utilization management nurse

Brighton Health Plan Solutions

<div>
 <strong>
  About The Role
  <br/>
  <br/>
 </strong>
 BHPS provides Utilization Management services to its clients. The Utilization Management Nurse performs medical necessity and benefit review requests in accordance with national standards, contractual requirements, and a member&rsquo;s benefit coverage while working remotely.
 <br/>
 <br/>
 <strong>
  Primary Responsibilities
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Performs clinical utilization reviews using evidenced based guidelines, policies and nationally recognized clinical criteria and internal policies/procedures
  </li>
  <li>
   Identifies potential Third-Party Liability and Coordination of Benefit Cases and notifies appropriate parties/departments
  </li>
  <li>
   Collaborates with healthcare partners to ensure timely review of services and care
  </li>
  <li>
   Provides referrals to Case management, Disease Management, Appeals &amp; Grievances, and Quality Departments as needed
  </li>
  <li>
   Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards
  </li>
  <li>
   Identifies potential quality of care issues, service or treatment delays and intervenes as clinically appropriate
  </li>
  <li>
   Triages and prioritizes cases and other assigned duties to meet required turnaround times
  </li>
  <li>
   Prepares and presents cases to Medical Director (MD) for medical director oversight and necessity determinations
  </li>
  <li>
   Communicates determinations to providers and/or members in compliance with regulatory and accreditation requirements
  </li>
  <li>
   Duties as assigned
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Essential Qualifications
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Current Licensed Practical Nurse (LPN) with state licensure. Must retain active and unrestricted licensure throughout employment
  </li>
  <li>
   Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
  </li>
  <li>
   Must be able to work independently
  </li>
  <li>
   Must be detail oriented and have strong organizational and time management skills
  </li>
  <li>
   Adaptive to a high pace and changing environment- flexibility in assignment
  </li>
  <li>
   Proficient in Utilization Review process including benefit interpretation, contract language, medical and policy review
  </li>
  <li>
   Proficient in MCG and CMS criteria sets
  </li>
  <li>
   Experience with both inpatient and outpatient reviews including Behavioral Health, DME, Genetic Testing, Clinical Trials, Oncology, and/or elective surgical cases preferred
  </li>
  <li>
   Working knowledge of URAC and NCQA
  </li>
  <li>
   2+ years&rsquo; experience in a UM team within managed care setting
  </li>
  <li>
   3+ years&rsquo; experience in clinical nurse setting preferred
  </li>
  <li>
   TPA Experience preferred
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  About
  <br/>
  <br/>
 </strong>
 At Brighton Health Plan Solutions, LLC, our people are committed to the improvement of how healthcare is accessed and delivered. When you join our team, you&rsquo;ll become part of a diverse and welcoming culture focused on encouragement, respect and increasing diversity, inclusion and a sense of belonging at every level. Here, you&rsquo;ll be encouraged to bring your authentic self to work with all of your unique abilities.
 <br/>
 <br/>
 Brighton Health Plan Solutions partners with self-insured employers, Taft-Hartley Trusts, health systems, providers as well as other TPAs, and enables them to solve the problems facing today&rsquo;s healthcare with our flexible and cutting-edge third-party administration services. Our unique perspective stems from decades of health plan management expertise, our proprietary provider networks, and innovative technology platform. As a healthcare enablement company, we unlock opportunities that provide clients with the customizable tools they need to enhance the member experience, improve health outcomes and achieve their healthcare goals and objectives. Together with our trusted partners, we are transforming the health plan experience with the promise of turning today&rsquo;s challenges into tomorrow&rsquo;s solutions.
 <br/>
 <br/>
 Come be a part of the Brightest Ideas in Healthcare&trade;.
 <br/>
 <br/>
 <strong>
  Company Mission
  <br/>
  <br/>
 </strong>
 Transform the health plan experience &ndash; how health care is accessed and delivered &ndash; by bringing outstanding products and services to our partners.
 <br/>
 <br/>
 <strong>
  Company Vision
  <br/>
  <br/>
 </strong>
 Redefine health care quality and value by aligning the incentives of our partners in powerful and unique ways.
 <br/>
 <br/>
 Powered by JazzHR
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 <br/>
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</div>


