utilization management rn

Humana

<div><h1 class="jobSectionHeader">Become a part of our caring community and help us put health first 
</h1>
Why Humana? 
At Humana, caring is everything. You look after our members and patients. We look after you. If caring means something to you too, we've got a spot for you. We design competitive and flexible benefits packages to provide our employees a sense of financial security now and in the future. 
Fostering a culture of inclusion is part of the fabric of who we are. We must have a workplace that reflects the people we serve and thrives in part because every person can bring their whole self to work to make an impact. Our vibrant, diverse culture and environment of inclusion is one of our greatest strengths. 
About Humana Healthy Horizons 
Humana Healthy Horizons is more than a health plan. We're human care. Humana Healthy Horizons focuses on helping people achieve their best health. Our dedicated strategies across various markets and states are enabled by partnerships with state and local governments, community-based organizations, and national partners committed to removing barriers to helping people achieve their best health. 
The Utilization Management (UM) Nurse 2 uses clinical nursing skills to support the coordination, documentation, and communication of medical services and benefit administration determinations. The Utilization Management Nurse 2's work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.
Position Responsibilities:<ul><li>
Uses clinical knowledge toward interpreting criteria and procedures to provide the best and most appropriate treatment, care, or services for Enrollees</li><li>
Coordinates and communicates with Providers, Enrollees or other parties to facilitate optimal care and treatment</li><li>
Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas</li><li>
Uses judgement regarding own work methods, occasionally in ambiguous situation, and receiving guidance where needed</li><li>
Follows established guidelines and procedures</li><li>
Periodic travel to Humana Oklahoma City office for meetings and training</li></ul><h1 class="jobSectionHeader"> 

Use your skills to make an impact 

</h1>Required Qualifications:<ul><li>
Must Reside in Oklahoma</li><li>
An active Licensed Registered Nurse (RN), unrestricted</li><li>
3+ years of prior clinical experience, preferably in an acute care, skilled or rehabilitation clinical setting</li><li>
Comprehensive knowledge of Microsoft Excel and Outlook</li><li>
Ability to work a weekend rotation</li></ul>
Preferred Qualifications:<ul><li>
Previous experience in Utilization Management</li><li>
Prior experience with EPIC Programs</li><li>
Previous remote work experience</li></ul>
WAH Internet Statement
To ensure Home or Hybrid Home/Office employees&rsquo; ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria:<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.</li></ul>
HireVue
As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.
SSN Alert
Humana values personal identity protection. Please be aware that applicants may be asked to provide their Social Security Number, if it is not already on file. When required, an email will be sent from Humana@myworkday.com with instructions on how to add the information into your official application on Humana&rsquo;s secure website.
Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
Scheduled Weekly Hours
40
Pay Range
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. 

$71,100 - $97,800 per year 

This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.
Description of Benefits
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.<h1 class="jobSectionHeader"> 
About us 
</h1>
Humana Inc. (NYSE: HUM) is committed to putting health first &ndash; for our teammates, our customers and our company. Through our Humana insurance services and 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, Medicaid, families, individuals, military service personnel, and communities at large. 
 
Equal Opportunity Employer
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 RN - Physical Health

Novant Health

<div>What We Offer:

 Why This Role Matters
The Utilization Review RN plays a critical role in ensuring the integrity and compliance of patient health records, while supporting patient care by driving accuracy and adherence to ensure accurate and compliant billing. 
What You&rsquo;ll Do:<ul><li>
Schedule - Monday - Friday, daytime hours, weekend, and holiday rotations are required.</li><li>
Conduct thorough chart reviews, within the assigned facilities, to ensure Medicare rules are adhered to for compliance and reimbursement.</li><li>
Provide administrative and technical support to the Utilization Review team to ensure timely payer communication, authorization tracking, and accurate documentation.</li><li>
Process large volumes of confidential patient and payer information to support billing workflows (includes managing payor communications and processing authorizations).</li><li>
Collaborate with physicians and other members of the healthcare team to promote and adhere to regulatory compliance.</li><li>
Participate in quality improvement initiatives within the department.</li><li>
Maintain compliance and regulatory standards and organizational policies. All Utilization Review activities are performed in accordance with the current policies and procedures, mission, vision, and values of Novant Health.</li><li>
Establish and maintain effective work relationships with both internal and external customers.</li></ul>
What You&rsquo;ll Need:
Required:<ul><li>
Current RN licensure in the appropriate state.</li><li>
Graduate of an accredited school of nursing.</li></ul>
Preferred:<ul><li>
Bachelor&rsquo;s degree in Nursing.</li><li>
2+ years of healthcare experience including utilization review or related experience.</li></ul>
What&rsquo;s In It for You:<ul><li>
Comprehensive benefits include health, dental, vision, and life insurance.</li><li>
Retirement fund with matching contributions.</li><li>
Tuition assistance for qualifying team members.</li></ul></div>

