utilization management um nurse

Brighton Health Plan Solutions

<div>
 
 About The Role
 
 
 
 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.
 
 
 
 Primary Responsibilities
 
 
 
 <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
 
 
 </li>
 </ul>
 
 Essential Qualifications
 
 
 
 <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
 
 
 </li>
 </ul>
 
 About
 
 
 
 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.
 
 
 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.
 
 
 Come be a part of the Brightest Ideas in Healthcare&trade;.
 
 
 
 Company Mission
 
 
 
 Transform the health plan experience &ndash; how health care is accessed and delivered &ndash; by bringing outstanding products and services to our partners.
 
 
 
 Company Vision
 
 
 
 Redefine health care quality and value by aligning the incentives of our partners in powerful and unique ways.
 
 
 Powered by JazzHR
 
 
 DLcZRrpbP4
</div>

Utilization Management Nurse

Alignment Healthcare

<div>Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.
Alignment Health is seeking a remote Utilization Management (UM) Nurse &ndash; Pre-Service (LVN or RN, active California license required) to join our growing UM team. 
 
In this role, you&rsquo;ll review prior authorization requests for medical necessity across inpatient and outpatient services, applying CMS guidelines and Milliman Care Guidelines (MCG) to support timely, accurate determinations. You&rsquo;ll partner closely with providers and medical directors to ensure members receive high-quality, cost-effective care. 
 
This is a fast-paced, production-driven role ideal for nurses with recent pre-service UM experience in a managed care setting who are comfortable managing multiple cases, meeting turnaround time expectations, and collaborating cross-functionally in a fully remote environment. 
 
Schedule:
 
<ul><li>Monday &ndash; Friday, 8:00 AM &ndash; 5:00 PM Pacific Time (must be able to consistently work these hours)</li><li>Candidates must reside within Pacific, Mountain, or Central time zones to align with business hours.</li><li>Weekend rotation: approximately 1 weekend day every 5&ndash;6 weeks (4&ndash;8 hour shift between 8:00 AM &ndash; 5:00 PM Pacific Time)</li></ul>
General Duties / Responsibilities: 
1. Review pre-certification requests for medical necessity and refer to medical director any referral that requires additional expertise. 
2. Utilize CMS guidelines (LCD, NCD) to assist in determinations of referrals and utilize Milliman Care Guidelines (MCG) to assist in determinations of referrals. 
3. Maintain goals for established turn-around time (TAT) for referral processing. 
4. Initiate single service agreements (SSA) when services required are not available in network. 
5. Maintain a professional rapport with providers, physicians, support staff and patients in order to process pre-certification referrals as efficiently as possible. 
6. Verify eligibility and / or benefit coverage for requested services. 
7. Verify accuracy of ICD 10 and CPT coding in processing pre-certification requests. 
8. Contact requesting provider and request medical records, orders, and / or necessary documentation in order to process related pre-service requests / authorizations when necessary. 
9. Review referral denials for appropriate guidelines and language. 
10. Assist medical directors in reviewing and responding to appeals and Grievances 
11. Contact members and maintain documentation of call for expedited requests. 
12. Other duties as assigned.
Job Requirements:
Experience:
Required:<ul><li>
Minimum (3) years' nursing experience in clinical setting.</li><li>
Minimum (1) year experience UM experience with pre-service.</li><li>
Minimum (1) year experience with managed care (Medicaid and / or Medicare).</li><li>
Minimum 1 year of experience with the application of UM criteria (i.e., CMS National and Local Coverage Determinations, etc.)</li><li>
Minimum (1) year experience in a medical setting working with IPAs, entering referrals / prior authorizations preferred</li><li>
Minimum (1) Experience with the application of clinical criteria, specifically Milliman Care Guidelines (MCG)</li></ul>
Education:<ul><li>Required: High School Diploma or GED.</li><li>Preferred: Associates or Bachelor's degree in Nursing</li></ul>
Licensure:
Required:<ul><li>
Must have and maintain an active, valid, and unrestricted LVN or RN license in California (Non-Compact)</li><li>
Immediately upon hire, must be willing to obtain LVN and / or RN licensure in Nevada, (Non-compact), Arizona (Compact), North Carolina (Compact), and Texas (Compact) which will be reimbursed by company.</li></ul>
Preferred:<ul><li>
CPHQ or ABQAURP, or Six Sigma certification</li><li>
Medical Terminology Certificate.</li></ul>
Training:<ul><li>Required: None</li><li>Preferred: Medical Terminology. Six Sigma</li></ul>
Specialized Skills:
Required:<ul><li>
Knowledge of ICD-10, CPT codes, managed care plans, medical terminology and referral system (Access Express / Portal / N-coder).</li><li>
Knowledgeable with CMS (Chapter 13) guidelines and regulations.</li><li>
Computer Skills: Word, Excel, Microsoft Outlook</li><li>
Language Skills: Effective written and verbal communication skills; able to establish and maintain a constructive relationship with diverse members, management, employees and vendors.</li><li>
Mathematical Skills: Able to perform mathematical calculations and calculate simple statistics correctly.</li><li>
Reasoning Skills: Able to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution.</li><li>
Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.</li><li>
Report Analysis Skills: Comprehend and analyze statistical reports.</li></ul>
Preferred:<ul><li>
Bilingual English and Spanish</li><li>
Transplant knowledge a plus</li></ul>
Essential Physical Functions:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
1. While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.
2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.
Pay Range: $77,905.00 - $116,858.00
Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc.
Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.<ul><li>DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health&rsquo;s talent acquisition team, please email careers@ahcusa.com.</li></ul></div>

