utilization manager

White Glove Placement, Inc.

<div>Looking for a fully remote opportunity where your clinical expertise drives meaningful outcomes? We&rsquo;re hiring experienced Behavioral Health Utilization Managers to support outpatient and diversionary services in a dynamic, fast-paced environment.
Assignment Details<ul><li>
Schedule: 8-hour day shifts (Monday&ndash;Friday)</li><li>
Assignment Length: 14 weeks</li><li>
Guaranteed Hours: 40/week</li><li>
Location: Remote (occasional travel to Massachusetts may be required)</li></ul> 
Requirements:<ul><li>
For Clinical UM Role:<ul><li>
Master&rsquo;s degree in Social Work, Counseling, Psychology, or related field</li><li>
Active independent license: LICSW, LMHC, or LMFT (MA and/or NH)</li><li>
5&ndash;7 years of behavioral health experience, preferably in managed care</li></ul>
For ABA UM Role:<ul><li>
BCBA (Board Certified Behavior Analyst) required</li><li>
Independent licensure preferred but not required</li></ul></li></ul> 
Simple, Stress-Free Onboarding
Getting started is easy. Apply today, and a dedicated, friendly recruiter will guide you through every step.
Why Work with Us
White Glove Placement isn&rsquo;t your average agency&mdash;we&rsquo;re a team built for today&rsquo;s nurses. Based in New York and trusted across the U.S., we combine premium travel opportunities with personal support that puts you first. From competitive pay packages to concierge-level service, we help you grow your career while living life on your terms. Wherever your journey takes you, we&rsquo;ve got your back.
#NWLP</div>

Remote Behavioral Health Utilization Manager (LMSW/BCBA)

Ochsner Health

<div>We've made a lot of progress since opening the doors in 1942, but one thing has never changed - our commitment to serve, heal, lead, educate, and innovate. We believe that every award earned, every record broken and every patient helped is because of the dedicated employees who fill our hallways.
At Ochsner, whether you work with patients every day or support those who do, you are making a difference and that matters. Come make a difference at Ochsner Health and discover your future today!
This determines the psychosocial, environmental, and family economic dynamics that may affect the patient. Functions as the liaison and communicator with the patient, caregivers, multi-disciplinary team members, and post-acute care and third party payers. Confirms a clear, specific care setting order by the physician and applies hospital approved medical necessity criteria to review appropriate admissions and levels of care. Documents completed reviews in the hospital approved data set.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential duties. 
 
This job description is a summary of the primary duties and responsibilities of the job and position. It is not intended to be a comprehensive or all-inclusive listing of duties and responsibilities. Contents are subject to change at the company's discretion. 
Education
Required - Graduate of an accredited school of nursing.
Preferred - Bachelor&rsquo;s degree in nursing. 
Work Experience
Required - 1 year of hospital based experience in the delivery of patient care.
Preferred - Experience in case management or utilization review. 
Certifications
Required - Current Registered Nurse license in state of practice.
Preferred - Commission for Case Manager (CCM), Certified Professional Utilization Review (CPUR), Certified Professional in Utilization Management (CPUM) or Certified Professional in Healthcare Management (CPHM) certification.
Knowledge Skills and Abilities (KSAs)<ul><li>
Proficiency in using computers, software, and web-based applications.</li><li>
Effective verbal and written communication skills and ability to present information clearly and professionally to varying levels of individuals throughout the patient care process.</li><li>
Good knowledge of business/finance.</li><li>
Ability to work a flexible work schedule (e.g. 24/7, weekend, holiday, on call availability) and travel throughout and between facilities.</li></ul> 
Job Duties<ul><li>
Directs and coordinates all admissions and transfers to, from, and within the hospital while coordinating with parallel processing of Environmental Services (EVS) and transport operations that tie into patient flow.</li><li>
Facilitates professional relationships between unit leadership, operational coordinators, nursing staff, Regional Referral Center, medical staff, admitting office and interdisciplinary teams to provide patient/room assignment based on patient diagnosis, acuity, MD orders and patient flow.</li><li>
Manages aspects of the planning process in anticipation of the patient&rsquo;s movement through the healthcare system.</li><li>
Interacts with managed care/ third party payers to obtain financial certification for appropriate reimbursement and to minimize reimbursement denials.</li><li>
Manages the care of assigned patients through the healthcare system based on the patient&rsquo;s individual needs, serving as a a contact person for the rehabilitation team, internal admissions team, clients and external sources to enhance outcomes.</li><li>
Educates clients, family members or significant others, referral sources, hospital personnel, external payers, and internal/external case managers as to rehabilitation program benefits and services.</li><li>
Adapts behavior to the specific patient population, including but not limited to respect for privacy, method of introduction to the patient, adapting explanation of services or procedures to be performed, requesting permissions and communication style.</li><li>
Performs other related duties as required.</li></ul>
The above statements describe the general nature and level of work only. They are not an exhaustive list of all required responsibilities, duties, and skills. Other duties may be added, or this description amended at any time.
Remains knowledgeable on current federal, state and local laws, accreditation standards or regulatory agency requirements that apply to the assigned area of responsibility and ensures compliance with all such laws, regulations and standards. 
This employer maintains and complies with its Compliance &amp; Privacy Program and Standards of Conduct, including the immediate reporting of any known or suspected unethical or questionable behaviors or conduct; patient/employee safety, patient privacy, and/or other compliance-related concerns. 
The employer is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status, or disability status. 
Physical and Environmental Demands 
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.
Medium Work - Exerting 20 to 50 pounds of force occasionally, and/or 10 to 25 pounds of force frequently, and/or greater than negligible up to 10 pounds of force constantly to move objects. (Constantly: activity or condition exists 2/3 or more of the time) to move objects. Physical demand requirements are in excess of those for Sedentary Work. Even though the weight lifted may be only a negligible amount, a job should be rated Light Work: (1) when it requires walking or standing to a significant degree; or (2) when it requires sitting most of the time but entails pushing and/or pulling of arm or leg controls; and/or (3) when the job requires working at a production rate pace entailing the constant pushing and/or pulling of materials even though the weight of those materials is negligible. NOTE: The constant stress and strain of maintaining a production rate pace, especially in an industrial setting, can be and is physically demanding of a worker even though the amount of force exerted is negligible. 
 
