We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary Supports comprehensive coordination of medical services through composition and auditing of approval, extensions, and denial letters. Promotes and supports quality effectiveness of the healthcare services. Maintains accurate and complete documentation to meet risk management, regulatory, and accreditation requirements. Promotes communication, both internally and externally to enhance effectiveness of medical management services. Training Schedule-9am-6pm Monday-Friday Perm Schedule-9am-8pm Thursday - Sunday Required Qualifications - Must have active, current, and unrestricted RN license in the state of residence -1+ years of clinical experience - Must be willing and able to work occasional holiday and weekends depending on business needs Preferred Qualifications 1+ years as a RN - Utilization management experience - Managed care experience - Must be a team player - Good communication skills - Good grammar and syntax - Ability to multi-task - Schedule flexibility Education Associates degree required BSN preferred Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $32.01 - $68.55 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan . No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 03/25/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary Supports comprehensive coordination of medical services through composition and auditing of approval, extensions, and denial letters. Promotes and supports quality effectiveness of the healthcare services. Maintains accurate and complete documentation to meet risk management, regulatory, and accreditation requirements. Promotes communication, both internally and externally to enhance effectiveness of medical management services. Required Qualifications - Must have active, current, and unrestricted RN license in the state of residence -1+ years of clinical experience - Must be willing and able to work Monday through Friday, 11:00am to 7:00pm EST - Must be willing and able to work occasional holiday and weekends depending on business needs Preferred Qualifications - Utilization management experience - Managed care experience - Must be a team player - Good communication skills - Good grammar and syntax - Ability to multi-task - Schedule flexibility Education Associates degree required BSN preferred Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $32.01 - $68.55 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan . No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 03/25/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
Internal Employees: Please ensure that you are logged into Workday and applying through the Jobs Hub before proceeding. RN (Utilization Review) Job Description Utilization Review RN conducts medical certification review for medical necessity for acute care facility and services Uses nationally recognized, evidence-based guidelines approved by medical staff to recommend level of care to the physician and serve as a resource to the medical staff on issues related to admission qualifications, resource utilization, national and local coverage determinations and documentation improvement opportunities. Relays information as requested to the payer sources. Assures the highest quality, most cost effective patient care in the most appropriate setting. Responsibilities Assessment - Collects pertinent data and information relative to the patient's health or the situation. Recognizes normal and abnormal findings when gathering data., Assumes responsibility for remaining current on all regulatory and reimbursement rules and regulations., Concurrently reviews medical necessity, bed status, length of stay and quality of care indicators on all assigned patients. Serves as coordinator for communication with payors and providers to determine the appropriateness of hospital level of care., Confers with attending physician and physician advisor if medically unnecessary inpatient treatment is contemplated., Consults with medical staff, care team, and case managers as necessary to resolve immediate progression-of-care barriers through appropriate administrative and medical channels., Coordinates Medicare appeals with the discharge planner, Director of Utilization Management, Physician Advisor and the QIO., Coordination of Care - Plans and evaluates care in collaboration with appropriate disciplines., Diagnosis - Analyzes assessment data to determine actual or potential diagnosis, problems, and issues., Evaluation - Evaluates progress toward attainment of goals and outcomes. Reports data and outcomes to others as appropriate., Implementation - Implements care or work plan in alignment with the plan and approved safety, infection control, and department/organization standards., Knowledge - In collaboration with leaders, actively pursues required knowledge and skills through orientation activities specific to the position, reading current literature and seeking new learning opportunities., Outcomes Identification - Identifies expected outcomes for a plan individualized to the patient or situations., Planning - Develops a plan that prescribes strategies to attain expected, measurable outcomes., Recognizes and responds appropriately to patient safety/risk factors., Refers all denials, as appropriate, to the Director of Utilization Management and/or Physician Advisor., Relationships - Establishes effective working relationships with peers, physicians, and other members of the health care / work team. Identifies and confers with appropriate resources regarding patient / work decisions., Reviews operating room (OR) schedule 48 hours in advance of scheduled procedures to confirm that all eligible Medicare and Medicaid admissions were identified and the coded procedure is or is not on the Medicare inpatient-only list. Confirms that physician’s admission orders accurately reflect status., Serves as a resource person to physicians, case managers, physician offices, and billing office for coverage and compliance issues., Serves as coordinator for third party payer reviews, certifications and authorizations., Teaching - Employs teaching strategies to promote health and a safe environment., Works closely with physician advisor to review resource utilization data and trends to identify outliers who may benefit from real-time coaching to improve outcomes. Requirements ADN (Required)RN-Registered Nurse - Illinois Department of Financial and Professional Regulation Compensation Estimated Compensation Range $66,768.00 - $103,500.80 Pay based on experience
Salary Range: $206,311.00 (Min.) - $278,520.00 (Mid.) - $350,729.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job Summary The Medical Director, Utilization Management provides clinical oversight of authorization decision making and processing, pre and post payment claims review activities, payment integrity clinical validation and program integrity functions. This position requires evaluation and insight for both medical and behavioral health cases. In this position, the Medical Director supports the development of and ensures the application of clinical policies are consistent with evidence-based medicine and regulatory requirements. The Medical Director collaborates with internal teams to support timely consistent and defensible clinical decisions and promotion of appropriate high-value care. In support of payment and program integrity initiatives, the Medical Director reviews clinical documentation to validate coding accuracy and appropriateness and completion of billed services. This position plays a critical role in the mitigation of Fraud, Waste and Abuse (FWA) and requires proactive analysis of service level utilization data to identify trends, outliers and emerging risk areas and recommend corrective action to minimize utilization variation, prevent improper payments and ensure financial stewardship. Works collaboratively with Health Services departments and key organizational stakeholders, to ensure alignment of utilization management, claims review, and regulatory compliance activities. Partners with executive leadership, clinical teams, and external stakeholders to improve outcomes, support regulatory compliance, and advance organizational goals. Duties Provides physician leadership within the Health Services division, with primary responsibility for overseeing Utilization Management (UM) reviews, conducting medical claims review under Payment Integrity and supporting Behavioral Health (BH). Applies clinical expertise and evidence-based criteria to