Utilization Management Nurse

Humana

<div>
 <strong>
  Become a part of our caring community
  <br/>
  <br/>
 </strong>
 The Utilization Management Registered Nurse uses clinical nursing skills to interpret and support the coordination, documentation and communication of medical services and benefit administration determinations. You will report to the Manager of Utilization Management and serve as a member of the One Home/Home Solutions Utilization Management team. This team manages post-acute care services. These services include Skilled Nursing Facility (SNF), Home Health, and Durable Medical Equipment (DME). The team's goal is to ensure members receive the appropriate level of care in the most appropriate setting.
 <br/>
 <br/>
 <strong>
  As a Utilization Management Registered Nurse
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   You will use clinical nursing skills to interpret and support the coordination, documentation and communication of medical services and benefit administration determinations.
  </li>
  <li>
   Using established medical criteria, you will make determinations based on information provided by the attending physician and other care providers
  </li>
  <li>
   You will complete request determinations within established processing time frames. (i.e. 10 reviews per day?)
  </li>
  <li>
   You will communicate with providers, members, or other parties to facilitate care and treatment.
  </li>
  <li>
   You will help deliver coordinated care for our members
  </li>
  <li>
   You will understand department, segment, and organizational strategy and operating goals, including their linkages to related areas.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Required Qualifications
  <br/>
  <br/>
 </strong>
 <strong>
  Use your skills to make an impact
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Must hold Compact Registered Nurse (RN) license in your state of residence
  </li>
  <li>
   Greater than one year of clinical experience as a RN in a hospital, SNF, Home Health, or acute care setting.
  </li>
  <li>
   Must be passionate about contributing to an organization focused on improving consumer experiences
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Preferred Qualifications
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Previous experience in utilization management/utilization review for a health plan or acute care setting
  </li>
  <li>
   Basic knowledge of medical necessity criteria such as Milliman Care Guidelines or Interqual.
  </li>
  <li>
   Experience working in a fully remote, metrics-focused role
  </li>
  <li>
   Experience as an MDS Coordinator or discharge planner in an acute care setting
  </li>
  <li>
   Experience as an RN for a Medicare Certified Home Health agency
  </li>
  <li>
   Health Plan or Medicare / Medicaid Experience
  </li>
  <li>
   Call center or triage experience
  </li>
  <li>
   BSN or bachelor's degree in a related field
   <br/>
   <br/>
  </li>
 </ul>
 Additional Information
 <br/>
 <br/>
 <strong>
  Work-at-Home Information
  <br/>
  <br/>
 </strong>
 To ensure Home or Hybrid Home/Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria:
 <br/>
 <br/>
 <ul>
  <li>
   At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested.
  </li>
  <li>
   Satellite, cellular and microwave connection can be used only if approved by leadership.
  </li>
  <li>
   Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
  </li>
  <li>
   Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job.
  </li>
  <li>
   Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.
   <br/>
   <br/>
  </li>
 </ul>
 Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
 <br/>
 <br/>
 <strong>
  Scheduled Weekly Hours
  <br/>
  <br/>
 </strong>
 40
 <br/>
 <br/>
 <strong>
  Pay Range
  <br/>
  <br/>
 </strong>
 The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.
 <br/>
 <br/>
 $71,100 - $97,800 per year
 <br/>
 <br/>
 This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.
 <br/>
 <br/>
 <strong>
  Description Of Benefits
  <br/>
  <br/>
 </strong>
 Humana, Inc. and its affiliated subsidiaries (collectively, &ldquo;Humana&rdquo;) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
 <br/>
 <br/>
 <strong>
  About Us
  <br/>
  <br/>
 </strong>
 About Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health &ndash; delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer at Humana.com and at CenterWell.com.
 <br/>
 <br/>
 <strong>
  Equal Opportunity Employer
  <br/>
  <br/>
 </strong>
 It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.
</div>


