Utilization Review Nurse Jobs

RN Utilization Review Full-time
Baptist Health South Florida

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

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

Cardiac Cath Lab Nurse Reviewer - Quality | M-F

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

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

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

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

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

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

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

Registered Nurse Utilization Review

Ascension Austin, TX
$78,561.60 - $110,905.60 / year
Your future role at a glance Location: Remote Facility: Dell Children's Medical Center - Austin Department: Utilization Management Schedule: Days l Full-time Salary range: $78,561.60 - $110,905.60 per year #UM2026 Life at Ascension: Where purpose meets opportunity Ascension is a leading nonprofit Catholic health system with a culture and associate experience grounded in service, growth, care and connection. We empower our 99,000+ associates to bring their skills and expertise every day to reimagining healthcare, together. Recognized as one of the Best 150+ Places to Work in Healthcare and a Military-Friendly Gold Employer, you’ll find an inclusive and supportive environment where your contributions truly matter. Benefits that help you thrive Comprehensive health coverage: medical, dental, vision, prescription coverage and HSA/FSA options Financial security & retirement: employer-matched 403(b), planning and hardship resources, disability and life insurance Time to recharge: pro-rated paid time off (PTO) and holidays Career growth: Ascension-paid tuition (Vocare), reimbursement, ongoing professional development and online learning Emotional well-being: Employee Assistance Program , counseling and peer support, spiritual care and stress management resources Family support: parental leave, adoption assistance and family benefits Other benefits: optional legal and pet insurance, transportation savings and more Benefit options and eligibility vary by position, scheduled hours and location. Benefits are subject to change at any time. Your recruiter will provide the most up-to-date details during the hiring process. How you’ll make an impact in this role Evaluate medical necessity for admissions and service requests to ensure patients receive the most appropriate care at the right time. Lead the discharge planning process by collaborating with the healthcare team to create seamless transitions and safe returns home for patients. Navigate complex case management scenarios, providing expert consultation to resolve barriers to care and optimize patient outcomes. Ensure full compliance with federal and third-party regulations, protecting the integrity of our clinical services and reimbursement processes. Resolve documentation and reimbursement challenges to support the department in reducing claim denials and improving operational efficiency. What minimum requirements you’ll need Licensure / Certification / Registration: Licensed Registered Nurse credentialed from the Texas Board of Nursing or current home state license for multi-state license recognition "Compact State" obtained prior to hire date or job transfer date required. Education: Diploma from an accredited school/college of nursing OR Required professional licensure at time of hire. What additional preferences we're seeking Pediatric Utilization Management experienced required. Clinical Licensure: Active and unrestricted Registered Nurse (RN) license or equivalent clinical credential required for medical necessity determination. Compact or TX state license required. Utilization Management Expertise: Proven experience applying medical necessity criteria (such as InterQual or Milliman) within a clinical or payer environment. Equal employment opportunity employer Ascension provides Equal Employment Opportunities (EEO) to all associates and applicants for employment without regard to race, color, religion, sex/gender, sexual orientation, gender identity or expression, pregnancy, childbirth, and related medical conditions, lactation, breastfeeding, national origin, citizenship, age, disability, genetic information, veteran status, marital status, all as defined by applicable law, and any other legally protected status or characteristic in accordance with applicable federal, state and local laws. For further information, view the EEO Know Your Rights (English) poster or EEO Know Your Rights (Spanish) poster. Fraud prevention notice Prospective applicants should be vigilant against fraudulent job offers and interview requests. Scammers may use sophisticated tactics to impersonate Ascension employees. To ensure your safety, please remember: Ascension will never ask for payment or to provide banking or financial information as part of the job application or hiring process. Our legitimate email communications will always come from an @ascension.org email address; do not trust other domains, and an official offer will only be extended to candidates who have completed a job application through our authorized applicant tracking system. E-Verify statement Employer does not participate in E-Verify and therefore cannot employ STEM OPT candidates.
RN Utilization Review Full-time
Ascension