behavioral health and medical/surgical services, conducting claims reviews in compliance with regulatory timeframe requirements. Leads efforts to strengthen Payment Integrity by overseeing clinical validation of requested services, ensuring alignment between documentation and medical necessity. Analyzes utilization and claims data to identify trends, outliers, cost drivers, and opportunities to reduce unnecessary services and prevent improper payments. Identifies and mitigates Fraud, Waste, and Abuse (FWA) risks by detecting patterns, and partners with internal teams as appropriate. Develops, approves, and updates medical policies, procedures, and standards of care based on current, evidence-based practices. Oversees and reviews the delivery of patient care to ensure it meets quality standards and regulatory guidelines. Guides quality assurance and performance improvement (QAPI) programs and participates in quality review committees. Maintains and enforces compliance with all federal and state laws, accreditation standards (such as NCQA), and other regulatory requirements. Assists in the preparation and monitoring of departmental budgets, including managing costs and resource utilization. Performs other duties as assigned. Duties Continued Education Required Doctor of Medicine (M.D.) Education Preferred Experience Required: At least 8 years of experience in medical management, managed care and quality management. Experience in Payment Integrity. Experience in maintaining liaison with Federal, State, and local bodies and medical organizations. Experience in performance management and possession of strong analytic ability. Extensive post-medical degree experience in clinical practice. Significant experience in a clinical development, medical affairs, or management role within the biotech, pharmaceutical, or healthcare industry. Proven experience in a physician leadership role, including managing teams. Preferred: Experience with Medicaid managed care and/or governmental programs for underserved, safety net populations including women, children, person with disabilities, seniors, and those of varied ethnic and cultural backgrounds. Skills Required: Ability to provide leadership to physicians, nurses, and other health care professionals, and an interest and involvement in the affairs of the health care community. Excellent written and verbal communication skills with the ability to effectively collaborate with multidisciplinary teams and senior leadership. Strong leadership, consensus-building, and stakeholder engagement skills, as well as a commitment to evidence-based practice, continuous quality improvement, regulatory compliance, and health equity. Demonstrated ability for teamwork and collaborative problem-solving. Commitment to patient-centered, value-based care. Strong leadership presence with the ability to lead, mentor, and motivate a team. Exceptional presentation skills to effectively convey complex medical concepts to diverse audiences. Ability to think strategically and take a broad, business-oriented perspective. Strong analytical and problem-solving skills, with a data-driven approach to evaluating programs. Ability to work in a fast-paced, dynamic, and often ambiguous environment. Licenses/Certifications Required Board Certified, preferably in Internal Medicine, Family Medicine, Emergency Medicine or Psychiatry. Clinical License to practice or an Administrative License to review Utilization Management cases. - Active, current and unrestricted California License Licenses/Certifications Preferred Certification as a Certified Medical Director (CMD) Required Training Physical Requirements Light Additional Information Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. L.A. Care offers a wide range of benefits including Paid Time Off (PTO) Tuition Reimbursement Retirement Plans Medical, Dental and Vision Wellness Program Volunteer Time Off (VTO)
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Regular business hours are 8:00 am-8:00 pm EST. Must be available to work any 8 hour shift within this timeframe with start times ranging from 8:00 am-11:30am EST. About Us American Health Holding, Inc. (AHH), a division of Aetna/CVS Health, is a URAC-accredited medical management organization founded in 1993. We provide flexible, cost-effective care management solutions that promote high-quality healthcare for members. Position Summary Join our Utilization Management team as a Nurse Consultant, where you'll apply clinical judgment and evidence-based criteria to review inpatient and outpatient services. You'll collaborate with providers, authorize care, and escalate cases when needed, all while navigating multiple systems and maintaining accurate documentation. This role suits nurses who thrive in fast-paced environments, are highly organized, and comfortable with computer-based work. Key Responsibilities Apply critical thinking and evidence-based clinical criteria to evaluate outpatient and inpatient services requiring precertification and concurrent review. Conduct clinical reviews via phone and electronic documentation, collaborating with healthcare providers to gather necessary information. Use established guidelines to authorize services or escalate to Medical Directors as needed. Navigate multiple computer systems efficiently while maintaining accurate documentation. Thrive in a fast-paced, high-volume environment with strong organizational, multitasking, and prioritization skills. Perform sedentary work that primarily involves extended periods of sitting, as well as frequent talking, listening, and use of a computer. Flexibility to provide coverage for other Utilization Management (UM) Nurses across various UM specialty teams as needed, ensuring continuity of care and operational support. Participate in occasional on-call rotations, including some weekends and holidays, per URAC and client requirements. Remote Work Expectations This is a 100% remote role; candidates must have a dedicated workspace free of interruptions. Dependents must have separate care arrangements during work hours, as continuous care responsibilities during shift times are not permitted. Required Qualifications Active unrestricted state Registered Nurse licensure in state of residence required. Minimum 5 years of relevant experience in Nursing. At least 1 year of Utilization Management experience in concurrent review or prior authorization. Strong decision-making skills and clinical judgment in independent scenarios. Proficient with phone systems, clinical documentation tools, and navigating multiple digital platforms. Commitment to attend a mandatory 3-week training (Monday–Friday, 8:30am–5:00pm EST) with 100% participation. Preferred Qualifications 1+ year of experience in a managed care organization (MCO). Experience in a high-volume clinical call center or prior remote work environment. Education Associate's degree in nursing (RN) required, BSN preferred. Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $29.10 - $62.32 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan . No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits This job does not have an application deadline, as CVS Health accepts applications on an ongoing basis. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
Overview Performs utilization review of inpatient admissions, outpatient surgeries, and ancillary services. Performs precertification, concurrent and retrospective reviews, and coordination of discharge planning. Determines medical necessity and appropriateness of services using clinical review criteria. Collaborates with physicians and other providers to facilitate provision of services throughout the health care continuum. Acts as a member advocate by expediting the care process through the continuum, working in concert with the health care team to maintain high quality and cost effective care delivery. Requires an Associates of Nursing (ASN). Bachelors of Nursing (BSN) preferred. Requires an active Registered Nurse (RN) license in the state of Indiana or an active Nurse Licensure Compact (NLC) RN license. Requires that the RN has graduated from a nationally accredited nursing program. Requires 3-5 years of relevant experience. Basic Life Support certification through the AHA or other advanced life support certifications may be required per unit/department specialty according to patient care policies. Requires proficiency in Microsoft Office and applications. Requires understanding of medical record requirements, regulations and policies.