Utilization Management Registered Nurse

Palm Medical Centers

<div><b>Position Summary:</b><br>
The <b>Concurrent Review Nurse</b> is responsible for performing utilization management activities to ensure medical services are delivered effectively, efficiently, and appropriately. This includes reviewing inpatient admissions and ongoing hospital stays to determine medical necessity, appropriateness of care, and length of stay in accordance with clinical guidelines and payer requirements.<br>
<br>
<b>Key Responsibilities:</b><ul><li>
Conduct timely and accurate concurrent reviews of inpatient hospitalizations and other levels of care.</li><li>
Evaluate clinical documentation against evidence-based criteria (e.g., InterQual&reg;, MCG) to determine medical necessity and appropriate level of care.</li><li>
Collaborate with physicians, hospital staff, and insurance companies to coordinate patient care and discharge planning.</li><li>
Communicate utilization review decisions and recommendations to providers and payers.</li><li>
Document all reviews, decisions, and communications in accordance with regulatory and organizational standards.</li><li>
Identify cases requiring escalation or peer review and follow established procedures.</li><li>
Ensure compliance with CMS guidelines, accreditation standards (e.g., NCQA, URAC), and HIPAA.</li><li>
Participate in quality improvement initiatives and departmental meetings</li></ul><b>
Qualifications:</b><br>
<br>
<b>Education &amp; Licensure:</b><ul><li>
Registered Nurse (RN) license, active and in good standing, required.</li><li>
Associate or Bachelor&rsquo;s degree in nursing (BSN preferred).</li></ul><b>
Experience:</b><ul><li>
Minimum 2 years of clinical experience (e.g., med-surg, critical care).</li><li>
At least 1 year of utilization review, case management, or managed care experience preferred.</li></ul><b>
Skills &amp; Competencies:</b><ul><li>
Knowledge of InterQual&reg;, MCG, or other clinical review guidelines.</li><li>
Familiarity with Medicare/Medicaid and commercial insurance regulations.</li><li>
Strong analytical and clinical judgment skills.</li><li>
Effective communication and negotiation skills.</li><li>
Proficient with electronic medical records (EMRs) and utilization review platforms.</li><li>
Detail-oriented with excellent organizational skills.</li></ul><b>
Work Environment:</b><ul><li>
Remote</li></ul><p><br>
Palm Primary Care is an equal opportunity employer that is committed to diversity and inclusion in the workplace. We prohibit discrimination and harassment of any kind based on race, color, sex, religion, sexual orientation, national origin, disability, genetic information, pregnancy, or any other protected characteristic as outlined by federal, state, or local laws.<br>
<br>
This policy applies to all employment practices within our organization, including hiring, recruiting, promotion, termination, layoff, recall, leave of absence, compensation, benefits, training, and apprenticeship. Palm Primary Care makes hiring decisions based solely on qualifications, merit, and business needs at the time.</p><p>
</p><p>9cbfR8Lziz</p></div>