Registered Nurse Utilization Review

Ascension Round Rock, TX
$78,561.60 - $110,905.60 / year
Your future role at a glance Location: Remote Facility: Ascension Seton Williamson - Round Rock, TX Department: Utilization Management Schedule: Days l Full-time Salary range: $78,561.60 - $110,905.60 per year #UM2026 Life at Ascension: Where purpose meets opportunity Ascension is a leading nonprofit Catholic health system with a culture and associate experience grounded in service, growth, care and connection. We empower our 99,000+ associates to bring their skills and expertise every day to reimagining healthcare, together. Recognized as one of the Best 150+ Places to Work in Healthcare and a Military-Friendly Gold Employer, you’ll find an inclusive and supportive environment where your contributions truly matter. Benefits that help you thrive Comprehensive health coverage: medical, dental, vision, prescription coverage and HSA/FSA options Financial security & retirement: employer-matched 403(b), planning and hardship resources, disability and life insurance Time to recharge: pro-rated paid time off (PTO) and holidays Career growth: Ascension-paid tuition (Vocare), reimbursement, ongoing professional development and online learning Emotional well-being: Employee Assistance Program , counseling and peer support, spiritual care and stress management resources Family support: parental leave, adoption assistance and family benefits Other benefits: optional legal and pet insurance, transportation savings and more Benefit options and eligibility vary by position, scheduled hours and location. Benefits are subject to change at any time. Your recruiter will provide the most up-to-date details during the hiring process. How you’ll make an impact in this role Evaluate medical necessity for admissions and service requests to ensure patients receive the most appropriate care at the right time. Lead the discharge planning process by collaborating with the healthcare team to create seamless transitions and safe returns home for patients. Navigate complex case management scenarios, providing expert consultation to resolve barriers to care and optimize patient outcomes. Ensure full compliance with federal and third-party regulations, protecting the integrity of our clinical services and reimbursement processes. Resolve documentation and reimbursement challenges to support the department in reducing claim denials and improving operational efficiency. What minimum requirements you’ll need Licensure / Certification / Registration: Licensed Registered Nurse credentialed from the Texas Board of Nursing or current home state license for multi-state license recognition "Compact State" obtained prior to hire date or job transfer date required. Education: Diploma from an accredited school/college of nursing OR Required professional licensure at time of hire. What additional preferences we're seeking Clinical Licensure: Active and unrestricted Registered Nurse (RN) license or equivalent clinical credential required for medical necessity determination. Compact or TX state license required. Utilization Management Expertise: Proven experience applying medical necessity criteria (such as InterQual or Milliman) within a clinical or payer environment. Equal employment opportunity employer Ascension provides Equal Employment Opportunities (EEO) to all associates and applicants for employment without regard to race, color, religion, sex/gender, sexual orientation, gender identity or expression, pregnancy, childbirth, and related medical conditions, lactation, breastfeeding, national origin, citizenship, age, disability, genetic information, veteran status, marital status, all as defined by applicable law, and any other legally protected status or characteristic in accordance with applicable federal, state and local laws. For further information, view the EEO Know Your Rights (English) poster or EEO Know Your Rights (Spanish) poster. Fraud prevention notice Prospective applicants should be vigilant against fraudulent job offers and interview requests. Scammers may use sophisticated tactics to impersonate Ascension employees. To ensure your safety, please remember: Ascension will never ask for payment or to provide banking or financial information as part of the job application or hiring process. Our legitimate email communications will always come from an @ascension.org email address; do not trust other domains, and an official offer will only be extended to candidates who have completed a job application through our authorized applicant tracking system. E-Verify statement Employer does not participate in E-Verify and therefore cannot employ STEM OPT candidates.
RN Pediatric Utilization Review Full-time
Cook Children's Health Care System

UM/ECM - RN Reviewer HP

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

Clinical Review Nurse - Concurrent Review

Centene CA
$27.02 - $48.55 / hour
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. Schedule: Mon–Fri, 8am–5pm PT Daily volume: 17–20 concurrent reviews/day Training: 4/5 weeks Ramp-up: 12 weeks, 0 → 20 cases, with preceptor support. RN + UM experience; managed care/health plan/hospital UM background. Review hospital requests for payment approval and determine authorization for a defined number of inpatient days California RN license required Position Purpose: Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member. Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines Reviews member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities Collaborates with care management on referral of members as appropriate Performs other duties as assigned Complies with all policies and standards Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience. 2+ years of acute care experience required. Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. License/Certification: For Health Net of California: RN license required Pay Range: $27.02 - $48.55 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
RN Utilization Review Full-time
University of Miami Health System

