurance medical necessity criteria. Complete task training for all routine cleaning and decontamination processes for all surfaces contaminated by a communicable disease to ensure a high level of patient, visitor, employee, and external customer Performs other assigned duties as needed
It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you’ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development. The pay range for this position is [[salaryMin]] - [[salaryMid]] per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits , and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities. We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings. Gainwell Technologies is committed to a diverse, equitable, and inclusive workplace. We are proud to be an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), 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. We celebrate diversity and are dedicated to creating an inclusive environment for all employees.