About Us Bakersfield Behavioral Healthcare Hospital, located in Bakersfield, California, is an acute psychiatric and behavioral 90-bed facility situated on 8.8 acres. We offer inpatient and outpatient services for children, adolescents, and adults needing mental/behavioral health, chemical dependency; and co-occurring disorders treatment through our medically supervised detoxification. Within our Workplace Community, BBHH is striving daily to be one of the BEST PLACES TO WORK not just here in Kern County, but throughout the Behavioral Healthcare Community. By offering amazing benefits, encouraging individual growth and development, and incorporating our CARES values system into our daily operations, we are creating a JUST workplace culture where people enjoy coming to work each day. BBHH CARES about your experience as a candidate and we encourage you to apply to our open positions. Compassion Acceptance Respect Empowerment Sincerity Job Summary Our progressive and dedicated healthcare team strives to change the lives of our patients and provide exceptional care. This RN position is in our Inpatient units. The attention to detail and level of situational awareness required of the staff in the Inpatient Unit is paramount to the success of all patient outcomes. Our CARES values system must be on display in every act of patient care, no matter the circumstances. BBHH is a fast-paced environment that requires critical thinking, teamwork, and excellent communication between staff and patients. We are looking for a Registered Nurse to provide excellent care and to join our Workplace Community in our effort to be the best hospital we can be. POSITION SUMMARY: The Admissions RN (Intake Packet Reviewer) is responsible for conducting comprehensive clinical reviews of referral packets to determine patient eligibility for admission to Bakersfield Behavioral Healthcare Hospital (BBHH). This position evaluates medical history, psychiatric diagnosis, acuity level, risk factors, exclusionary criteria, and medical stability to ensure the hospital can safely and appropriately meet the patient’s needs. The role requires sound clinical judgment, knowledge of psychiatric standards of care, regulatory awareness, and the ability to assess admission risk in alignment with California law, CMS Conditions of Participation, and Joint Commission standards. Some of the fundamentals we're looking for in those who apply to this position include: Someone who demonstrates sound leadership skills and utilizes these skills in organizing the activities and schedules for medical and/or non-medical tasks on the unit. A caring, compassionate human being with a record of consistently showcasing high-quality clinical and interpersonal skills to be an exemplary role model to others Someone capable of displaying basic knowledge of treatment procedures; interventions common to acute psychotic as well as non-violent crisis intervention practice; A person with basic knowledge of abnormal psychology, application of this knowledge to the care of our patients, and fluency in medical terminology in psychiatric care; Someone with thorough familiarity of psych and the use of psychotropic medications, basic teaching and training skills helpful; problem-solving; An organized individual with exceptional organizational and time management skills; crisis intervention skills; Someone with strong written and oral communication skills in the English language; skills in facilitating and/or co-facilitating process-oriented and didactic groups. WHAT WE'RE LOOKING FOR Simply put: HUMANS WHO CARE Though we do need to meet some minimum requirements for the position such a High School Diploma or Equivalent, and a current California RN License we're really looking for people who bring their HEART to work. If you have previous experience in a mental healthcare hospital environment where your attention was focused on the assessments of human behavior, psychiatry, psychology, or other mental healthcare situations, then your application to this position will be moved to the shortlist of candidates. Minimum of two (2) years psychiatric nursing experience (acute inpatient preferred). • Strong knowledge of psychiatric diagnoses, risk stratification, and medical comorbidities. • Demonstrated ability to independently analyze clinical information and exercise sound judgment. • Working knowledge of Title 22, CMS, and Joint Commission standards related to psychiatric facilities. • Strong written documentation skills. • Experience reviewing referral packets or conducting medical necessity reviews. Our patients, our community, and our co-workers RELY on us to be committed to their wellness, Through prevention, intervention, treatment, and education, we can and we will make a difference not just here in Bakersfield, but throughout our extended communities. You should have a current CPR certification when you apply or obtain certification prior to your start date. If you don't have a current CPR certification, just let us know and we'll make sure you get it before you start -- and even cover the cost for you. Additionally, you'll complete a "Handle-With-Care" Physical Restraint Technique Training during your orientation so that you know how and when to engage when such an event occurs. You should know that this position operates on an Alternate Work Schedule of 12-hour shifts from 6:00am to 6:30pm or 6:00pm to 6:30am. SPECIFIC SCHEDULE REQUIREMENTS: Monday 6a-6:30p, Tuesday 6a-6:30p and every other Saturday 6a-6:30p. BBHH encourages ALL qualified candidates to apply. The RN position pays between $44.00-$61.38 per hour based on the experience you bring with you. We look forward to reviewing your application TODAY! Bakersfield Behavioral Healthcare Hospital is proud to offer a suite of benefits to those who join our workplace community. *Benefits eligibility varies based on employment status (full-time, part-time, per diem, temporary, etc.). Some of the benefits you can expect as a Full-Time employee include: Paid Time Off over THREE WEEKS of Paid Time Off in your first year!!! Life Insurance Short-Term Disability Insurance Long-Term Disability Insurance Medical Insurance Dental Insurance Vision Insurance Pet Insurance Accident Insurance 401k Retirement Plan Discounted Meals Employee Assistance Program TUITION Assistance