Case Manager RN - Utilization Review

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

Clinical Review Nurse - Concurrent Review

Centene MI
$27.02 - $48.55 / hour
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. Position Purpose: Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member. Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines Reviews member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities Collaborates with care management on referral of members as appropriate Performs other duties as assigned Complies with all policies and standards This position is remote. Candidates with an active Compact Nursing License are strongly preferred. Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience. 2+ years of acute care experience required. Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. License/Certification: LPN - Licensed Practical Nurse - State Licensure requirer. Pay Range: $27.02 - $48.55 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
RN Utilization Review Per Diem
UNC Health

RN Utilization Manager (Per Diem)- Rex Case Management

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

RN Utilization Manager - Rex Case Management

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

Managed Care Utilization Review Nurse

Texas Health and Human Services Abilene, TX
$5,425.33 - $8,886.16 / month
Join the Texas Health and Human Services Commission (HHSC) and be part of a team committed to creating a positive impact in the lives of fellow Texans. At HHSC, your contributions matter, and we support you at each stage of your life and work journey. Our comprehensive benefits package includes 100% paid employee health insurance for full-time eligible employees, a defined benefit pension plan, generous time off benefits, numerous opportunities for career advancement and more. Explore more details on the Benefits of Working at HHS webpage . Functional Title: Managed Care Utilization Review Nurse Job Title: Nurse III Agency: Health & Human Services Comm Department: UR LTSS FTE Random Mmt Study Posting Number: 14463 Closing Date: 03/17/2026 Posting Audience: Internal and External Occupational Category: Healthcare Practitioners and Technical Salary Range: $5,425.33 - $8,886.16 Pay Frequency: Monthly Salary Group: TEXAS-B-24 Shift: Day Additional Shift: Days (First) Telework: Eligible for Telework Travel: Up to 75% Regular/Temporary: Regular Full Time/Part Time: Full time FLSA Exempt/Non-Exempt: Exempt Facility Location: Job Location City: ABILENE Job Location Address: 4601 S 1ST ST Other Locations: Abilene; Anson; Canutillo; El Paso MOS Codes: 290X,46AX,46FX,46NX,46PX,46SX,46YX,66B,66C,66E,66F,66G,66H,66N,66P,66R,66S,66T,66W Nurse III Under the direct supervision of the UR nurse supervisor, the UR Nurse III conducts reviews of assessments, individual service plans (ISPs) and other relevant documentation to evaluate long term services and supports (LTSS) in Medicaid managed care; and to determine compliance with policies, procedures, rules, laws, contract standards, and correctness of needs assessments for Medicaid managed care LTSS. The UR nurse uses an array of evaluation methods, including review of records and face to face interviews with waiver members for validation of service needs and service delivery. The UR nurse uses program knowledge and nursing expertise to determine service needs and quality. This position has moderate latitude for use of initiative and independent nursing judgment in the required evaluations. The UR nurse III will be responsible for complex policy interpretations, validation of, or recommendations for clinical review decisions made by Medicaid managed care organizations (MCOs) and provider agencies. This position will also be responsible for timely and accurate reporting. The UR Nurse III will also be responsible for working collaboratively with MCOs and providers to ensure coinciding and/or mutually dependent functions are accomplished smoothly. Essential Job Functions: Attends work on a regular and predictable schedule in accordance with agency leave policy and performs other duties as assigned. Implements UR activities. Reviews MCO policies and procedures, nursing activities, medical records, assessments including medical necessity/level of care (MN/LOC), and ISPs, to determine compliance with policies and procedures, correctness of assessments, standards of care, and quality of service. Makes recommendations for improvement as a result of the reviews. 