Utilization Review RN

Providence

<div>Description
Utilization Review RN at Providence System Offices Discovery Park-Irvine, CA. This position is Part-Time and will work 8-hour, Day shifts.
Provide prospective, retrospective, and concurrent utilization reviews for our Southern CA ministries. Conduct clinical reviews and review medical records daily during admission for all payers, as required by the health plans. This role requires a strong clinical background combined with well-developed knowledge and skills in Utilization Management, medical necessity, and patient status determination. The Utilization Management RN must effectively and efficiently manage a diverse workload in a fast-paced, rapidly changing regulatory environment, demonstrating excellent negotiation, communication, problem-solving, and decision-making skills.
Providence caregivers are not simply valued &ndash; they&rsquo;re invaluable. Join our team at Providence California Regional Services and thrive in our culture of patient-focused, whole-person care built on understanding, commitment, and mutual respect. Your voice matters here, because we know that to inspire and retain the best people, we must empower them.
Required Qualifications:
<ul><li>Associate's Degree in Nursing.</li>
<li>Upon hire: California Registered Nurse License</li>
<li>2 years experience working in a remote UR environment or working as an acute hospital case manager.</li>
</ul>Preferred Qualifications:
<ul><li>Bachelor's Degree in Nursing.</li>
<li>Master's Degree in Nursing.</li>
<li>Experience working with Interqual guidelines.</li>
<li>Experience in a multi-hospital and/or integrated healthcare system.</li>
</ul>Why Join Providence?
Our best-in-class benefits are uniquely designed to support you and your family in staying well, growing professionally, and achieving financial security. We take care of you, so you can focus on delivering our Mission of caring for everyone, especially the most vulnerable in our communities.
About Providence
At Providence, our strength lies in Our Promise of &ldquo;Know me, care for me, ease my way.&rdquo; Working at our family of organizations means that regardless of your role, we&rsquo;ll walk alongside you in your career, supporting you so you can support others. We provide best-in-class benefits and we foster an inclusive workplace where diversity is valued, and everyone is essential, heard and respected. Together, our 120,000 caregivers (all employees) serve in over 50 hospitals, over 1,000 clinics and a full range of health and social services across Alaska, California, Montana, New Mexico, Oregon, Texas and Washington. As a comprehensive health care organization, we are serving more people, advancing best practices and continuing our more than 100-year tradition of serving the poor and vulnerable.
Posted are the minimum and the maximum wage rates on the wage range for this position. The successful candidate's placement on the wage range for this position will be determined based upon relevant job experience and other applicable factors. These amounts are the base pay range; additional compensation may be available for this role, such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities.
Providence offers a comprehensive benefits package including a retirement 401(k) Savings Plan with employer matching, health care benefits (medical, dental, vision), life insurance, disability insurance, time off benefits (paid parental leave, vacations, holidays, health issues), voluntary benefits, well-being resources and much more. Learn more at providence.jobs/benefits.
Applicants in the Unincorporated County of Los Angeles: Qualified applications with arrest or conviction records will be considered for employment in accordance with the Unincorporated Los Angeles County Fair Chance Ordinance for Employers and the California Fair Chance Act.
About the Team
The Sisters of Providence and Sisters of St. Joseph of Orange have deep roots in California, bringing health care and education to communities from the redwood forests to the beach shores of Orange county - and everywhere in between. In Southern California, Providence provides care throughout Los Angeles County, Orange County, High Desert and beyond.
Our award-winning and comprehensive medical centers are known for outstanding programs in cancer, cardiology, neurosciences, orthopedics, women's services, emergency and trauma care, pediatrics and neonatal intensive care. Our not-for-profit network provides a full spectrum of care with leading-edge diagnostics and treatment, outpatient health centers, physician groups and clinics, numerous outreach programs, and hospice and home care, and even our own Providence High School.
Providence is proud to be an Equal Opportunity Employer. We are committed to the principle that every workforce member has the right to work in surroundings that are free from all forms of unlawful discrimination and harassment on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law. We believe diversity makes us stronger, so we are dedicated to shaping an inclusive workforce, learning from each other, and creating equal opportunities for advancement.
Requsition ID: 420761
Company: Providence Jobs
Job Category: Health Information Management
Job Function: Revenue Cycle
Job Schedule: Part time
Job Shift: Day
Career Track: Nursing
Department: 7000 UTILIZATION MGMT OCHD
Address: CA Irvine 15480 Laguna Canyon Rd
Work Location: Providence System Offices Discovery Park-Irvine
Workplace Type: On-site
Pay Range: $57.28 - $88.92
The amounts listed are the base pay range; additional compensation may be available for this role, such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities.</div>