Concurrent Review Nurse

Advanced Health Coordinated Care Organization

<div>
 We are currently hiring a
 <strong>
  Part-time
 </strong>
 <strong>
  REMOTE Utilization Review Nurse!
 </strong>
 If you are a licensed nurse with excellent critical thinking skills, have experience in acute care settings and utilization review, and value being part of a team that makes a difference, you may be the right person for the position!
 <strong>
  Apply today!
  <br/>
  <br/>
 </strong>
 <strong>
  Classification:
 </strong>
 NON-EXEMPT |
 <strong>
  Status &amp; Schedule:
 </strong>
 PART-TIME, 20-HRS/WEEK, GENERALLY MONDAY &ndash; FRIDAY, BUT MAY INCLUDE ADDITIONAL HOURS TO MEET THE NEEDS OF THE POSITION
 <br/>
 <br/>
 <strong>
  Location:
 </strong>
 REMOTE, LOCAL TO OREGON STRONGLY PREFERRED
 <br/>
 <br/>
 <strong>
  Work Location:
 </strong>
 OR, CA, AZ, TX, FL
 <br/>
 <br/>
 <strong>
  Salary:
 </strong>
 $35.29 - $47.37/HOURLY
 <br/>
 <br/>
 <strong>
  Department:
 </strong>
 MEDICAL SERVICES/UTILIZATION REVIEW |
 <strong>
  Reports to:
 </strong>
 DIRECTOR OF MEDICAL SERVICES |
 <strong>
  Supervision Exercised:
 </strong>
 NON-SUPERVISORY
 <br/>
 <br/>
 <strong>
  JOB PURPOSE: Utilization Review Nurse
  <br/>
  <br/>
 </strong>
 The Clinical Review Nurse is responsible for providing clinically efficient and effective utilization management. Reviews prior authorization requests for appropriate care and setting by following evidence based clinical guidelines, medical necessity criteria and health plan guidelines. Reviews and applies hierarchy of criteria to all referral and preauthorization requests from the PCP's and specialists that require a medical necessity determination. Is involved in assuring that the patient receives high-quality cost-effective care. Uses sound clinical judgement and managed care principles in the coordination of care. Prepares any case that does not meet medical necessity guidelines for medical appropriateness of procedure, service, or treatment for review with the Physician Reviewer for a decision.
 <br/>
 <br/>
 <strong>
  QUALIFICATIONS, EDUCATION, And EXPERIENCE
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Nursing degree from an accredited nursing program
  </li>
  <li>
   Unrestricted Oregon RN license
  </li>
  <li>
   Experience with a similar population in health plans or managed care
  </li>
  <li>
   Experience administering OHP, Medicare benefits or utilization review highly preferred.
   <br/>
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  ESSENTIAL RESPONSIBILITIES: Licensed Utilization Review
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Maintains clinical expertise and knowledge of scientific progress in nursing and medical arena and incorporates this information into the clinical review and care coordination processes
  </li>
  <li>
   Performs clinical review for appropriate utilization of medical services by applying appropriate medical necessity criteria guidelines
  </li>
  <li>
   Authorizes healthcare services in compliance with contractual agreements, Health Plan guidelines and appropriate medical necessity criteria
  </li>
  <li>
   Provides accurate and timely documentation within internal system supporting rational of decision based on clinical review
  </li>
  <li>
   Identifies members who are appropriate for care coordination programs and collaborates with the Medical Management team for care coordination of the member's needs along the continuum of care
  </li>
  <li>
   Meets timeliness standards for referral and prior authorization activities
  </li>
  <li>
   Sends appropriate notifications for Third Party Liability (TPL) and/or possible Stop Loss
  </li>
  <li>
   Forward relevant information of members requiring special interventions to Advanced Health
  </li>
  <li>
   Participate in quality and organizational process improvement activities and teams when requested
  </li>
  <li>
   Assist in audit preparation as directed
  </li>
  <li>
   Ensure compliance with company policies and procedures as applicable to area(s) of responsibility
  </li>
  <li>
   Handle confidential information and materials appropriately and maintains a secure work area
  </li>
  <li>
   Maintains the confidentiality of all company procedures, results, and information about patients, contracts, and all other proprietary information regarding company business.
  </li>
  <li>
   Ensure compliance with company policies and procedures as applicable to area(s) of responsibility
  </li>
  <li>
   Handle confidential information and materials appropriately and maintain a secure work area
  </li>
  <li>
   Other duties as assigned
   <br/>
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  ESSENTIAL RESPONSIBILITIES: ORGANIZATIONAL TEAM MEMBER
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Participate in quality and organizational process improvement activities and teams when requested
  </li>
  <li>
   Support and contribute to effective safety, quality, and risk management efforts by adhering to established; policies and procedures, maintaining a safe environment, promoting accident prevention, and identifying and reporting potential liabilities
  </li>
  <li>
   Openly, clearly, and respectfully share and receive information, opinions, concerns, and feedback in a supportive manner
  </li>
  <li>