40% Produces routine and specialized data and information for program reports. (20%) Responsible for timely and accurate reporting of program activities. 15%. Informs and collaborates with internal divisions as necessary on program outcomes. 10% Interprets complex state and federal laws, regulations, and rules related to the program. Perform other duties as assigned. 15% Registrations, Licensure Requirements or Certifications: State of Texas Registered Nurse license in good standing. Knowledge Skills Abilities: Knowledge of: nursing techniques and procedures; health care laws, rules, standards, and regulations; medical diagnoses and procedures; accepted medical treatment programs; community health and nursing care principles, practices and procedures; Medicaid and managed care regulations and procedures; utilization management and review principles and practices; and health care needs and services for the aged and disabled as well as pediatric special needs. Skill in: organizing work; care and treatment of patients; written and verbal communication necessary to organize, develop, and review unit policies, rules, and guidelines; and to consult, teach, and provide clear and concise directions and reports. Ability to: identify appropriate nursing care and other health care services; prepare, maintain, and present reports; explain and interpret applicable health laws, rules, standards, and regulations; organize, coordinate and evaluate nursing activities and delivery of public health services; recognize patterns of medical necessity treatment, fraud, abuse, and neglect; use a personal computer, fax machine and copier, telephone conferencing functions, and components of the Microsoft Office suite and Outlook e-mail; travel independently throughout the state as necessary. Ability to gather, assemble, correlate, and analyze facts; to devise solutions to problems; to develop and evaluate policies and procedures; and to prepare reports. Initial Screening Criteria: Experience in nursing work. Graduation from an accredited four-year college or university with major course work in nursing (BSN or MSN preferred), or from an accredited nursing program. Experience in program evaluation, Utilization Review, and Long-Term Services and Supports (LTSS) is preferred. Experience in pediatrics, adult and geriatric health preferred. Managed Care experience preferred. Additional Information: Location based on office availability and applicant preference. This position can telework after successful completion of initial orientation period or in accordance with business needs. Review our Tips for Success when applying for jobs at DFPS, DSHS and HHSC . Active Duty, Military, Reservists, Guardsmen, and Veterans : Military occupation(s) that relate to the initial selection criteria and registration or licensure requirements for this position may include, but not limited to those listed in this posting. All active-duty military, reservists, guardsmen, and veterans are encouraged to apply if qualified to fill this position. For more information please see the Texas State Auditor’s Job Descriptions, Military Crosswalk and Military Crosswalk Guide at Texas State Auditor's Office - Job Descriptions . ADA Accommodations: In compliance with the Americans with Disabilities Act (ADA), HHSC and DSHS agencies will provide reasonable accommodation during the hiring and selection process for qualified individuals with a disability. If you need assistance completing the on-line application, contact the HHS Employee Service Center at 1-888-894-4747. If you are contacted for an interview and need accommodation to participate in the interview process, please notify the person scheduling the interview. Pre-Employment Checks and Work Eligibility: Depending on the program area and position requirements, applicants selected for hire may be required to pass background and other due diligence checks. HHSC uses E-Verify. You must bring your I-9 documentation with you on your first day of work. Download the I-9 Form Telework Disclaimer: This position may be eligible for telework. Please note, all HHS positions are subject to state and agency telework policies in addition to the discretion of the direct supervisor and business needs.
RN Utilization Review Part-time
Temple Health