Utilization Review RN - Part-time - REMOTE

Matrix Providers

Matrix Providers is hiring a Registered Nurse - Utilization Management to join our team of talented professionals who provide health care services to our Military Service Members and their families in at Buckley AFB, Aurora, CO. Employment Status: Full Time Compensation: $36.57 - $51.96 per hour Benefits: Competitive financial package with a comprehensive insurance package including health, dental, vision, and life coverage. Accrued Paid Time Off (PTO) Paid Holidays (Outlined in Handbook) 401(k) Plan Minimum Requirements Registered Nurse (RN) Utilization Management: Degree/Education: Bachelor&rsquo;s degree in nursing. Certifications: Basic Life Support Certified/certification eligible in relevant specialty such as: Certified Managed Care Nurse through the American Board of Managed Care Nurses; Certification in Health Care Quality and Management (HCQM) through American Board of Quality Assurance and Utilization Review Physicians (ABQARP) Certified Informatics Nursing, Ambulatory Care Nursing, Medical-Surgical Nursing or Nursing Case Management through the American Nurses Credentialing Center Utilization Management Accreditation through National Committee for Quality Assurance (NCQA) are desired. Experience: A minimum of 36 months total nursing experience in a direct patient care clinical setting. Must have utilization management, utilization review or case management experience for 12 recent consecutive months within the last 12 months. Licensure/Registration: Current, full, active, and unrestricted license to practice as a Registered Nurse. Overview: Serve as a key member of the Utilization Management team, providing comprehensive support to TRICARE beneficiaries. Function independently to ensure appropriate, cost-effective healthcare delivery within TRICARE and Military Health System (MHS) guidelines. Key Responsibilities: Manage a robust Utilization Management program, conducting reviews (prospective, concurrent, retrospective) to ensure proper use of patient care services. Analyze trends, identify inefficiencies, and recommend process improvements to optimize patient care at appropriate levels. Coordinate with military and civilian providers to ensure services meet medical necessity, cost-effectiveness, and TRICARE standards. Serve as a resource for primary care managers, interpreting guidelines, monitoring referrals, and optimizing MTF and civilian healthcare services. Identify and address access/utilization challenges, including enrollment, procedures, inpatient admissions, claims, and grievances. Conduct systematic monitoring and evaluation of utilization metrics, identifying areas for improvement and reporting findings. Provide training to healthcare providers on referral practices for quality and cost-effective care. Qualifications: Advanced knowledge of TRICARE, MHS policies, and referral management systems. Strong analytical skills with the ability to interpret data and recommend solutions. Experience with Electronic Health Records (MHS Genesis preferred). Interpersonal skills to collaborate effectively with diverse teams and stakeholders. Desired Skills: Familiarity with government regulations, healthcare financing, and quality/risk management. Proficiency in office automation software and DHA-approved documentation systems. This role supports healthcare excellence by optimizing resources, improving care quality, and ensuring compliance with TRICARE and DHA standards. We support our employees with an accessible dedicated representative to assist you throughout the duration of your contract. We firmly believe that a healthy work/life balance enables you to perform at your best. Our mission is to serve America&rsquo;s military family by aligning exceptional healthcare workers like you with rewarding career opportunities. Come home to Matrix. #INDKK