It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you’ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development. Summary We are seeking a talented individual for a Nurse Reviewer Appeals and Hearings to coordinate and perform all appeal related duties including analyzing and responding appropriately to appeals from providers; reviewing documentation to ensure all aspects of the appeal have been addressed properly and accurately; prepare case files and case summaries for hearings; and participate in in virtual and on-site hearings. Your role in our mission Reviews provider appeals and redeterminations using approved clinical and coding guidelines and documents appeal determinations clearly and concisely. Analyzes and reviews appeal documentation to ensure all aspects of the appeal have been addressed properly and accurately while maintaining production goals and quality standards. Prepares case files and case summaries for hearings and actively participates in hearings in conjunction with the Medical Director. Assist management with training new reviewers to include daily monitoring, mentoring, feedback and education. Maintains current knowledge of clinical criteria guidelines and/or coding guidelines; successfully completes required CEUs to maintain RN license and/or coding certification. Responsible for attending training and scheduled meetings to enhance skills and working knowledge of clinical policies, procedures, rules, and regulations. Actively cross-trains to perform reviews of multiple claim types to provide a flexible workforce to meet client needs. What we're looking for Active, Unrestricted RN license from the United States and in the primary home residency, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), 5+ years clinical experience or 5+ years medical record coding experience required 3+ years utilization review experience or claims auditing required Working knowledge of the appeals and hearings process Experience using MCG or InterQual criteria preferred Excellent written communication skills including ability to write clear, concise, accurate, and fact-based rationales in support of appeal determinations. Excellent oral communication skills with particular emphasis on verbally presenting case summaries and decisions. Ability to multi-task in a fast-paced production environment. What you should expect in this role Work Location: Remote within the United States Travel Requirement: Up to 25% Travel for onsite hearing testimony Applications will be accepted through April 17, 2026. The pay range for this position is $84,000.00 - $95,000.00 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.
St. Luke's is proud of the skills, experience and compassion of its employees. The employees of St. Luke's are our most valuable asset! Individually and together, our employees are dedicated to satisfying the mission of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care. The RN DRG Downgrades Appeals Review Specialist is responsible for the retrospective clinical review and defense of inpatient DRG downgrades, clinical validation denials, and medical necessity determinations issued by governmental and commercial payers. JOB DUTIES AND RESPONSIBILITIES: Conduct retrospective clinical record reviews to evaluate DRG downgrades, clinical validation denials, and medical necessity determinations. Analyze documentation in conjunction with MS-DRG logic and ICD-10-CM/PCS coding guidelines to determine appeal opportunity. Develop and submit defensible first- and second-level appeal letters using clinical evidence, regulatory guidance, coding standards, and payer policy. Collaborate with Physician Advisors, Coding leadership, and CDI to support higher-level appeals (e.g., IRO, ALJ, payer conferences). Identify denial trends and provide structured feedback to Coding and CDI leadership to reduce future payer vulnerability. Participate in payer audit response processes (RAC, QIO, MIC, commercial auditors) and assist in preparation for formal appeal proceedings. Maintain accurate documentation within EPIC, payer audit platforms, and internal tracking tools to support reporting and performance monitoring. Review denial data and appeal outcomes to assist leadership in assessing revenue impact, case resolution trends, and operational improvement opportunities. Maintain current knowledge of MS-DRG methodology, ICD-10-CM/PCS coding guidelines, clinical validation standards, federal and commercial payer policies, and medical necessity criteria. Serve as a clinical resource regarding documentation specificity and disease process validation as it relates to reimbursement defense. PHYSICAL AND SENSORY REQUIREMENTS: Sitting, standing and light lifting. Repetitive arm/finger use retrieving/viewing computerized patient medical record and abstracting of patient information. Corrected vision and hearing to within normal range. Hearing as it relates to normal conversation. Works inside with adequate lighting, comfortable temperature and ventilation. EDUCATION: Registered Nurse required. BSN preferred. Active RN license required. CDI certification (CDIP, CCDS) preferred. TRAINING AND EXPERIENCE: Minimum five (5) years RN experience in adult inpatient acute care (medical/surgical or critical care). Strongly preferred: Clinical Documentation Improvement (CDI) experience. Strongly preferred: DRG downgrade or clinical validation denial experience. Strongly preferred: Utilization review or payer medical review experience. Familiarity with MS-DRG reimbursement methodology. Demonstrated understanding of disease pathophysiology and documentation specificity requirements. Working knowledge of ICD-10-CM/PCS fundamentals. Understanding of payer audit and appeal processes. Experience with EPIC and encoder tools (e.g., 3M) preferred. Please complete your application using your full legal name and current home address. Be sure to include employment history for the past seven (7) years, including your present employer. Additionally, you are encouraged to upload a current resume, including all work history, education, and/or certifications and licenses, if applicable. It is highly recommended that you create a profile at the conclusion of submitting your first application. Thank you for your interest in St. Luke's!! St. Luke's University Health Network is an Equal Opportunity Employer.