   Work collaboratively by mentoring new and existing co-workers, building bridges, and creating rapport with team members across the organization
  </li>
  <li>
   Provide excellent customer service to all internal and external customers, which includes team members, members, students, visitors, and vendors, by consistently exceeding the customer&rsquo;s expectations
  </li>
  <li>
   Recognize new developments and remain current in [position&rsquo;s expertise] best practice standards and anticipate organizational modifications
  </li>
  <li>
   Advance personal knowledge base by pursuing continuing education to enhance professional competence
  </li>
  <li>
   Promote individual and organizational integrity by exhibiting ethical behavior to maintain high standards
  </li>
  <li>
   Represent organization at meetings and conferences as applicable
   <br/>
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  KNOWLEDGE, SKILLS, And ABILITIES
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Knowledge of OHP program requirements, benefit package, eligibility categories, and Oregon Division of Medical Assistance Program (MAP) rules and regulations preferred
  </li>
  <li>
   Knowledge of ICD, CPT, and HCPCS codes
  </li>
  <li>
   Proficient in Milliman Clinical Guidelines (MCG)
  </li>
  <li>
   Strong attention to detail
  </li>
  <li>
   Ability to think and work independently with minimum supervision
  </li>
  <li>
   Provide critical attention to detail for accuracy and timeliness
  </li>
  <li>
   Ability to manage multiple tasks and remain flexible in a dynamic work environment
  </li>
  <li>
   Ability to report to work as scheduled, and willingness to work a flexible schedule when needed
  </li>
  <li>
   Proficient in Microsoft Office Suite and Windows Operating System (OS)
  </li>
  <li>
   Training in or awareness of Health Literacy, Poverty Informed, Systemic Oppression, language access and the use of healthcare interpreters, uses of data to drive health equity, Cultural Awareness, Trauma-Informed Care, Adverse Childhood Experiences (ACEs), Culturally and Linguistically Appropriate Service (CLAS) Standards, and universal access
  </li>
  <li>
   Knowledge and understanding of how the positions&rsquo; responsibilities contribute to the department and company goals and mission
  </li>
  <li>
   Knowledge of federal and state laws including OSHA, HIPAA, Waste Fraud and Abuse
  </li>
  <li>
   Awareness and understanding of equity, diversity, inclusion, and the equity lens: ability to analyze the unfair benefits and/or burdens within a society or population by understanding the social, political, and environmental contexts of policies, programs, and practices
  </li>
  <li>
   Excellent people skills and friendly demeanor
  </li>
  <li>
   Critical thinking skills of using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems
  </li>
  <li>
   Attention to detail and organization skills
  </li>
  <li>
   Ability to handle stress and sensitive situations effectively while projecting a professional attitude
  </li>
  <li>
   Ability to communicate professionally, both conversing and written
  </li>
  <li>
   Ability to work with diverse populations and interact with people of differing personalities and backgrounds
  </li>
  <li>
   Sensitive to economic considerations, human needs and aware of how one&rsquo;s actions may affect others
  </li>
  <li>
   Ability to organize and work in a sensitive manner with people from other cultures
  </li>
  <li>
   Poised; maintains composure and sense of purpose
   <br/>
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  WORKING CONDITIONS
  <br/>
  <br/>
 </strong>
 This position must have the ability to remain in a stationary position, occasionally move about inside the office to access office machinery, printer, etc., frequently communicate and exchange accurate information.
 <br/>
 <br/>
 <strong>
  Work Condition:
 </strong>
 Remote Work Environment
 <br/>
 <br/>
 <ul>
  <li>
   Employee generally works within a remote work from home environment.
  </li>
  <li>
   Travel may be required on occasion.
  </li>
  <li>
   Hours of operations and specific staff scheduling may vary based on operational need.
   <br/>
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Exposed to:
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Employee is responsible for maintaining a safe work environment that is conducive to successful productivity and work output.
  </li>
  <li>
   Machines, equipment, tools, and supplies used: Constantly operates a computer or other office productivity machinery or software, such as fax, copier, calculator, multi-line telephone system, or scanner.
  </li>
  <li>
   May answer a high volume of telephone calls, complete documentation, and use computer programs to either obtain or record information.
   <br/>
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Multiple Duties:
 </strong>
 Must be able to work under conditions of frequent interruption and be able to stay on task.
 <br/>
 <br/>
 This job description is intended to provide only basic guidelines for meeting job requirements. This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of DOCS Management Services employees. Other duties, responsibilities and activities may change or be assigned at any time with or without notice.
</div>