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

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

RN Utilization Manager - Medicine, Oncology, Cardiac, & Psychiatry Services

UNC Health Chapel Hill, NC
$35.87 - $51.57 / hour
Description Areas of focus include Medicine, Oncology, Cardiac, and Psychiatry Services Preferences given to candidates with Medical Surgical and/or Psychiatry bedside experience. The Team: Completes clinical reviews for all areas: Inpatient, Observation, Extended Recovery Ensures compliance in accordance to government's federal rules and regulations related to patient care and reimbursement Interacts with the Interdisciplinary Team for patient care progression Protects hospital revenue by working with payors for insurance authorizations, denials, and appeals Delivers mandated federal notices to patients/ patient representatives related to their payer source 40 hrs/week (Monday-Friday) Weekend rotation Holiday rotation No Nights No on-call Become part of an inclusive organization with over 40,000 teammates, whose mission is to improve the health and well-being of the unique communities we serve. Summary: Works in collaboration with the patient/family, and interdisciplinary team (including physicians, other care providers, and payors), and assesses the patient care progression from acute care episode through post discharge for quality, efficiency, and effectiveness. The Utilization Manager works collaboratively with other Clinical Care Management staff to ensure patient needs are met and care delivery is coordinated across the continuum. The Utilization Manager completes admission, continued stay, and discharge reviews in accordance with federal regulations & the Hospitals? Utilization Management Plan. In addition, the Utilization Manager is responsible for revenue protection by reconciling physician orders, bed billing type, and medical necessity. This may include delivering notifications to patients directly. Interface is completed verbally, via email, data base tasks, or other electronic communication and via telephone. Responsibilities: 1. Clinical Review Process - Uses approved criteria and conducts admission review/status change review within 24 hours of patient admission to the hospital to ensure appropriateness of the setting and timely implementation of the plan of care. Identifies and obtains observation status as appropriate. Partners with physicians, nursing, and other care providers to help ensure timely and accurate documentation of patient data and treatments. Communicates daily with the Case Manager to manage level of care transitions & appropriate utilization of services. Coordinates with the support center to assure third party payor pre-certification and/or re-certifications when required. Utilizes high risk screening criteria to make appropriate referrals to Manager. 2. Discharge Facilitation - Identifies patient/families with the complex psychosocial, on-going medical discharge planning issues, continuing care needs by initiating appropriate case management referrals. Initiates appropriate social work referrals. 3. Utilization Management Process - Performs utilization management assessments and interventions, using collaboration with interdisciplinary team approach, on assigned patients as appropriate to ensure optimal patient outcomes. Using approved criteria, conducts continued stay and quality reviews to monitor the patient's progress along the continuum of care and intervenes as necessary to ensure appropriateness of setting and that the services provided are quality-driven, efficient, and effective. Enters all pertinent review data into the correct computer system in a timely manner. Consults with Physician Advisor as necessary to resolve barriers through appropriate administrative and medical channels. 4. Utilization Outcomes Management - Monitors and guides to trend interdisciplinary documentation and guides medical staff in documentation that will assist in coding accuracy, enhance quality of care, reflect accurate severity of illness and appropriate reimbursement. Facilitates patient movement to appropriate (acuity) level of care including observation status issues through collaboration with patient/family, multidisciplinary team, third party payors and resource center. Provides information regarding denials and approvals to designated entities. Assists in coordination of practice parameter development with the assigned departments/sections/specialties of Medical Staff. Oversees collection and analysis of patient care and financial data relevant to the target case types. Directs delivery of notifications to patients (includes traveling to hospital(s) to deliver notifications. Other Information Other information: Education Requirements: ● Graduation from a state-accredited school of professional nursing ● If hired after October 1, 2015, must be enrolled in an accredited program within four years of employment, and obtain a Bachelor's degree with a major in Nursing or a Master's degree with a major in Nursing within seven years of employment date. Licensure/Certification Requirements: ● Licensed to practice as a Registered Nurse in the state of North Carolina. Professional Experience Requirements: ● Two (2) years of clinical experience in a medical facility and/or comparable Utilization Management experience. Knowledge/Skills/and Abilities Requirements: Job Details Legal Employer: STATE Entity: UNC Medical Center Organization Unit: UNCH Care Mgmt-Medical Center Work Type: Full Time Standard Hours Per Week: 40.00 Salary Range: $35.87 - $51.57 per hour (Hiring Range) Pay offers are determined by experience and internal equity Work Assignment Type: Onsite Work Schedule: Day Job Location of Job: US:NC:Chapel Hill Exempt From Overtime: Exempt: Yes This is a State position employed by UNC Health Care System with UNC Health benefits. If, however, you are presently an employee of another North Carolina agency and currently participate in TSERS or the ORP, you will be eligible to continue participating in those plans at UNC Health. Qualified applicants will be considered without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, status as a protected veteran or political affiliation. UNC Health makes reasonable accommodations for applicants' and employees' religious practices and beliefs, as well as applicants and employees with disabilities. All interested applicants are invited to apply for career opportunities. Please email applicant.accommodations@unchealth.unc.edu if you need a reasonable accommodation to search and/or to apply for a career opportunity.
RN Utilization Review Full-time
Cooper University Health Care