Utilization Management (UM) – Pre-Service (Remote | California RN / LVN | Pacific Time Schedule)

WPS—A health solutions company

<div>
 Our
 
 Utilization Management RN (Registered Nurse)
 
 evaluates efficiency, appropriateness, and medical necessity for medical services, and procedures for our Health Plan. This role uses clinical knowledge to provide judgment to review medical services with evidence-based criteria, authorize requested services as appropriate. Our
 
 Utilization Management RN
 
 will be responsible for referring questionable cases to medical directors to prevent unnecessary procedures, treatments, or prolonged hospital stays.
 
 
 
 Salary Range
 
 
 
 
 $75,000 ~ $100,000
 
 
 
 
 The base pay offered for this position may vary within the posted range based on your job-related knowledge, skills, and experience.
 
 
 
 
 Work Location
 
 
 
 
 We are open to remote work in the following approved states:
 
 
 
 Colorado, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, New Jersey, North Carolina, Ohio, South Carolina, Texas, Virginia, Wisconsin
 
 
 
 How do I know this opportunity is right for me? If you:
 
 
 
 <ul>
 <li>
 Enjoy working with healthcare professionals to facilitate appropriate and quality services in a cost-effective manner to positively impact medical loss ratio.
 </li>
 <li>
 Can work closely with Medical Directors to facilitate decision-making process for the Health Services department.
 </li>
 <li>
 Have experience reviewing medical and behavioral health prior authorization requests for medical necessity and appropriateness of requested treatment according to medical policies and evidence-based criteria.
 </li>
 <li>
 Have experience working closely with members of Health Services, and key contacts in Sales, Member Services, Claims, Provider Contracting, and Billing &amp; Enrollment.
 </li>
 <li>
 Can document case summaries and refer cases to Medical Director that do not meet internal or external guidelines, policies, or medical criteria.
 </li>
 <li>
 Like to be accountable to monitor and maintain inventory in the Utilization Management queue to meet productivity standards.
 </li>
 <li>
 Enjoy evaluating, analyzing, and reporting trends in utilization changes in all healthcare delivery areas.
 </li>
 <li>
 Can make recommendations and implement changes consistent with Health Services objectives of quality care and reasonable cost.
 </li>
 <li>
 Would enjoy identifying opportunities and provide recommendations to improve department processes.
 </li>
 <li>
 Have Identified legal or liability issues and refer potential ethical or risk management issues to the appropriate department for resolution.
 </li>
 <li>
 Have participated in training new nursing staff on department workflows, policies, and procedures.
 </li>
 <li>
 Can work cross functionally to support other departmental efforts to ensure overall efficiency, quality, productivity, and compliance with all departmental, regulatory and URAC standards.
 
 
 </li>
 </ul>
 
 Minimum Qualifications
 
 
 
 <ul>
 <li>
 Registered Nurse (RN) with current licensure in the state of Wisconsin.
 </li>
 <li>
 4 or more years of experience as a Registered Nurse in varied clinical settings (i.e., hospital, clinic, home care, skilled nursing facility, etc.).
 </li>
 <li>
 2 or more years of experience in Managed Care (i.e., prior authorization, utilization review).
 </li>
 <li>
 Demonstrated experience managing and coordinating care effectively for case managed members.
 </li>
 <li>
 Strong knowledge of current medical practices, medical coding, trends and patterns of care.
 </li>
 <li>
 Familiarity with health plan operations, payer/provider relationships, and insurance benefits.
 </li>
 <li>
 Strong diverse experience and expertise that includes:
 </li>
 <ul>
 <li>
 The ability to work independently, manage a case load, and prioritization.
 </li>
 <li>
 Excellent analytical, critical thinking, problem-solving skills and decision-making skills.
 </li>
 <li>
 Excellent communication and interpersonal skills to work with members, providers, and teams
 </li>
 <li>
 Proficiency in Microsoft Office and healthcare software and systems.
 