Registered Nurse - Utilization Management

Guidehealth

<div>
 
 Company Description
 
 
 
 
 WHO IS GUIDEHEALTH?
 
 
 
 Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. Our goal is to make great healthcare affordable, improve the health of patients, and restore the fulfillment of practicing medicine for providers. Driven by empathy and powered by AI and predictive analytics, Guidehealth leverages remotely-embedded Healthguides&trade; and a centralized Managed Service Organization to build stronger connections with patients and providers. Physician-led, Guidehealth empowers our partners to deliver high-quality healthcare focused on outcomes and value inside and outside the exam room for all patients.
 
 
 
 Job Description
 
 
 
 
 Job Description
 
 
 
 We are seeking a
 
 Clinical Care Manager
 
 who is passionate about advancing high‑quality, compliant, patient‑centered care through precise and timely Utilization Review. In this role, you will apply clinical expertise and regulatory knowledge to evaluate healthcare services, ensure medically necessary care, support provider decision-making, and promote effective care coordination.
 
 
 This is a detailed, analytical, and highly collaborative role that directly contributes to the integrity of care management operations and the member experience.
 
 
 
 What You&rsquo;ll Be Doing
 
 
 
 
 Utilization Review &amp; Clinical Determinations
 
 
 
 <ul>
 <li>
 Complete timely review of healthcare services using appropriate medical criteria to support determinations.
 </li>
 <li>
 Document clinical findings and rationale clearly and accurately in accordance with federal/state regulations, URAC standards, and Guidehealth policies.
 </li>
 <li>
 Communicate precertification and concurrent review decisions&mdash;verbally and in writing&mdash;to required parties within defined timeframes.
 
 
 </li>
 </ul>
 
 Clinical Consultation &amp; Collaboration
 
 
 
 <ul>
 <li>
 Partner with the Medical Director and Peer Reviewers for cases requiring medical necessity evaluation, treatment appropriateness, or quality‑of‑care review.
 </li>
 <li>
 Communicate routinely with ordering providers, provider organizations, and when appropriate, members or their representatives.
 
 
 </li>
 </ul>
 
 Care Coordination &amp; Member Support
 
 
 
 <ul>
 <li>
 Identify and refer eligible members to disease management programs to enhance care quality and continuity.
 </li>
 <li>
 Manage and document on‑call phone communications with members and providers on a rotational basis.
 
 
 </li>
 </ul>
 
 Compliance, Quality &amp; Documentation
 
 
 
 <ul>
 <li>
 Maintain confidentiality of all member information and case records.
 </li>
 <li>
 Participate in quality management initiatives and support related documentation, reporting, data collection, and committee activities.
 </li>
 <li>
 Prepare benefit exhaustion letters upon request.
 </li>
 <li>
 Assist with the design and maintenance of clinical and/or client-specific reports, spreadsheets, and analyses.
 </li>
 <li>
 Maintain current knowledge of relevant regulations, multi‑jurisdictional requirements, medical group guidelines, and URAC standards.
 
 
 </li>
 </ul>
 
 Professional Development
 
 
 
 <ul>
 <li>
 Maintain ongoing professional education and growth aligned with Illinois nursing regulations and contemporary clinical practice.
 
