utilization management specialist

SSM Health

<div><div>It's more than a career, it's a calling.
MO-REMOTE
Worker Type:
Regular
Job Summary:
Serves as the Utilization Management system-wide point of coordination between regional clinical and operational team leaders, physician liaisons, and revenue cycle leaders.
Job Responsibilities and Requirements:
PRIMARY RESPONSIBILITIES<ul><li>
Serves as the direct resource for the regional physician liaisons regarding Utilization Management (UM) initiatives and regional specific UM issues.</li><li>
Performs audits on UM denial write off accounts to ensure accurate categorizing of the root cause of denial and to identify potential opportunities for claims re-bill.</li><li>
Collaborates with Managed Care Organization (MCO) team members to stay abreast of contractual updates to develop and maintain UM payer grids with contractual requirements.</li><li>
Serves as a UM subject matter expert on state and federal regulatory requirements related to UM processes.</li><li>
Represents the system UM team on committees and work groups as assigned by leadership.</li><li>
Presents critical messages and complex information and reports to UM leadership.</li><li>
Provides responses to questions and concerns raised by physician liaisons, clinical and operational team members, providers, and UM leaders.</li><li>
Supports UM leadership and collaborating teams and providers with resources, data, and education to improve UM outcomes.</li><li>
Applies the existing body of evidence-based practice and scientific knowledge in health care to medical-surgical nursing practice, ensuring that nursing care is delivered based on patient&rsquo;s age-specific needs and clinical needs as described in the department's Scope of Service.</li><li>
Performs other duties as assigned.</li></ul>
EDUCATION<ul><li>
Graduate of accredited school of nursing or education equivalency for licensing</li></ul>
EXPERIENCE<ul><li>
Two years' acute nursing experience, four years of Utilization Management experience</li></ul>
PHYSICAL REQUIREMENTS
Frequent lifting/carrying and pushing/pulling objects weighing 0-25 lbs. 
Frequent sitting, standing, walking, reaching and repetitive foot/leg and hand/arm movements. 
Frequent use of vision and depth perception for distances near (20 inches or less) and far (20 feet or more) and to identify and distinguish colors. 
Frequent use of hearing and speech to share information through oral communication. Ability to hear alarms, malfunctioning machinery, etc. 
Frequent keyboard use/data entry. 
Occasional bending, stooping, kneeling, squatting, twisting and gripping. 
Occasional lifting/carrying and pushing/pulling objects weighing 25-50 lbs. 
Rare climbing.
REQUIRED PROFESSIONAL LICENSE AND/OR CERTIFICATIONS 
 
State of Work Location: Illinois<ul><li>
 Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR)</li></ul> 
 
State of Work Location: Missouri<ul><li>
 Registered Nurse (RN) Issued by Compact State</li><li>
 Or</li><li>
 Registered Nurse (RN) - Missouri Division of Professional Registration</li></ul> 
 
State of Work Location: Oklahoma<ul><li>
 Registered Nurse (RN) Issued by Compact State</li><li>
 Or</li><li>
 Registered Nurse (RN) - Oklahoma Board of Nursing (OBN)</li></ul> 
 
State of Work Location: Wisconsin<ul><li>
 Registered Nurse (RN) Issued by Compact State</li><li>
 Or</li><li>
 Registered Nurse (RN) - Wisconsin Department of Safety and Professional Services</li></ul>
Work Shift:
Day Shift (United States of America)<div><div><div><div><div><div><div>
Job Type:</div></div></div></div></div></div></div>
Employee
Department:
8746030033 Sys Utilization Management
Scheduled Weekly Hours:
40
Benefits:
SSM Health values our exceptional employees by offering a comprehensive benefits package to fit their needs.<ul><li>
Paid Parental Leave: we offer eligible team members one week of paid parental leave for newborns or newly adopted children (pro-rated based on FTE).</li><li>
Flexible Payment Options: our voluntary benefit offered through DailyPay offers eligible hourly team members instant access to their earned, unpaid base pay (fees may apply) before payday.</li><li>
Upfront Tuition Coverage: we provide upfront tuition coverage through FlexPath Funded for eligible team members.</li></ul>
Explore All Benefits
SSM Health is an equal opportunity employer. SSM Health does not discriminate on the basis of race, color, religion, national origin, age, disability, sex, sexual orientation, gender identity, pregnancy, veteran status, or any other characteristic protected by applicable law. Click here to learn more.</div></div>