 </li>
 </ul>
 </ul>
 
 Preferred Qualifications
 
 
 
 <ul>
 <li>
 Bachelor&rsquo;s degree in nursing (BSN).
 </li>
 <li>
 Health insurance background in Point of Service (POS), Preferred Provider Organization (PPO), or Medicare Supplement) plans.
 </li>
 <li>
 Knowledge of Utilization Review Accreditation Commission (URAC).
 </li>
 <li>
 Certified Managed Care Nurse (CMCN).
 </li>
 <li>
 Technical experience with word processing, spreadsheets, and proficiency with electronic medical record (EMR) systems and/or other managed care software.
 
 
 </li>
 </ul>
 
 Remote Work Requirements
 
 
 
 <ul>
 <li>
 High speed cable or fiber internet
 </li>
 <li>
 Minimum of 10 Mbps downstream and at least 1 Mbps upstream internet connection (can be checked at https://speedtest.net)
 </li>
 <li>
 Please review Remote Worker FAQs for additional information
 
 
 </li>
 </ul>
 
 Benefits
 
 
 
 <ul>
 <li>
 Remote and hybrid work options available
 </li>
 <li>
 Performance bonus and/or merit increase opportunities
 </li>
 <li>
 401(k) with a 100% match for the first 3% of your salary and a 50% match for the next 2% of your salary (100% vested immediately)
 </li>
 <li>
 Competitive paid time off
 </li>
 <li>
 Health insurance, dental insurance, and telehealth services start DAY 1
 </li>
 <li>
 Professional and Leadership Development Programs
 </li>
 <li>
 Review additional benefits: (https://www.wpshealthsolutions.com/careers/)
 
 
 </li>
 </ul>
 
 Who We Are
 
 
 
 WPS, a health solutions company, is a leading not-for-profit health insurer and federal government contractor headquartered in Madison, Wisconsin. WPS offers health insurance plans for individuals, families, seniors and group health plans for small to large businesses. We process claims and provide customer support for beneficiaries of the Medicare program and manage benefits for millions of active-duty and retired military personnel across the U.S. and abroad. WPS has been making healthcare easier for the people we serve for nearly 80 years. Proud to be military and veteran ready.
 
 
 
 Culture Drives Our Success
 
 
 
 WPS&rsquo; culture is where the great work and innovations of our people are seen, fueled and rewarded. We accomplish this by creating an open and empowering employee experience. We recognize the benefits of employee engagement as an investment in our workforce&mdash;both current and future&mdash;to effectively seek, leverage, and include differing and unique perspectives that fuel agility and innovation on high-performing teams. This results in people bringing their authentic selves to work every day in an organization that successfully adapts to business changes and new opportunities.
 
 
 We are proud of the recognition we have received from local and national organization regarding our culture and workplace: WPS Newsroom - Awards and Recognition.
 
 
 
 Sign up for
 
 
 Job Alerts
 
 
 
 
 FOLLOW US!
 
 
 
 
 Instagram
 
 
 
 
 LinkedIn
 
 
 
 
 Facebook
 
 
 
 
 WPS Health Blog
 
</div>

Utilization Management RN

Humana

<div>
 
 Become a part of our caring community
 
 
 
 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.
 
 
 
 As a Utilization Management Registered Nurse
 
 
 
 <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.
 
 
 </li>
 </ul>
 
 Required Qualifications
 
 
 
 
 Use your skills to make an impact
 
 
 
 <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
 
 
 </li>
 </ul>
 
 Preferred Qualifications
 
 
 
 <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
 
 
 </li>
 </ul>
 Additional Information
 
 
 
 Work-at-Home Information
 
 
 
 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:
 
 
 <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>
 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.
 
 
 
 About Us
 
 
 
 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.
 
 
 
 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 Registered Nurse

Search 10000+ Utilization management um nurse jobs near you this April. New roles added regularly across leading industries. Apply today.

10000 utilization management um nurse jobs Near Me

Utilization Management Nurse

Utilization Management (UM) – Pre-Service (Remote | California RN / LVN | Pacific Time Schedule)

Utilization Management RN

Utilization Management Registered Nurse

Utilization Management Registered Nurse

Utilization Management Registered Nurse

Utilization Management Registered Nurse