 
 </li>
 </ul>
 Qualifications
 
 
 
 Minimum Qualifications
 
 
 
 <ul>
 <li>
 Active, unrestricted Registered Nurse (RN) license in Illinois.
 </li>
 <li>
 5+ years of experience across varied healthcare settings.
 </li>
 <li>
 Knowledge of utilization review, managed care processes, and community health.
 </li>
 <li>
 Meets Illinois CE requirement of 20 hours per 2‑year RN license renewal cycle.
 </li>
 <li>
 Strong proficiency in Microsoft 365 (Word, Excel, PowerPoint, etc.).
 </li>
 <li>
 Excellent written, verbal, and organizational skills.
 </li>
 <li>
 Ability to prioritize effectively amid rapidly changing business needs.
 </li>
 <li>
 Demonstrates strong clinical judgment, compassion, and a positive attitude.
 
 
 </li>
 </ul>
 
 Preferred Qualifications
 
 
 
 <ul>
 <li>
 Advanced degree or certification in Case Management, Utilization Review, and/or Quality.
 </li>
 <li>
 Interest in Clinical Informatics.
 </li>
 <li>
 Knowledge of Population Health and Health Disparities.
 </li>
 <li>
 Previous experience in health insurance or managed care settings.
 
 
 </li>
 </ul>
 Additional Information
 
 
 All your information will be kept confidential according to EEO guidelines.
 
 
 
 ALIVE with Purpose: How We Thrive at Guidehealth
 
 
 
 At Guidehealth, our values come to life in everything we do.
 
 
 <ul>
 <li>
 We are Driven by Accountability &mdash; grounded in transparency, reliability, and integrity as we navigate challenges and opportunities alike.
 </li>
 <li>
 Always Growing, Always Learning &mdash; staying curious and continuously improving inspires us to shape a better future for healthcare.
 </li>
 <li>
 With Collaborative Innovation, we solve problems creatively, making every experience better for our employees and the patients we serve.
 </li>
 <li>
 At Guidehealth, Every Voice Matters &mdash; we believe our collective strength is rooted in the unique perspectives of each team member.
 </li>
 <li>
 And through Empathy in Action, we build stronger connections with those who count on us.
 </li>
 <li>
 This is what it means to be ALIVE with purpose. This is how we thrive &mdash; together &mdash; at Guidehealth.
 
 
 </li>
 </ul>
 
 BENEFITS:
 
 
 
 While you are hard at work advancing value-based healthcare, we are here to ensure YOU have the care you and your family need and the opportunities for growth and development. Our commitments to you include:
 
 
 <ul>
 <li>
 Work from Home: Guidehealth is a fully remote company, providing you the flexibility to spend less time commuting and more time focusing on your professional goals and personal needs.
 </li>
 <li>
 Keep Health a Priority: We offer comprehensive Medical, Dental, and Vision plans to keep you covered.
 </li>
 <li>
 Plan for the Future: Our 401(k) plan includes a 3% employer match to your 6% contribution.
 </li>
 <li>
 Have Peace of Mind: We provide Life and Disability insurance for those "just in case" moments. Additionally, we offer voluntary Life options to keep you and your loved ones protected.
 </li>
 <li>
 Feel Supported When You Need It Most: Our Employee Assistance Program (EAP) is here to help you through tough times.
 </li>
 <li>
 Take Time for Yourself: We offer paid time off plans helping you achieve work-life balance and meet your personal goals.
 </li>
 <li>
 Support Your New Family: Welcoming a new family member takes time and commitment. Guidehealth offers paid parental leave to give you the time you need.
 </li>
 <li>
 Learn and Grow: Your professional growth is important to us. Guidehealth offers various resources dedicated to your learning and development to advance your career with us.
 
 
 </li>
 </ul>
 All full-time employees of Guidehealth who work 30 hours per week or more are eligible for our comprehensive benefits package. Temporary employees and contractors are not eligible for benefits.
 
 
 
 COMPENSATION:
 
 
 
 The listed compensation range listed is paid bi-weekly per our standard payroll practices. Final base pay decisions are dependent upon a variety of factors which may include, but are not limited to: skill set, years of relevant experience, education, location, and licensure/certifications.
 