RN-Utilization Management and Denials Liaison

Highmark Health

<div><h2 class="jobSectionHeader">Company :
</h2>Highmark Inc.
<h2 class="jobSectionHeader">Job Description :
</h2>JOB SUMMARY This job implements effective utilization management strategies including: review of appropriateness of health care services, application of criteria to ensure appropriate resource utilization, identification of opportunities for referral to a Health Coach/case management, and identification and resolution of quality issues. Monitors and analyzes the delivery of health care services; educates providers and members on a proactive basis; and analyzes qualitative and quantitative data in developing strategies to improve provider performance/satisfaction and member satisfaction. Responds to customer inquiries and offers interventions and/or alternatives. ESSENTIAL RESPONSIBILITIES Implement care management review processes that are consistent with established industry and corporate standards and are within the care manager&rsquo;s professional discipline. Function in accordance with applicable state, federal laws and regulatory compliance. Implement all care management reviews according to accepted and established criteria, as well as other approved guidelines and medical policies. Promote quality and efficiency in the delivery of care management services. Respect the member&rsquo;s right to privacy, sharing only information relevant to the member&rsquo;s care and within the framework of applicable laws. Practice within the scope of ethical principles. Identify and refer members whose healthcare outcomes might be enhanced by Health Coaching/case management interventions. Employ collaborative interventions which focus, facilitate, and maximize the member&rsquo;s health care outcomes. Is familiar with the various care options and provider resources available to the member. Educate professional and facility providers and vendors for the purpose of streamlining and improving processes, while developing network rapport and relationships. Develop and sustain positive working relationships with internal and external customers. Utilize outcomes data to improve ongoing care management services. Other duties as assigned or requested EDUCATION Required None Substitutions None Preferred Bachelor&rsquo;s Degree in Nursing EXPERIENCE Required 3 years of related, progressive clinical experience in the area of specialization Experience in a clinical setting Preferred Experience in UM/CM/QA/Managed Care LICENSES AND CERTIFICATIONS Required Current State of PA RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC). Additional specific state licensure(s) may be required depending on where clinical care is being provided. Preferred Certification in utilization management or a related field SKILLS Working knowledge of pertinent regulatory and compliance guidelines and medical policies Ability to multi task and perform in a fast paced and often intense environment Excellent written and verbal communication skills Ability to analyze data, measure outcomes, and develop action plans Be enthusiastic, innovative, and flexible Be a team player who possesses strong analytical and organizational skills Demonstrated ability to prioritize work demands and meet deadlines Excellent computer and software knowledge and skills Languages (Other than English) None Travel Requirement 0% - 25% PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS Position Type Office-Based Teaches/trains others regularly Occasionally Travel regularly from the office to various work sites or from site-to-site Does Not Apply Works primarily out-of-the office selling products/services (sales employees) Does Not Apply Physical work site required Yes Lifting: up to 10 pounds Constantly Lifting: 10 to 25 pounds Occasionally Lifting: 25 to 50 pounds Rarely, Occasionally Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job. Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies. As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company&rsquo;s Handbook of Privacy Policies and Practices and Information Security Policy. Furthermore, it is every employee&rsquo;s responsibility to comply with the company&rsquo;s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.
Pay Range Minimum:
$68,400.00
Pay Range Maximum:
$105,900.00
Base pay is determined by a variety of factors including a candidate&rsquo;s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below.
For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org
California Consumer Privacy Act Employees, Contractors, and Applicants Notice</div>

Care Manager RN (Remote)

Molina Healthcare

<div>JOB DESCRIPTION Job Summary
Provides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care. 
Essential Job Duties 
<div> 
<ul><li>Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines.</li><li>Analyzes clinical service requests from members or providers against evidence based clinical guidelines.</li><li>Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures.</li><li>Conducts reviews to determine prior authorization/financial responsibility for Molina and its members.</li><li>Processes requests within required timelines.</li><li>Refers appropriate cases to medical directors (MDs) and presents cases in a consistent and efficient manner.</li><li>Requests additional information from members or providers as needed.</li><li>Makes appropriate referrals to other clinical programs.</li><li>Collaborates with multidisciplinary teams to promote the Molina care model.</li><li>Adheres to utilization management (UM) policies and procedures.</li></ul> 
</div>Required Qualifications
<ul><li>At least 2 years health care experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience.</li><li>Clinical licensure and/or certification required ONLY if required by state contract, regulation, business operating model, or state board licensing mandates. If licensed, license must be active and unrestricted in state of practice.</li><li>Ability to prioritize and manage multiple deadlines.</li><li>Excellent organizational, problem-solving and critical-thinking skills.</li><li>Strong written and verbal communication skills.</li><li>Microsoft Office suite/applicable software program(s) proficiency.</li></ul> 