REMOTE Utilization Review Nurse - Managed Care

Trillium Health Resources

<div><div><b>Pay Plan Title: </b>Registered Nurse</div><div><b>
Working Title: </b>Registered Nurse, UM &ndash; Physical Health</div><div><b>
FLSA Status: </b>Exempt</div><div><b>
Posting Salary Range: </b>$66,240 - $88,595</div><div><b>
Office Location: </b>Remote within North Carolina.</div><div></div><div><b><br>
POSTING DETAILS:</b></div><div></div><div><b><br>
Make an Impact</b></div><div></div><div><br>
Trillium Health Resources is a Tailored Plan and Managed Care Organization (MCO) serving 46 counties across North Carolina. We manage services for individuals with serious mental health needs, substance use disorders, traumatic brain injuries, and intellectual/development (IDD) disabilities. Our mission is to help individuals and families build strong foundations for healthy, fulfilling lives.</div><div></div><div><b><br>
Why Work for Us</b>?</div><div></div><div><br>
Trillium believes that empowering others begins with supporting our team. We offer our employees:</div><div></div><div><br>
<ul><li>
A collaborative, mission-driven work environment</li><li>
Competitive benefits and work-from-home options for most positions</li><li>
Opportunities for professional growth in a diverse inclusive culture</li></ul></div><div></div><div><br>
Every day, our work changes lives &ndash; from children thriving through early intervention and school-based therapies, to adults with severe mental illness living independently and contributing to their communities.</div><div></div><div><br>
If you are looking for a unique opportunity to make a tangible impact on the lives of others, apply today!</div><div></div><div><b><br>
What We&rsquo;re Looking For</b></div><div></div><div><br>
Trillium Health Resources has a career opening for a Registered Nurse to join our Utilization Management team! The Registered Nurse, UM &ndash; Physical Health, is responsible for ensuring timely and accurate determination and notification of reviews and reconsiderations based on the review determination status. The Registered Nurse, UM &ndash; Physical Health, will generate approval, modifications, and denials communications, to include member and provider notification of review determination. This position also facilitates, coordinates, and approves medically necessary reviews that meet established criteria.</div><div></div><div><b><br>
On a typical day, you might:</b></div><div></div><div><br>
<ul><li>
Perform prospective/preservice, concurrent, post-service, and retrospective claims medical review processes. Utilizing considerable clinical judgement, independent analysis, critical-thinking skills, and detailed knowledge of clinical coverage policies, clinical practice guidelines, and benefit plans to complete reviews and determinations within required turnaround times specific to the case type. Identify cases needing Medical Director review or input. Present cases to Medical Director for potential review or determinations when needed.</li><li>
Perform telephonic admission and concurrent review, and collaborate with on-site facility staff, physicians, providers, care management, the member, and significant others to develop and implement a successful discharge plan, if contracted by client.</li><li>