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours. Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function. Typical office working environment with productivity and quality expectations. Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor. Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment. Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding. Effective communication skills, both verbal and written Required Qualifications - 2+ years of experience as a Registered Nurse in adult acute care/critical care setting - Must have active current and unrestricted RN licensure in state of residence - Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours Preferred Qualifications - 2+ years of clinical experience required in med surg or specialty area - Managed Care experience preferred, especially Utilization Management - Preference for those residing in Central Time zones Education Associates Degree required BSN preferred Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $26.01 - $56.14 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan . No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 03/27/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
RESPONSIBILITIES I. JOB SUMMARY/RESPONSIBILITIES: • Facilitates peer review and performance improvement activities (case review, professionalism review, practitioner health, OPPE reports) for the Medical Staff in accordance with the mission of The Queen’s Health System (QHS). • Produces reports for the medical staff reappointment process. • Facilitates activities of the Professional Practice Evaluation Committee (PPEC) and Leadership Council. • Meets requirements of regulatory and accreditation agencies. II. TYPICAL PHYSICAL DEMANDS: • Essential: seeing, hearing, speaking. • Constant: sitting. • Occasional: standing, walking, finger dexterity. • Infrequent: kneeling, climbing stairs, stooping/bending, lifting, pushing/pulling and carrying usual weight of 10 pounds, reaching above, at and below shoulder level. • Operates computer, copier, facsimile, and telephone. III. TYPICAL WORKING CONDITIONS: • Not substantially subjected to adverse environmental conditions. • Work environment may be stressful due to workload. IV. MINIMUM QUALIFICATIONS: A. EDUCATION/CERTIFICATION AND LICENSURE: • Bachelor's degree in health care related field. B. EXPERIENCE: • One (1) year medical staff peer review and performance improvement experience in a healthcare facility; or two (2) years clinical experience with competency in summarizing patient’s medical history. • Knowledge of regulatory and licensing agency standards, medical staff bylaws, and rules/regulations. Ability to interpret and apply guidelines and procedures. • Knowledge and skill in data collection, data entry, data analysis, data presentation and reporting. • Skill in establishing and maintaining effective working relationships with staff, physicians, consultants, hospital committees, administrators, and staff. • Ability to communicate effectively both orally and in writing with all levels throughout the organization. • Proficiency with Microsoft office applications, i.e. Word, Excel, Outlook, etc. • Prior experience in medical staff credentialing/reappointment preferred. Equal Opportunity Employer/Disability/Vet
JOB DESCRIPTION Job SummaryProvides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care. Must be licensed in CA. Essential Job Duties • Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines. • Analyzes clinical service requests from members or providers against evidence based clinical guidelines. • Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. • Conducts reviews to determine prior authorization/financial responsibility for Molina and its members. • Processes requests within required timelines. • Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner. • Requests additional information from members or providers as needed. • Makes appropriate referrals to other clinical programs. • Collaborates with multidisciplinary teams to promote the Molina care model. • Adheres to utilization management (UM) policies and procedures. Required Qualifications • At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience. • Registered Nurse (RN). License must be active and unrestricted in state of practice. • Ability to prioritize and manage multiple deadlines. • Excellent organizational, problem-solving and critical-thinking skills. • Strong written and verbal communication skills. • Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications • Certified Professional in Healthcare Management (CPHM). • Recent hospital experience in an intensive care unit (ICU) or emergency room. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $30.37 - $59.21 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
JOB DESCRIPTION Job SummaryProvides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care. Must be licensed in CA. Essential Job Duties • Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines. • Analyzes clinical service requests from members or providers against evidence based clinical guidelines. • Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. • Conducts reviews to determine prior authorization/financial responsibility for Molina and its members. • Processes requests within required timelines. • Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner. • Requests additional information from members or providers as needed. • Makes appropriate referrals to other clinical programs. • Collaborates with multidisciplinary teams to promote the Molina care model. • Adheres to utilization management (UM) policies and procedures. Required Qualifications • At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience. • Registered Nurse (RN). License must be active and unrestricted in state of practice. • Ability to prioritize and manage multiple deadlines. • Excellent organizational, problem-solving and critical-thinking skills. • Strong written and verbal communication skills. • Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications • Certified Professional in Healthcare Management (CPHM). • Recent hospital experience in an intensive care unit (ICU) or emergency room. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $30.37 - $59.21 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
JOB DESCRIPTION Job SummaryProvides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care. Must be licensed in CA. Essential Job Duties • Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines. • Analyzes clinical service requests from members or providers against evidence based clinical guidelines. • Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. • Conducts reviews to determine prior authorization/financial responsibility for Molina and its members. • Processes requests within required timelines. • Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner. • Requests additional information from members or providers as needed. • Makes appropriate referrals to other clinical programs. • Collaborates with multidisciplinary teams to promote the Molina care model. • Adheres to utilization management (UM) policies and procedures. Required Qualifications • At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience. • Registered Nurse (RN). License must be active and unrestricted in state of practice. • Ability to prioritize and manage multiple deadlines. • Excellent organizational, problem-solving and critical-thinking skills. • Strong written and verbal communication skills. • Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications • Certified Professional in Healthcare Management (CPHM). • Recent hospital experience in an intensive care unit (ICU) or emergency room. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $30.37 - $59.21 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