 
 
 OUR COMMITMENT TO EQUAL OPPORTUNITY EMPLOYMENT
 
 
 
 Diversity, inclusion, and belonging are at the core of Guidehealth&rsquo;s values. We are an equal opportunity employer. We enthusiastically accept our responsibility to make employment decisions without regard to race, religious creed, color, age, sex, sexual orientation and identity, national origin, citizenship, religion, marital status, familial status, physical, sensory, or medical disability, Family and Medical Leave, military or veteran status, pregnancy, childbirth or other related medical conditions, or any other classification protected by federal, state, and local laws and ordinances. Our management is fully dedicated to ensuring the fulfillment of this policy with respect to hiring, placement, promotion, transfer, demotion, layoff, termination, recruitment advertising, pay, and other forms of compensation, training, and general treatment during employment.
 
 
 
 Our Comittment To Protection Of Patient And Company Data
 
 
 
 This position is responsible for following all Security policies and procedures in order to protect all PHI and PII under Guidehealth&rsquo;s custodianship as well as Guidehealth Intellectual Properties. For any security-specific roles, the responsibilities would be further defined by the hiring manager.
 
 
 As a remote-first organization handling sensitive healthcare data, Guidehealth verifies candidate identity at multiple stages of the hiring and onboarding to safeguard patient privacy, data security, and compliance requirements.
 
 
 
 Remote Work Technical Requirements
 
 
 
 Guidehealth is a fully remote company. We provide new employees with the necessary equipment to function in their role at no charge to the employee. Employees provide their own internet connection, capable of conducting video calls on camera and connecting to various internal and external systems. The required internet speed is a minimum of 100 mbps download, 10 mbps upload. Please run a speed test here to confirm your internet connection meets these requirements.
</div>

Utilization Management Registered Nurse

Talent Groups

<div>
 
 
 Inpatient Utilization Management Clinician
 
 
 
 
 Remote (Occasional travel to Charlestown MA )
 
 
 
 
 3 months Contract
 
 
 
 
 
 
 
 Qualifications:
 
 
 
 Active, unrestricted RN license in state of residence.
 
 
 
 
 
 
 Education:
 
 
 
 Nursing degree or diploma required, bachelor&rsquo;s degree in nursing
 
 
 
 
 
 
 Preferred/Desirable:
 
 
 <ul>
 <li>
 Bachelor&rsquo;s degree
 </li>
 <li>
 RN license in state of MA, NH or compact license
 </li>
 <li>
 Medicare and Medicaid knowledge
 </li>
 </ul>
 
 
 
 
 
 Experience:
 
 
 <ul>
 <li>
 2+ years utilization review experience and evidence-based guidelines (InterQual Guidelines)
 </li>
 <li>
 Managed care experience
 </li>
 <li>
 Experience performing discharge planning
 </li>
 <li>
 All employees working remotely will be required to adhere to Wellenses&rsquo; Telecommuter Policy
 </li>
 </ul>
 
 
 
 
 
 Licensure, Certification or Conditions of Employment:
 
 
 <ul>
 <li>
 Active, unrestricted RN license in state of residence
 </li>
 <li>
 Pre-employment background check
 </li>
 <li>
 Ability to take after hours call, including evening/nights/weekends
 </li>
 </ul>
 