UTILIZATION REVIEW RN

Cooper University Health Care Middle Township, NJ
About us Cooper University Health Care is an integrated healthcare delivery system serving residents and visitors throughout Cape May County. The system includes Cooper University Hospital Cape Regional; three urgent care facilities; nearly 30 primary care and specialty care offices in multiple locations throughout Cape May County; The Cancer Center at Cooper University Hospital Cape Regional; the Claire C. Brodesser Surgery Center; AMI at Cooper, Miracles Fitness and numerous freestanding outpatient facilities providing wound care, lab, and physical therapy services. We have a commitment to our employees by providing competitive rates and compensation programs. Cooper offers full and part time employees a comprehensive employee benefits program, including health, dental, vision, life, disability, retirement, on-site Early Education Center (employee discount), attractive working conditions, and the chance to build and explore a career opportunity by offering professional development. Short Description Responsible for facilitating and coordinating the care delivered to an assigned group of patients though multidisciplinary and patient/family collaboration to ensure quality and cost effective outcomes are delivered within appropriate length of stay parameters. Education Requirements NJ RN license required. BSN preferred. 3-5 years recent clinical experience, preferably in area of population speciality.
RN Utilization Review Part-time
Temple Health

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

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

Fraud and Abuse Review Nurse- Remote

Gainwell Technologies LLC AR
$64,000 - $80,000 / year
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 As a Fraud and Abuse Review Nurse- Remote at Gainwell, you can contribute your skills as we harness the power of technology to help our clients improve the health and well-being of the members they serve — a community’s most vulnerable. Connect your passion with purpose, teaming with people who thrive on finding innovative solutions to some of healthcare’s biggest challenges. Here are the details on this position. Job Duties Conduct objective desk and medical record audits to verify service documentation, determine appropriate administration, and validate coding/billing accuracy. Collaborate with internal teams (e.g., Provider Services, Contracting and Credentialing, Healthcare Services, Member Services, Claims) to collect relevant documentation for investigations. Identify potential healthcare fraud, waste, and abuse by analyzing aberrant coding and billing patterns through utilization review. Communicate effectively with physicians and healthcare professionals during investigations. Prepare accurate and timely reports detailing audit findings for internal and external stakeholders. Provide provider education on best practices (e.g., coding) based on national/local guidelines, contractual obligations, and regulatory requirements. Identify process improvement opportunities and recommend system enhancements to optimize investigative outcomes and performance. Data analysis of claims and utilization of benefits to identify potentially aberrant billing patterns. Job Qualifications Graduate from an accredited School of Nursing. Active, unrestricted RN license in good standing. Preferred: Bachelor’s Degree in Nursing. Required Experience Minimum of five years of clinical nursing experience with broad clinical knowledge. Experience in medical review and coding/billing audits for both professional and facility-based services. Strong understanding of medical terminology, CPT, ICD-9/10, HCPCS, and DRG coding requirements. Experience with government healthcare programs (Medicare, Medicaid, SCHIP). What you should expect in this role Remote (work from home) environment Benefits on first day of employment 0-10% of travel Applications for this posting will be accepted until March 22, 2026. The pay range for this position is $64,000.00 - $80,000.00 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 defines “wages” and “wage rates” to include “all forms of pay, including, but not limited to, salary, overtime pay, bonuses, stock, stock options, profit sharing and bonus plans, life insurance, vacation and holiday pay, cleaning or gasoline allowances, hotel accommodations, reimbursement for travel expenses, and benefits.
RN Utilization Review Full-time
Olympic Medical Center