Maintain accurate records in the designated medical management system and/or claims systems.</li><li>
Generate appropriate member and provider communication for all determinations within the required timelines as defined by the most current department policy.</li></ul></div><div></div><div><b><br>
Employee Benefits:</b></div><div></div><div><br>
Trillium knows that work/life balance is essential. That&rsquo;s why we offer:</div><div></div><div><br>
<ul><li>
Typical working hours: 8:30 am &ndash; 5:00 pm; flexible work schedules with some roles with management approval.</li><li>
Work-from-home options available for most positions</li><li>
Health Insurance with no premium for employee coverage</li><li>
Flexible Spending Accounts</li><li>
24 days of Paid Time Off (PTO) plus 12 paid holidays in your first year</li><li>
NC Local Government Retirement Pension (defined-benefit plan) https://www.myncretirement.gov/systems-funds/local-governmental-employees-retirement-system-lgers/lgers-handbook</li><li>
401k with 5% employer match and immediate vesting</li><li>
Public Service Loan Forgiveness (PSLF) qualifying employer</li><li>
Quarterly stipend for remote work supplies</li></ul></div><div></div><div><b><br>
Qualifications</b></div><div></div><div><br>
Required:</div><div><ul><li>
Fully licensed by the North Carolina State Board of Nursing as an RN.</li><li>
Minimum two (2) years of Utilization Management/Review experience, to include clinical acute inpatient care (ER, ICU, Med-Surg), behavioral health, compliance, or evidence-based clinical decision support tools (ex: MCG/InterQual).</li><li>
Must have a valid driver&rsquo;s license.</li><li>
Must reside within North Carolina.</li><li>
Must be able to travel within catchment as required.</li></ul></div><div></div><div><br>
Preferred:</div><div><ul><li>
Clinical experience in a managed care organization, health plan or hospital setting.</li><li>
Utilization Management certification.</li></ul></div><div></div><div><b><br>
Deadline for Application:</b> Monday, May 18, 2026 at 11:59pm</div><div></div><div><b><br>
How to Apply</b></div><div></div><div><br>
To be considered, submit your application and resume through our ADP Career Center. Your resume must include:</div><div></div><div><br>
<ul><li>
Employer name, dates of service (month/year), average hours worked per week, and essential job duties</li><li>
Education details (degree type, date awarded, institution, field of study)</li><li>
Licensure/certification information, if applicable</li></ul></div><div></div><div><br>
After submission, your resume will be reviewed to ensure it meets the essential criteria for the position. You&rsquo;ll be notified by HR regarding your application status as appropriate. All applicants will receive a final update once the recruitment cycle closes.</div><div></div><div><br>
Join our Talent Community through ADP to stay informed about future opportunities. Be sure to keep your resume updated in your profile.</div><div></div><div><b><br>
Trillium Health Resources is an Equal Employment Opportunity (EEO) employer and a drug-free workplace. All candidates must pass a drug test as a condition of employment.</b></div><div></div><div><i><br>
#Innovation #Technology #Careers #NorthCarolina #BehavioralHealth</i></div></div>