Preferred Qualifications<div> 
<ul><li>Certified Professional in Healthcare Management (CPHM).</li><li>Recent hospital experience in a medical unit or emergency room.</li></ul> 
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</div></div>

Care Review Clinician

White Plains

<div>Job Summary
Cardiac Cath Lab Tech
White Plains
Full-time
In-Office | White Plains, NY, United States 
The Register Cardiovascular Invasive Specialist is a health care professional working under the direction of an Invasive Cardiologist and Nurse Manager. Through the utilization of specialized equipment assists in performing diagnostic and therapeutic procedures resulting in accurate diagnosis and optimal treatment of heart disease while maintaining maximum patient safety and comfort. The primary roles of Registered Cardiovascular Invasive Specialist include setting up imaging equipment, patient monitoring, procedure documentation and equipment circulator. They are a scrub assistant who works in an environment with the application of ionizing radiation for Cardiac, Electrophysiology, and other Vascular procedures.
FLU VACCINE REQUIRED NO EXCEPTIONS
High School Diploma required.
A graduate of a certificate or degree program or post-secondary educational program in health science (includes but not limited to, cardiovascular technology, ultrasound, radiologic technology, respiratory therapy, nursing or paramedic/EMT).
Bachelor of Science Degree preferred
Successful completion of scrub technician training program or hospital-based training program
One-year scrub technician or cardiac technician experience preferred.
BLS, ACLS required
RCIS preferred
Demonstrates excellent clinical judgment and ability to apply new concepts and skills in invasive cardiology
Demonstrates responsibility for own professional development
#Workwolf</div>

Cardiac Cath Lab Tech

Insight Global

<div>
 
 
 JOB DESCRIPTION
 
 
 
 
 
 
 This role supports workplace strategy, occupancy planning, and ongoing employee moves across multiple R&amp;D buildings. The Workplace Space Planning Specialist will partner closely with architects and workplace leadership to transform occupancy and utilization data into actionable space plans. The ideal candidate is sharp with numbers, comfortable working in databases and spreadsheets, and thrives in a fast-moving environment where space reshuffles and data requests are continuous.
 
 
 
 
 
 
 RESPONSIBILITIES
 
 
 <ul>
 <li>
 Own and maintain Plans of Record by building, department, team, and location.
 </li>
 <li>
 Analyze occupancy data including headcount, square footage per person, utilization rates, and growth projections.
 </li>
 <li>
 Query, extract, and manipulate datasets to identify trends, surface anomalies, and support scenario modeling.
 </li>
 <li>
 Conduct building test fits and validate space layouts against business needs in partnership with architects.
 </li>
 <li>
 Support ongoing employee moves and reshuffles, balancing people's needs with business priorities.
 </li>
 <li>
 Build and present analysis using Excel and PowerPoint for senior leadership audiences.
 </li>
 <li>
 Support scenario planning for large populations (10K+ employees, VP organizations).
 </li>
 </ul>
 
 
 SKILLS AND EXPERIENCE
 
 
 <ul>
 <li>
 Experience in workplace planning, occupancy planning, space strategy, or data-driven operations.
 </li>
 <li>
 Strong analytical foundation &mdash; comfortable working with structured datasets and translating numbers into clear recommendations.
 </li>
 <li>
 Advanced Excel and strong PowerPoint skills.
 </li>
 <li>
 SQL or equivalent data querying experience.
 </li>
 <li>
 Familiarity with BI or visualization tools such as Tableau, Power BI, or Looker.
 </li>
 <li>
 Experience in R&amp;D, tech campus, or large enterprise real estate environments.
 </li>
 <li>
 Strong communication skills; organized, proactive, and comfortable supporting senior leaders.
 </li>
 </ul>
 
 
 
 
 
 Exact compensation may vary based on several factors, including skills, experience, and education.
 