Utilization Management Nurse I

Olympic Medical Center Port Angeles, WA
$39.76 - $68.19 / hour
ABOUT OLYMPIC MEDICAL CENTER: Imagine working on Washington State’s beautiful North Olympic Peninsula where recreational opportunities abound. Whether you enjoy hiking, camping, fishing, kayaking or cycling, the Olympic Peninsula is home to numerous adventures for outdoor enthusiasts. It's a great place to live, work, play and raise a family. Bordered by the scenic Olympic National Park, the Strait of Juan de Fuca and the Pacific Coast - with Seattle and Victoria, BC just a ferry ride away - you won’t find a better location. You’ll receive a competitive salary, excellent benefits, relocation assistance plus an amazing PNW lifestyle – a perfect combination! FTE: 100% WORK SHIFT Days PAY RANGE: $39.76 - $68.19 UNION: SEIU 1199-RN and LPN SHIFT DIFFERENTIALS/PREMIUMS: Weekend & Holiday Shifts: Yes On-Call Shifts: No Shift Differentials: Evening $3.00/hour Night $5.00/hour Premiums: Weekend Premium $4.50/hour Standby Premium $4.00/hour Charge Premium $3.25/hour Float/PM Premium $2.50/hour Per Diem Premium 15% (on rate of pay, in lieu of benefits) Certification Premium $2.00/hour JOB DESCRIPTION: Under general direction using established level of care criteria/guidelines, the Utilization Management RN I monitors the appropriateness of hospital admissions and stays. Monitoring includes review of admission status, medical necessity (severity of illness and intensity of service), and continued stay to comply with government and insurance company reimbursement policies. The Utilization Management RN I consults with physician/supervisor as necessary to resolve deviations from established criteria, and obtains documentation needed for continued hospitalization. This position assists with claims resolution issues and appeals, develops and maintains community relations, and collaborates with interdisciplinary team to achieve maximum internal and external customer satisfaction, as well as resource stewardship. EDUCATION Graduate from an accredited school of nursing, required. BSN preferred. EXPERIENCE At least three years of professional nursing experience required. Preference is for nursing experience to have occurred in a clinical/acute setting. Experience in Utilization Management/In-Patient Case Management preferred. LICENSURE/CREDENTIALS Current Washington State RN license required. Basic Life Support (BLS) certification required within 30 days of hire. BENEFITS INFORMATION: Click here for information about our benefits . Equal Employment Opportunity (EEO) Statement: Olympic Medical Center is an Equal Opportunity Employer that values workplace diversity. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, or protected veteran status and will not be discriminated against on the basis of disability. For more information, please visit www.eeoc.gov .
RN Utilization Review Full-time
CareSource

Remote - Registered Nurse (RN) Clinical Care Reviewer - Massachusetts only

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

Clinical Coding and OASIS Review Manager, RN, PT, OT, SLP

BAYADA Home Health Care Merchantville, NJ
$77,000 - $81,000 / year
Please note- Candidates must have COS-C, HCS-O or COQS and HCS-D or BCHH-C in order to be considered, there is no flexibility around this requirement. BAYADA Home Health Care has an immediate opening for a Full Time, OASIS and Coding Review Manager with OASIS and Coding certification to work remotely. RN, PT, OT, and SLP's with certifications will be considered for this role. BAYADA believes that our clients and their families deserve home health care delivered with compassion, excellence, and reliability. Apply your skills and knowledge of OASIS and ICD-10 coding to help clients receive the home health care services they need. BAYADA Perks: This is a fully remote position. Base Salary: $77,000 - $81,000 / year BAYADA offers a comprehensive benefits plan that includes the following: Paid holidays, vacation and sick leave, vision, dental and medical health plans, employer paid life insurance, 401k with company match, direct deposit, and employee assistance program Responsibilities: Review clinical information for appropriateness, congruency, and accuracy as it relates to the OASIS and ICD 10 coding while using the Medicare PDGM billing model and CMS guidelines. Review and communicate OASIS edit recommendations to each clinician to promote OASIS accuracy. Perform final review and lock OASIS. Timely review and coding of OASIS documents with productivity maintained at the quarterly target set by the Director of MCM. Prevent or decrease the occasion of Medicare denials by assuring proper coding on the plan of care and accurate OASIS documentation. Provide support and communication to all disciplines within the service. Provide customer service/education and act as a resource to Medicare Certified Offices with regards to CMS guidelines, Home Care Coding, PDGM guidelines and billing related issues. Provide ongoing communication with service offices via e-mail, zoom, or telephone (specific to the service office needs). Communication with service offices monthly and as appropriate with a focus on documentation trends, star ratings and potential revenue impact. Perform related duties, or as required or requested by Manager/Director. Qualifications: Competency in PC skills required to perform job function Active State RN Nursing License, Physical (PT), Occupational (OT) or Speech (SLP) Therapists with required certifications with a minimum of 2 years clinical experience. Please note, while this is a clinical opening, BAYADA does have non-clinical openings available COS-C or HCS-O or COQS OASIS Certification and experience required BCHH-C or HCS-D Home Health Care Coding Certification and experience required HCHB, SHP, and Coding Center experience, a plus! Be part of a caring, professional team that is instrumental in providing the highest quality care while developing your career with an industry leader. Apply now for immediate consideration. OASIS Review, Utilization Review, Quality Assurance, Remote, Home Health Coding, Coder, Medicare As an accredited, regulated, certified, and licensed home health care provider, BAYADA complies with all state/local mandates. BAYADA is celebrating 50 years of compassion, excellence, and reliability. Learn more about our 50th anniversary celebration and how you can join in here. BAYADA Home Health Care, Inc., and its associated entities and joint venture partners, are Equal Opportunity Employers. All employment decisions are made on a non-discriminatory basis without regard to sex, race, color, age, disability, pregnancy or maternity, sexual orientation, gender identity, citizenship status, military status, or any other similarly protected status in accordance with federal, state and local laws. Hence, we strongly encourage applications from people with these identities or who are members of other marginalized communities.
RN Utilization Review Full-time
North Mississippi Health Services