Duties performed routinely require exposure to blood, body fluid and tissue. 
The incumbent works in a patient care area; works in an area where patients enter; works directly with patients; and/or works with specimens that could contain diseases. There may be an occupational risk for exposure to all communicable diseases.
Because the incumbent works within a healthcare setting, there may be occupational risk for exposure to hazardous medications or hazardous waste within the environment through receipt, transport, storage, preparation, dispensing, administration, cleaning and/or disposal of contaminated waste. The risk level of exposure may increase depending on the essential job duties of the role.
Are you ready to make a difference? Apply Today!
Ochsner Health does not consider an individual an applicant until they have formally applied to the open position on this careers website.
Please refer to the job description to determine whether the position you are interested in is remote or on-site. Individuals who reside in and will work from the following areas are not eligible for remote work position: Colorado, California, Hawaii, Illinois, Maryland, Massachusetts, Minnesota, New Jersey, New York, Vermont, Washington, and Washington D.C.
Ochsner Health endeavors to make our site accessible to all users. If you would like to contact us regarding the accessibility of our website, or if you need an accommodation to complete the application process, please contact our HR Employee Solution Center at 504-842-4748 (select option 1) or careers@ochsner.org. This contact information is for accommodation requests only and cannot be used to inquire about the status of applications.
Ochsner is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to any legally protected class, including protected veterans and individuals with disabilities.</div>

RN, Utilization Manager - OLGMC - PRN Various Shifts

UofL Health

<div><h1 class="jobSectionHeader">Primary Location:
</h1>Frazier Rehab Institute - UMC
<h1 class="jobSectionHeader">Address:
</h1>220 Abraham Flexner Way&amp;#xa;Louisville, KY 40202&amp;#xa;
<h1 class="jobSectionHeader">Shift:
</h1>Salary Shift (United States of America)
<h1 class="jobSectionHeader">Job Description Summary:
</h1><h1 class="jobSectionHeader">Job Description:
</h1>We are Hiring at Frazier Rehab Institute, Care Management 
About Frazier Rehab
Known for world-class care in comprehensive acute rehab, Frazier Rehabilitation Institute provides extensive therapy across a number of specialties for inpatient and outpatient rehab needs. Extensive specialty rehab programs, highly-skilled therapists, state-of-the-art facilities and innovative therapeutic techniques have earned national recognition for Frazier Rehab Institute making it one of the top rehab institutions in the region. Frazier Rehab Institute offers a multitude of specialty programs to meet the specialized rehab needs of patients. 
Job Summary
This position is responsible for providing comprehensive assessments on patients (pediatric and adult patients) and being the primary liaison between the patient / family and the treatment team. The Case Manager ensures that the patient&rsquo;s individualized treatment plan is carried out in a focused, cost effective, goal directed manner. As a member of the interdisciplinary team the case manager will also facilitate the development, coordination, and implementation of the discharge plan as well as any other outside arrangements to ensure continuity of care.
<h1 class="jobSectionHeader">Additional Job Description:
</h1>Required Qualifications
<ul><li>Licensed or eligible for license in Kentucky
</li><li>Basic Life Support (BLS) accredited by the American Heart Association (AHA)
</li><li>Bachelor&rsquo;s degree from accredited college in Nursing or Social Work. Will consider RN with A.D.N. if actively pursuing BSN, with BSN completion required within 2 years of hire.
</li><li>Current licensure in Kentucky as a LCSW or CSW or RN.
</li><li>Must have 2-3 years experience as an RN plus utilization management or discharge planning/case management experience. Minimum two years experience performing utilization review and/or quality assurance activities in an acute care facility or HMO/PPO/PRO preferred. Must be able to adjust priorities quickly, organize multiple tasks simultaneously, and work interdependently with many levels of staff. Attention to detail; strong organizational, interpersonal and communication skills; and innovative problem solving skills required. Must be able to adjust work hours depending on depending upon departmental needs as determined by the director or manager. 
</li></ul>Preferred Qualifications
<ul><li>Certification in a nursing specialty area or CCM</li></ul></div>