 
 
 
 
 
 
 Benefit packages for this role will start on the 1st day of employment and include medical, dental, and vision insurance, as well as HSA, FSA, and DCFSA account options, and 401k retirement account access with employer matching. Employees in this role are also entitled to paid sick leave and/or other paid time off as provided by applicable law.
 
 
</div>

Business Operations Analyst

Nika

<div>NIKA is hiring for a Multi-Site Support Specialist to support the Defense Health Agency&rsquo;s (DHA) DMLSS Division based out of San Antonio, TX. 


Named a Top Workplace by the Washington Post, NIKA is a well-established company that is focused on growth within an entrepreneurial environment. We work with governments to operate and manage their real property. Our operations management, engineering, and project management services provide our customers with value and expertise to ensure operational readiness for complex and mission-critical facilities. NIKA benefits include PTO, holidays, medical/dental/vision insurance, 401k matching, and an understanding of work/life balance. 


Job Description:

Support the DHA DMLSS/LogiCole Program Manager and coordinate directly with DHA to support all AOR activities. The AOR Manager shall coordinate all site visits with MTF staff personnel to include scheduling and conducting teleconferences prior to each visit. The AOR Manager shall perform DMLSS inspection and analysis, coordinate with DHA to develop and implement measures and plans to improve DMLSS utilization and data quality, submit trip reports and manage local DSS within the respective, provide monthly assessment reports on issues, concerns, staff, and status of DMLSS improvements. 

<ul><li>
Provide comprehensive on-site transition assistance and business process conversions to DHA, MTF Facility Management staff and DSS Contract Staff.</li><li>
Coordinate and perform site visits to MTFs based upon the initial preliminary assessments, development of work plan and schedule, and one or more of the following: site requests, DHA or other requests, known DMLSS FM utilization problems and/or personnel turnover. The (Contractor) shall provide written trip reports and a quantitative evaluation of MTF DMLSS-FM within 5 days of completion of a site visit. A final copy of trip reports and inspections shall be furnished to DHA and MTF staff.</li><li>
Perform remote and onsite inspections, performance analysis, metrics, and quality assurance analysis based on DHA and DMLSS fundamentals business processes and practices utilizing metrics, BusinessObjects, and other applicable analysis tools to evaluate, identify, and report non-compliant DMLSS modules. Contractor shall meet with DHA POC and Facility Management staff to provide a full report with description of non-compliance, findings, course of action to correct deficiencies, provide tools to accomplish task and to improve overall performance and data quality.</li><li>
Provide support to DHA in the planning, development, management of training material, classroom training program, and web-based training seminars to ensure MTF staff and DMLSS Database Sustainment Specialists are fully trained and capable of performing their DMLSS duties or tasks.</li><li>
Ensure all new DSS employees attend a DMLSS-FM Basic course at a designated location provided by DHA.</li><li>
Coordinate performance work sessions with al FM staff to ensure continuous DMLSS implementation and improvement in the overall DMLSS performance addressed in the final site visits assessment or known issues throughout the DHA and MTFs.</li><li>
Provide on-site DHA business-process conversion assistance as requested. Contractor must identify and evaluate efficiency of business processes related to the DMLSS application and work with the MTF Facility Management staff to implement effective automated processes</li><li>
Implement on-site or remote data management at the direction of DHA with MTF coordination.</li><li>
Develop, update, assist, and manage comprehensive Business Objects reports to support site and DMLSS-FM utilization.</li><li>
Perform annual performance evaluation of DSS and upon request of known issues with DSS specialists.</li><li>
Attend various working groups and committees; provide meeting minutes.</li><li>
Perform other duties as assigned.</li><li>
Incumbent required to travel up to 30% of the time.</li></ul><ul><li>
Minimum of five (5) years DMLSS-FM experience.</li><li>
Working knowledge of DoD administrative policies, regulations, precedents and planning guidelines, and processes; knowledge of DoD program goals and objectives, the sequence and timing of key program events and milestones, and methods of evaluating the effectiveness of program accomplishments; knowledge of relationships with other Services programs impacting DHA goals and objectives.</li><li>
Possess excellent communication skills, both verbal and nonverbal.</li><li>
Exceptional attention to detail, time management, and organizational skills.</li><li>
Must be able to demonstrate effective decision-making abilities.</li><li>
Possess the ability to analyze information, interpret results, and problem-solving.</li><li>
Customer service oriented</li><li>
The ability to work confidently in a results-oriented environment</li><li>
Must be eligible to obtain security clearance</li><li>
Must be US Citizen.</li></ul>
NIKA provides equal employment opportunity to all individuals regardless of their race, color, creed, religion, gender, age, sexual orientation, national origin, disability, veteran status, or any other characteristic protected by state, federal, or local law. Further, NIKA takes affirmative action to ensure that applicants are employed and employees are treated during employment without regard to any of these characteristics. Discrimination of any type will not be tolerated.</div>