Our Mission To improve the health of the communities we serve through contemporary, innovative, quality healthcare solutions. Schedule : Monday - Friday (40hrs/week) About Us – Physician Reimbursement Center (PRC) Located inside the Freeman Business Center Vital part of our revenue cycle Our team consists of over eighty professionals that assure reimbursement for the valued services our clinicians provide What You’ll Do Performs a variety of duties in support of the quality assurance and compliance function of the Physician Reimbursement Center. Performs prospective chart reviews to ensure medical record accurately reflects the patient’s level of service, severity of illness and risk of mortality. Works closely with Medical Staff to clarify, assist and educate with documentation of evaluation and management coding. Requirements Minimum of 3 years of clinical experience in an acute care setting, (ICU, Medical/Surgical or Emergency Department nursing preferred). If homebound, must reside in one of the following states: Arkansas, Kansas, Missouri or Oklahoma. Current Missouri Registered Nurse license or current Registered Nurse license from a compact state. If a compact license is held, it must be in the nurse state of residence. Experience and skills in coding, billing and compliance. Preferred Requirements COSC Certification Freeman Perks and Programs For eligible full time and part time employees Freeman offers a wide variety of career opportunities, a great work culture and generous benefits, most starting day one! Health, vision, dental insurance Retirement with employer match Wellness program with discounts to Health Insurance or Cash Bonus with Participation Milestone payments with longevity of employment Paid Time Off (PTO) or Flex time off (FTO) Extended sick pay Learning Center designated only for Freeman Family members Payroll deduction at different locations such as The Daily Grind, Freeman Gift Shop, Cafeteria, etc
Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job Summary The Utilization Management Nurse Specialist RN II facilitates, coordinates, and approves medically necessary referrals that meet established criteria. Assures timely and accurate determination and notification of referrals and reconsiderations based on the referral determination status. Generates approval, modification and denial communications, to include member and provider notification of referral determination. Actively monitors for admissions in any inpatient setting. Performs telephonic and/or onsite admission and concurrent review, and collaborates with onsite staff, physicians, providers, member/family interaction to develop and implement a successful discharge plan. Works with the UM Manager and Physician Advisor on case reviews for pre-service, concurrent, post-service and retrospective claims medical review. Monitors and oversees the collection and transfer of data (medical records) and referral requests by Providers. Acts as a department resource for medical service requests /referral management and processes. Receives incoming calls from providers, professionally handles complex calls, researches to identify timely and accurate resolution steps. Follows up with caller to provide response or resolution steps. Answers all inquiries in a professional and courteous manner. Duties Promote and support team engagements, programs and activities to create and ensure a positive and productive workplace environment. Perform telephonic and/or onsite admission and concurrent review, and collaborates with onsite staff, physicians, providers, the member and significant others to develop and implement a successful discharge plan. Process, finalize and facilitate inbound requests that are received from providers. Generate appropriate member and provider communication for all determinations within the required timelines as defined by the most current department policy. Facilitate/review requests for Higher level of care or skilled nursing/discharge planning needs. Research for appropriate facilities, specialty providers and ancillary providers to utilize for all lines of business. Identification of potential areas of improvement within the provider network. Identify and initiate referrals for appropriate members to the various L.A. Care programs/processes and external community based programs or Linked and Carve Out Services (e.g. DDS/CCS/MH). Potential quality of care/potential fraud issues are identified and documented per L.A. Care policy. High risk/high cost cases and reports are maintained and referred to the Physician Advisor/UM Director. Document in platform/system of record. Utilize designated software system to document reviews and/or notes. Receive incoming calls from providers, professionally handle complex calls, research to identify timely and accurate resolution steps. Follow up with caller to provide response or resolution steps. Answer all inquiries in a professional and courteous manner. Perform other duties as assigned. Duties Continued Education Required Associate's Degree in Nursing Education Preferred Bachelor's Degree in Nursing Experience Required: At least 5 years of varied RN clinical experience in an acute hospital setting. At least 2 years of Utilization Management/Case Management experience in a hospital or HMO setting . Preferred: Managed Care experience performing UM and CM at a medical group or management services organization. Experience with Managed Medi-Cal, Medicare, and commercial lines of business. Skills Required: Must be computer literate, with expertise in Outlook, Word, Excel, PowerPoint. Effectively utilizes computer and appropriate software and interacts as needed with L.A. Care Information System. Knowledge of personal computer, keyboarding, and appropriate software to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment. Prepare clear, comprehensive written and oral reports and materials. Provision of excellent customer service required due to frequent communication with providers and other members of the interdisciplinary team Excellent time management and priority-setting skills. Maintains strict member confidentiality and complies with all HIPAA requirements. Strong verbal and written communication skills. Preferred: Knowledge of National Committee for Quality Assurance (NCQA) requirements for Utilization Management or Care Management (CM). Knowledge of Department of Health Care Services (DHCS) or Centers for Medicare and Medicaid Services(CMS) requirements for health plan compliance with UM or CM. Licenses/Certifications Required Registered Nurse (RN) - Active, current and unrestricted California License Licenses/Certifications Preferred Certified Case Manager (CCM) Required Training Physical Requirements Light Additional Information May work on occasional weekends and some holidays depending on business needs. Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. L.A. Care offers a wide range of benefits including Paid Time Off (PTO) Tuition Reimbursement Retirement Plans Medical, Dental and Vision Wellness Program Volunteer Time Off (VTO)
Capital Health is the region's leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advanced technology. Capital Health is a five-time Magnet-Recognized health system for nursing excellence and is comprised of 2 hospitals. Capital Health Medical Group is made up of more than 250 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region. Capital Health recognizes that attracting the best talent is key to our strategy and success as an organization. As a result, we aim for flexibility in structuring competitive compensation offers to ensure we can attract the best candidates. The listed pay range or pay rate reflects compensation for a full-time equivalent (1.0 FTE) position. Actual compensation may differ depending on assigned hours and position status (e.g., part-time). Pay Range: $39.40 - $59.19 Scheduled Weekly Hours: 40 Position Overview Shift: Fri, Sat, Sun or Sat, Sun, Mon (8:00am-8:00pm) Performs chart review of identified patients to identify quality, timeliness and appropriateness of patient care. Conducts admission reviews for Medicare, Medicaid beneficiaries, as well as private insurers and self pay patients, based on appropriate guidelines. Uses these criteria guidelines to screen for appropriateness for inpatient level of care or observation services based on physician certification (physicians H&P, treatment plan, potential risks and basis for expectation of a 2 midnight stay). Refers cases as appropriate, to the UR physician advisor for review and determination. Gathers clinical information to conduct continued stay utilization review activities with payers on a daily basis. Performs concurrent and retrospective clinical reviews with various payers, utilizing the appropriate guidelines as demonstrated by compliance with all applicable regulations, policies and timelines. Adheres to CMS guidelines for utilization reviews as evidenced by