Registered Nurse, UM – Physical Health

Boston Medical Center

<div><div><div><h3 class="jobSectionHeader"><b>Case Manager, Denials and Appeals, 40 Hours (Days)</b></h3>
 <div></div><div><div><ul><li>46146
</li> </ul></div><div></div><div><ul><li>850 Harrison Avenue, Boston, Massachusetts
</li> </ul></div><div></div><div><ul><li>Full Time</li></ul></div></div><div></div><div><div><div><b><br>
</b></div></div><div></div><div><b>
</b></div></div><div>The UM RN will be responsible for review of potential transfers to the BMC System for tertiary care, in conjunction with the multidisciplinary care team, utilizing medical necessity screening tools to complete initial and continued stay reviews in determining appropriate level of patient care, appropriateness of tests/procedures and an estimation of the patient&rsquo;s expected length of stay. This nurse secures authorization for the patient&rsquo;s clinical services through timely collaboration and communication with payers as required and follows the UR process, in addition to the pre-denial process as defined in the attached job description and in the Utilization Review Plan in accordance with the CMS Conditions of Participation for Utilization Review.<p></p><p><b>
POSITION SUMMARY:</b></p><p></p><p>
Utilizing a collaborative process, the care manager will assess, plan, implement, monitor, and evaluate the options and services required to meet an individual&rsquo;s health needs, using communication and available resources to promote quality, cost-effective outcomes. The care manager helps identify appropriate providers and facilities throughout the continuum of services while ensuring that available resources are being used in a timely and cost-effective manner in order to obtain optimum value for both the patient and the reimbursement source. This care manager is dedicated to handle the increased volume and to support the overall care management process and the department.</p><p></p><p><b>
Position: </b>Case Manager</p><p><b>
Department: </b>Denials and Appeals</p><p><b>
Schedule: </b>40 Hours (Days)</p><p></p><p><b>
JOB REQUIREMENTS</b></p><p></p><p><b>
EDUCATION:</b></p><p></p><p>
Graduate of an accredited BS Program in Nursing</p><p></p><p><b>
CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED</b>:</p><ul>
<li><p>
Licensed to practice as a Registered Nurse in the commonwealth of Massachusetts</p></li>
<li><p>
CCM or related certification attained within 24 months from the hire date is preferred</p></li>
</ul><p></p><p><b>
EXPERIENCE:</b></p><ul>
<li><p>
3-5 years of diversified clinical experience is required</p></li>
<li><p>
A minimum of 2 years of previous experience involving judgment and decision making, preferably in a utilization management/case management position</p></li>
</ul><p></p><p><b>
KNOWLEDGE AND SKILLS:</b></p><ul>
<li><p>
Extensive background and knowledge of current medical/surgical patterns of practice.</p></li>
<li><p>
Medical terminology and standard medical abbreviations.</p></li>
<li><p>
Managed care concepts, the various health care delivery systems</p></li>
<li><p>
Methods for assessing an individual are level of physical/mental impairment, understanding of the physical and psychological characteristics of illness, and understanding of expected treatment.</p></li>
<li><p>
Confidentiality issues and the legal and ethical issues pertaining to them.</p></li>
<li><p>
ICD-9 and CPT nomenclature and the ability to interpret and convert this information, as applicable.</p></li>
<li><p>
Knowledge of benefits and various plan contracts, eligibility issues and requirements.</p></li>
<li><p>
Role and functional responsibilities of case management professional; case management program philosophy and purpose within Managed Care Program</p></li>
<li><p>
Excellent interpersonal, verbal and written communication and negotiations skills</p></li>
<li><p>
Strong analytical, data management and PC skills</p></li>
</ul><h3 class="jobSectionHeader"><b>
NursingCM</b></h3><p></p><p><b>
Compensation Range:</b></p>
$38.05- $75.33<p>
This range offers an estimate based on the minimum job qualifications. However, our approach to determining base pay is comprehensive, and a broad range of factors is considered when making an offer. This includes education, experience, and licensure/certifications directly related to position requirements. In addition, BMCHS offers generous total compensation that includes, but is not limited to, benefits (medical, dental, vision, pharmacy), contract increases, Flexible Spending Accounts, 403(b) savings matches, earned time cash out, paid time off, career advancement opportunities, and resources to support employee and family wellbeing.</p><p></p><p>
Equal Opportunity Employer/Disabled/Veterans</p><p>
According to the FTC, there has been a rise in employment offer scams. Our current job openings are listed on our website and applications are received only through our website. We do not ask or require downloads of any applications, or &ldquo;apps&rdquo; job offers are not extended over text messages or social media platforms. We do not ask individuals to purchase equipment for or prior to employment.</p></div></div></div></div>

Case Manager, Denials and Appeals, 40 Hours (Days)

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Registered Nurse, UM – Physical Health

Case Manager, Denials and Appeals, 40 Hours (Days)