Coordinator-RN Utilization

North Mississippi Health Services Amory, MS
Coordinates Essential Functions Consults with physician services Utilizes clinical diagnostics, physician documentation and non-physician clinical guidelines to facilitate status determination of inpatient, outpatient or outpatient observation. Coordinates final status with admitting and attending physicians Performs initial and concurrent clinical reviews as indicated by payer and patient clinical needs Inpatient and/or outpatient notification and precertification of services to payers Facilitates peer to peer, written reconsiderations or appeals throughout all denial cycle as appropriate Facilitates appropriate observation utilization Consults with patient financial services Educations: Provides education and literature to physician services regarding IPPS and OPPS Educates physicians and other care team member on level of care criteria and other third party payer requirements Reporting/Recordkeeping: Updates patient’s medical records as required Shares medical necessity documentation with payers to facilitate reimbursement Regulation : Adheres to NMHS/NMMC Policies/Procedures/Guidelines Complies with applicable Local/State/Federal policies/procedures/guideline/regulations/laws/statues Requirements: Associates Degree in Nursing, required; Bachelor’s Degree preferred Licensed as a Registered Nurse by the Mississippi Board of Nursing; required Minimum of 5 years clinical and/or healthcare experience; required Excellent organizational and communication (written and verbal) skills; required Knowledge of various payer sources, federal/state laws/regulations, and cost containment; required Certified as an Accredited Case Manager (ACM); desirable Excellent interpersonal skills; required Demonstrates ability to care for a patient population from pediatric to geriatric; required
RN Utilization Review Full-time
Molina Healthcare

Care Review Clinician (RN)

Molina Healthcare Charleston, SC
$25.08 - $51.49 / hour
JOB DESCRIPTION Job SummaryProvides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines. • Analyzes clinical service requests from members or providers against evidence based clinical guidelines. • Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. • Conducts reviews to determine prior authorization/financial responsibility for Molina and its members. • Processes requests within required timelines. • Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner. • Requests additional information from members or providers as needed. • Makes appropriate referrals to other clinical programs. • Collaborates with multidisciplinary teams to promote the Molina care model. • Adheres to utilization management (UM) policies and procedures. Required Qualifications • At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience. • Registered Nurse (RN). License must be active and unrestricted in state of practice. • Ability to prioritize and manage multiple deadlines. • Excellent organizational, problem-solving and critical-thinking skills. • Strong written and verbal communication skills. • Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications • Certified Professional in Healthcare Management (CPHM). • Recent hospital experience in an intensive care unit (ICU) or emergency room. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $25.08 - $51.49 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
RN Utilization Review Full-time
Temple Health

RN Case Manager - Utilization Review (Temple Hospital Jeanes Campus)

Temple Health Philadelphia, PA
Utilizing InterQual and other appropriate criteria, responsible for reviewing all admissions and continued stay of patients in conformance with the established criteria set forth in the hospital's utilization management and quality assurance plan. Will determine the medical necessity for admission and continued stays for patients within department's scope of service and to meet the hospital's objectives for assuring a high quality of patient care as well as assuring the effective and efficient utilization of available health services. Identifies appropriate level of care for inpatients and outpatients requiring overnight care. Education Other Graduate Of An Accredited School Of Nursing Required Bachelor's Degree BSN Required Experience 1 year experience of recent Utilization Review in acute care or in insurance company setting. Required 1 Year Experience In Medical-surgical Setting. Required 1 year experience in working with competency utilizing InterQual criteria. Required General Experience In Working With Utilization Review Standards Required Licenses PA Registered Nurse License Required Certified Case Manager Preferred Multi State Compact RN License Required Or Schedule: Monday–Friday, 8:00 AM–4:30 PM