utilization of the relevant guidelines and appropriate referrals to the physician advisor and the UR Committee. Identifies, develops and implements strategies to reduce length of stay and resource consumption. . Confers proactively with admitting physician to provide coaching on accurate level of care determinations at point of hospital entry. Keeps current on all regulatory changes that affect delivery or reimbursement of acute care services. Uses knowledge of national and local coverage determinations to appropriately advise physicians. Understands and applies federal law regarding the use of Hospital Initiated Notice of Non-Coverage (HINN) and Lifetime Reserve Days letters. Identifies and records consistently any information on any progression of care or patient flow barriers using the Avoidable Days tool in the Utilization software program. Consults with medical staff, care team and case managers as necessary to resolve immediate progression of care barriers through appropriate administrative and medical channels. Engages care team colleagues in collaborative problem solving regarding appropriate utilization of resources. Recognizes and responds appropriately to patient safety and risk factors. Represents Utilization Management at various committees, professional organizations an physician groups as needed. Promotes the use of evidence based protocols and or order sets to influence high quality and cost effective care. Identifies, develops and implements strategies to reduce lengths of stay and resource consumption in the patient population. Participates in performance improvement activities. Promotes medical documentation that accurately reflects findings and interventions, presence of complication or comorbidities, and patient's need for continued stay. Identifies and records episodes of preventable delays or avoidable days due to failure of progression of care processes. Maintains appropriate documentation in the Utilization software system on each patient to include specific information of all resource utilization activities. Participates actively in daily huddles, patient care conferences, and hospitalist or nurse handoff reports to maintain knowledge about intensity of services and the progression of care. Identifies potentially wasteful or misused resources and recommends alternatives if appropriate by analyzing clinical protocols. Maintains related continuing education credits = 15 per calendar year. MINIMUM REQUIREMENTS Education: Minimum of Associate's degree in Nursing. Graduate of an accredited school of nursing. CPHQ, CCM or CPUR preferred. Experience: Three years of clinical nursing or two years quality management, utilization review or discharge planning experience. Other Credentials: Registered Nurse - NJ Knowledge and Skills: Three years of clinical nursing or two years quality management, utilization review or discharge planning experience. CPHQ, CCM or CPUR preferred. Special Training: Basic computer skills including the working knowledge of Microsoft Office, UR software and EMR. Possesses familiarity with MCG guidelines. Mental, Behavioral and Emotional Abilities: Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form. Usual Work Day: 8 Hours PHYSICAL DEMANDS AND WORK ENVIRONMENT Frequent physical demands include: Sitting , Standing , Walking Occasional physical demands include: Climbing (e.g., stairs or ladders) , Carry objects , Push/Pull , Twisting , Bending , Reaching forward , Reaching overhead , Keyboard use/repetitive motion , Talk or Hear Continuous physical demands include: Lifting Floor to Waist 10 lbs. Lifting Waist Level and Above 5 lbs. Sensory Requirements include: Accurate Near Vision, Accurate Far Vision, Accurate Color Discrimination, Accurate Depth Perception, Accurate Hearing Anticipated Occupational Exposure Risks Include the following: N/A This position is eligible for the following benefits: Medical Plan Prescription drug coverage & In-House Employee Pharmacy Dental Plan Vision Plan Flexible Spending Account (FSA) - Healthcare FSA - Dependent Care FSA Retirement Savings and Investment Plan Basic Group Term Life and Accidental Death & Dismemberment (AD&D) Insurance Supplemental Group Term Life & Accidental Death & Dismemberment Insurance Disability Benefits – Long Term Disability (LTD) Disability Benefits – Short Term Disability (STD) Employee Assistance Program Commuter Transit Commuter Parking Supplemental Life Insurance - Voluntary Life Spouse - Voluntary Life Employee - Voluntary Life Child Voluntary Legal Services Voluntary Accident, Critical Illness and Hospital Indemnity Insurance Voluntary Identity Theft Insurance Voluntary Pet Insurance Paid Time-Off Program The pay range listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future. When determining base salary and/or rate, several factors may be considered including, but not limited to location, years of relevant experience, education, credentials, negotiated contracts, budget, market data, and internal equity. Bonus and/or incentive eligibility are determined by role and level. The salary applies specifically to the position being advertised and does not include potential bonuses, incentive compensation, differential pay or other forms of compensation, compensation allowance, or benefits health or welfare. Actual total compensation may vary based on factors such as experience, skills, qualifications, and other relevant criteria.
Description: The Nurse Case Manager - Inpatient is responsible for coordinating the care and service of assigned patients with physicians, nurses, social workers and other members of the healthcare team to facilitate the progression of care from hospital admission through discharge. The Nurse Case Manager- Inpatient is also responsible for ensuring that the patient is placed in the appropriate level of care while monitoring the utilization of healthcare resources and discharge planning to achieve the desired clinical, financial, and resource utilization outcomes. Typical Duties: Provides an assessment for all observation status patients prior to observation placement. The patient is to be assessed throughout the shift to determine discharge readiness or the need to convert to an inpatient status by using the approved medical appropriateness criteria and all third-party payer regulatory requirement. Performs initial status review and level of care placement on all patients in an inpatient status using approved medical appropriate criteria in addition to third-party payer regulatory requirements. Conducts an initial clinical assessment on assigned patients as well as discharge planning assessment prior to admission, at the time of admission, or at discharge. Meets directly with the patient, family, and/or representative to assess needs and develop an individualized discharge plan based on the patient’s medical diagnosis, treatment plan, financial resources, and psychosocial issues, etc. Reassesses the discharge plan throughout the patient’s hospitalization with input from the healthcare team and patient, family, and/or representative and modifying as needed. Collaborates with the multi-disciplinary care team to ensure all needed clinical information is provided to the appropriate entities for the assigned level of care and supports the concurrent appeal process for any reduction in level of care or denial as requested. Maintains active communication with the patient, family, and/or representative, physicians, nursing and other members of the multi-disciplinary care team to effect timely, appropriate patient management; documents each component of the case management process and related activities. Identifies appropriate services not related to admission and assists in arrangement of services on an outpatient basis. Leads the Unit’s daily interdisciplinary rounds to ensure a comprehensive plan of care is developed, including identification of patient needs, assignment of tasks to resolve clinical issues, review of discharge barriers, and identification of discharge planning options. Generates referrals to the Case Management Physician Advisor according to departmental policies. Serves as an educational resource for physician, nursing staff and others concerning case management strategies essential in meeting the organization’s quality, utilization, financial and customer satisfaction objectives. Performs other related job duties as assigned.