DMLSS AOR-2 Manager

EUROPHON ACOUSTICS TRADING L.L.C

Project Engineer - Aluminum &amp; Fa&ccedil;adeLocation: Al Quoz, Dubai, UAE Employment Type: Full-TimeAbout UsEurosystems Group is a leading specialist in fa&ccedil;ade, aluminum, glazing, and architectural metal solutions, delivering landmark projects across the UAE and GCC. Our commitment to engineering excellence, innovation, and quality has made us a trusted partner for commercial, residential, hospitality, and mixed-use developments.Position OverviewWe are seeking an experienced Project Engineer &ndash; Aluminum &amp; Fa&ccedil;ade to support the successful execution of fa&ccedil;ade and aluminum projects from design coordination through installation and project completion. The ideal candidate will possess strong technical knowledge, project coordination skills, and hands-on experience in fa&ccedil;ade systems, curtain walls, glazing, and architectural aluminum works.Key Responsibilities<ul><li>Coordinate and manage the technical and operational aspects of fa&ccedil;ade and aluminum projects.</li><li>Review project specifications, drawings, shop drawings, and technical submittals.</li><li>Coordinate with design, production, procurement, site, and project management teams.</li><li>Monitor project progress and ensure activities are executed according to approved schedules.</li><li>Assist in project planning, resource allocation, and material coordination.</li><li>Conduct site inspections and ensure installation works comply with project specifications and quality standards.</li><li>Coordinate with consultants, contractors, suppliers, and subcontractors throughout the project lifecycle.</li><li>Resolve technical and site-related issues and provide engineering solutions.</li><li>Monitor project costs, material utilization, and productivity.</li><li>Ensure compliance with company QA/QC procedures, HSE standards, and project requirements.</li><li>Prepare project reports, progress updates, and technical documentation.</li></ul>Qualifications &amp; Experience<ul><li>Bachelor's Degree in Civil Engineering, Mechanical Engineering, Architecture, Structural Engineering, or a related discipline.</li><li>5&ndash;10 years of experience in aluminum, fa&ccedil;ade, curtain wall, glazing, or architectural metal works projects.</li><li>Strong technical knowledge of:</li><li>Curtain Wall Systems</li><li>Structural Glazing</li><li>Unitized Fa&ccedil;ade Systems</li><li>Cladding Systems</li><li>Aluminum Doors &amp; Windows</li><li>Architectural Metal Works</li><li>Experience in project coordination, site execution, and technical documentation.</li><li>Ability to review shop drawings, material submittals, and installation details.</li><li>Knowledge of UAE construction standards, authority requirements, and industry best practices.</li><li>Proficiency in AutoCAD, Microsoft Office, and project management tools.</li><li>Strong communication, problem-solving, and coordination skills.</li><li>UAE/GCC experience is preferred.</li><li>Valid UAE Driving License is an advantage.</li></ul>Why Join Us?<ul><li>Work on prestigious fa&ccedil;ade and building envelope projects across the UAE.</li><li>Join a leading and growing organization in the fa&ccedil;ade industry.</li><li>Collaborate with experienced engineering, production, and project teams.</li><li>Opportunities for professional development and career progression.</li><li>Dynamic and performance-driven work environment.</li></ul>Join Our TeamIf you have a passion for fa&ccedil;ade engineering and project execution and are looking to advance your career with a leading industry specialist, we invite you to apply and become part of our growing success.Job Type: Full-timePay: AED7,000.00 - AED11,000.00 per monthWork Location: In person

Project Engineer- Aluminum & Façade

Search 10000+ Utilization management specialist jobs near you this June. New roles added regularly across leading industries. Apply today.