 
</div>

Case Manager

Toney HealthCare Consulting, LLC

The Supervisor, Utilization Management &amp; Appeals is responsible for overseeing daily Utilization Management (UM) and Appeals operations while also providing hands-on overnight, weekend and holiday coverage. This role combines clinical leadership with operational execution to ensure timely, accurate, and compliant utilization and appeal workflows. The Supervisor provides guidance and oversight to UM nurses, supports complex case preparation, ensures regulatory compliance, and maintains operational continuity.This position plays a critical role in ensuring high-quality clinical documentation, effective workload management, and coordination with medical directors, providers, and internal stakeholders.Essential Functions / Key ResponsibilitiesLeadership &amp; Operations<ul><li>Supervise daily activities of UM and Appeals staff, including nurses.</li><li>Monitor workloads, productivity, and performance metrics to maintain service-level and regulatory compliance.</li><li>Provide clinical oversight and coaching on complex UM and Appeals cases; escalate to medical directors as appropriate.</li><li>Train, mentor, and evaluate team members; participate in hiring, corrective action, and performance management processes.</li><li>Develop, implement, and maintain standard operating procedures (SOPs) across UM and Appeals workflows.</li><li>Participate in audits, reporting, and continuous performance improvement initiatives.</li><li>Collaborate cross-functionally with medical directors, case management, providers, and client stakeholders to ensure appropriate care and avoid unnecessary utilization.</li></ul>Clinical &amp; Overnight Coverage<ul><li>Provide overnight, weekend, and holiday operational coverage to maintain continuous UM and Appeals workflows.</li><li>Manage and process work queues, including screening requests, creating authorizations, routing cases, and generating member and provider notifications.</li><li>Prepare accurate and thorough clinical summaries and documentation for physician review (non-decisional).</li><li>Review case data for completeness, accuracy, and regulatory alignment prior to submission.</li><li>Support Appeals intake, screening, and case preparation in accordance with appeal protocols.</li><li>Work independently during overnight and weekend hours with minimal supervision, maintaining productivity during low call-volume periods through assigned tasks.</li></ul>Compliance &amp; Knowledge Management<ul><li>Ensure adherence to federal and state regulations, NCQA/URAC standards, and payer-specific UM and Appeals requirements.</li><li>Maintain strong working knowledge of InterQual and/or MCG criteria.</li><li>Stay current on healthcare regulations, utilization trends, and evidence-based clinical guidelines.</li><li>Ensure consistent application of UM and Appeals policies across all shifts.</li></ul>Core Competencies<ul><li>Leads by example; fosters accountability, trust, and team engagement.</li><li>Thrives in fast-paced, evolving environments and adapts quickly to changing client needs.</li><li>Applies strong clinical judgment and analytical reasoning.</li><li>Anticipates operational challenges, investigates root causes, and implements solutions.</li><li>Communicates effectively with clinical, operational, and client-facing stakeholders.</li><li>Champions operational efficiency and service excellence.</li><li>Provides ongoing feedback, mentorship, and professional development.</li></ul>Required Education &amp; Experience<ul><li>Active, unrestricted Registered Nurse (RN) license in California.</li><li>Minimum of 5 years of Utilization Management experience and 2 years of Appeals experience.</li><li>At least 2 years of leadership or supervisory experience in a UM or Appeals setting.</li><li>Strong understanding of UM and Appeals processes, including intake, screening, and documentation.</li><li>Experience managing or supporting remote clinical teams.</li><li>Familiarity with Medicare, Medicaid, and commercial payer requirements.</li><li>Excellent written communication, attention to detail, and organizational skills.</li><li>Ability to work independently during overnight and weekend shifts.</li></ul>Preferred Qualifications<ul><li>Bachelor of Science in Nursing (BSN).</li><li>Consulting or project-based healthcare experience.</li></ul>Work Schedule<ul><li>Day and overnight coverage, including:</li><li>Weekdays: 5:00 PM &ndash; 8:00 AM (PT)</li><li>Weekends: 8:00 AM Saturday &ndash; 8:00 AM Monday (PT)</li><li>Required holidays and on-call rotation.</li></ul>Physical Requirements / Work Environment<ul><li>Fully remote role with occasional travel (less than 5%).</li><li>Must maintain a secure home office environment with required equipment.</li><li>Prolonged periods of sitting and computer use.</li><li>Ability to communicate clearly in both written and verbal formats.</li></ul>Pay: $50.00 - $60.00 per hourBenefits:<ul><li>401(k)</li><li>Dental insurance</li><li>Health insurance</li><li>Life insurance</li><li>Paid time off</li><li>Vision insurance</li></ul>Experience:<ul><li>Utilization management: 5 years (Required)</li><li>Appeals: 2 years (Required)</li><li>UM leadership : 2 years (Preferred)</li></ul>License/Certification:<ul><li>RN license in California? (Required)</li></ul>Shift availability:<ul><li>Day Shift (Required)</li><li>Night Shift (Required)</li><li>Overnight Shift (Required)</li></ul>Work Location: Remote

Supervisor, Utilization Management & Appeals (After-Hours/Overnight)

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