Responsibilities At Rolling Hills , our mission is to offer compassionate, safe, effective behavioral healthcare treatment. We use solution-focused strategies and diligently strive for a safe and positive environment for patients, families, and employees. We never forget that we provide care and comfort to people in need. The Utilization Management Coordinator monitor appropriate utilization of services throughout the course of treatment for patients admitted to the inpatient and outpatient programs and coordinates authorizations with third-party payers. The UM Coordinator reviews cases for appropriateness of admission, continued stay, and discharge planning while assisting in the promotion and maintenance of high quality patient care. Qualifications Education/Training : Must possess a current RN license or Master's Degree in Behavioral Health field (e.g. Counseling, Social Work, Psychology) Licensure/Certification: Current TN Driver License Current CPR (training provided) Current Handle With Care (training provided) Experience: Experience in a psychiatric setting as a counselor or nurse preferred; reading, writing, and mathematical skills at the masters' degree level; skills in application of DSM methodology; excellent telephone etiquette and tact; audible speech, with good enunciation; ability to interact effectively with persons of widely diverse roles, backgrounds, cultures, and socio-economic classes; effective oral and written communication skills; skills in analyzing and evaluating information; ability to concentrate on tasks and meet deadlines; basic data entry skills preferred; organizational, time management, problem solving, meet deadlines; basic data entry skills preferred; crisis management skills necessary; flexibility, creativity, and the ability to manage stress are necessary. EEO Statement All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers such as, openly support and fully commit to recruitment, selections, placement, promotion and compensation of individuals withouth regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws. We believe that diversity and inclusion amoung our teammates is critical to our success. Notice At UHS and all our subsidiares, our Human Resources deparments and recruiters are here to help prospective cadidates by matching skillset and expereince with the best possiblke career path at UHS and our subsidiares. We take pride in creating a highly efficient and best-in-class candidate experience. During the recrtuitment process, no recruiter or employee will request financial or personal information (Social Security Number, credit card or bank information, etc.) from you via email. The recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc. If you are suspicious of a job posting or job-related email mentioning UHS or its subsidiaries, let us know by contacting us at https://uhs.alertline.com or 1-800-852-3449. UHS is a registered trademark of UHS of Delaware, Inc., the management company for Universal Health Services, Inc. and a wholly-owened subsidiary of Universal Health Services, Inc. Universal Health Services, Inc. is a holding company and operates through its subsidiaries including its managment company, UHS of Delaware, Inc. All healthcare and management operations are conducted by subsidiares of Universal Health Services, Inc. To the extent any reference to UHS or UHS facilities on this webiste including any statements, articles or other publications contained herein relates to our healthcare or management operations it is referring to Universal Health Services' subsidiaries including UHS of Delaware. Further, the terms "we", "us", "our" or "the company" in such context similarly refer to the operations of Universal Health Services' subsididares including UHS of Delware. Any employment referenced in this website is not with Universal Health Servicesk, Inc. but solely with one of its subsidiares including but not limited to UHS of Delware, Inc. UHS is not accepting unsolicted assistance from search firms for this employment opportunity. Please, no phone calls or emails. All resumes submitted by search firms to any employee at UHS via email, the Internet or in any form and/or method without a valid written search agreement in place for this posiiton will be deemed the sole property of UHS. No fee will be paid in the event the candidate is hired by UHS as a result of the referral or through other means.
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.
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.
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
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.
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
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.
As a utilization review (UR) nurse, you help ensure that patients are receiving the appropriate level of care while being mindful of expenditures to your employer, whether you work for a hospital, managed care facility, or insurance company.
Wondering where you might work in this role? The federal government requires that organizations participating in Medicare and Medicaid conduct utilization reviews. This means that you’ll find a variety of workplace options for UR nurse jobs.
Education and Certifications for Utilization Review Nursing Jobs
Before you can work in utilization review, you must complete a nursing program from an approved institution. Once you pass the NCLEX and receive your license, you’ll want to gain clinical experience in direct patient care. Registered nurses may also want to pursue experience as an RN case manager.
While likely not required for most jobs, specialty certification can increase both your knowledge and also your leverage when it comes time to look for a new utilization review nurse job. Certifications include:
Health Utilization Management Certification (HUMC)
Put some effort into customizing your utilization review nurse resume to each job posting. For instance, if an employer is seeking a candidate “proficient in insurance prior authorizations and medical necessity criteria for different payers,” include that phrase in your resume. This helps demonstrate that your skills are a good fit for the job.
In your UR nurse cover letter, explain a bit about what drew you to this particular position. Remember, you don’t want just any old job — you want this job. To reinforce this sentiment as you apply to UR nurse jobs, search the employer’s website for their mission statement and see where your values overlap.
Interviewing for a Utilization Review Nurse Job
A job interview has the potential to determine whether or not you’ll get a job offer. Need some pointers? Review our nursing interview tips in advance to help you formulate smart answers to common questions and boost your confidence.
Learn how to answer interview questions about your strengths as a nurse:
Utilization Review Nurse Salary
The average annual salary for a UR nurse is around $91,600 for a registered nurse. Your location, level of education and experience, and employer can impact this number. For a more accurate picture of utilization review nurse jobs’ salary estimates in your area, explore the current UR nursing jobs on IntelyCare.
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Check out all the positions available right now. Want additional options? IntelyCare can match you with even more nursing jobs that interest you.