Social Worker/Case Manager, Frazier Rehab Institute

Centene

<div>You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. 
Remote Position: Will manage Prior Authorizations, Concurrent Review, and Retrospective Review Clinical Team for NICU Specialty. NICU experience required.
Position Purpose: Manages Prior Authorization, Concurrent Review, and/or Retrospective Review Clinical Review team to ensure appropriate care to members. Manages utilization management issues related to member care, provider interactions, and facilitates operations within utilization management.<ul><li>
Manages prior authorization, concurrent review, and retrospective clinical review team and ensures compliance with applicable guidelines, policies, and procedures</li><li>
Reviews and analyzes utilization management activities, operations, costs, and forecasted data to identify areas for improvement within utilization management (UM) to align to goals and objectives</li><li>
Develops, implements, and maintains compliance with utilization management policies and procedures</li><li>
Reviews utilization management reports to identify trends and areas of improvement and provide recommendations to senior leadership</li><li>
Maintains knowledge of processes, regulations, accreditation standards, and industry best practices related to utilization management</li><li>
Educates and provides resources for utilization management team on key initiatives and to facilitate on-going communication between utilization management team, members, and providers</li><li>
Works with the senior management team to develop and implement UM policies, procedures, and guidelines that ensure appropriate and effective utilization of healthcare services</li><li>
Works with utilization management senior management team to provide updates and insights on team goals and objectives</li><li>
Provides coaching and guidance to utilization management team to ensure adherence to quality and performance standards</li><li>
Assists utilization management senior leadership with onboarding, hiring, and training utilization management team members</li><li>
Leads and champions change within scope of responsibility</li><li>
Performs other duties as assigned</li><li>
Complies with all policies and standards</li></ul>
Education/Experience: Requires Graduate of an Accredited School of Nursing or Bachelor's degree and 5+ years of related experience.
2+ years supervisory experience preferred. 
Knowledge of utilization management principles preferred. 
 
License/Certification:<ul><li>
RN - Registered Nurse - State Licensure and/or Compact State Licensure required</li></ul>
Pay Range: $87,000.00 - $161,300.00 per year
Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. 
Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act</div>

Manager, Utilization Management

Trinity Health

Employment Type: 
Full time
 
Shift: 
Description: 
Reporting to the Director CVHP Operations, CVHP Operations, this position coordinates care and service for defined patient populations across the acute care continuum for CVHP members. This includes discharge planning, utilization management, care coordination, and support for resource utilization. This position works collaboratively with an interdisciplinary team to improve patient care through the effective utilization of the facility's resources. The incumbent makes significant contributions toward achievement of desired clinical, financial, and resource utilization outcomes.
 
1. High school diploma or equivalent is required. A degree from an accredited baccalaureate nursing program is preferred.
 2. Current licensure as a Registered Nurse in the state of California is required.
 3. Current American Heart Association (AHA) Healthcare Provider CPR card is required.
 4. CCM national certification is preferred.
 5. Experience with two (2) areas of clinical specialty is preferred.
 6. Excellent communication skills, critical thinking, creative problem-solving skills, and competent organizational and planning skills are required.
 7. Ability to be self-directed and tolerate frequent interruptions while managing a demanding workload is required.
 8. Knowledge regarding hospital protocol and procedures, clinical standards and outcomes, funding options, familiarity with community resources and outside professional agencies, familiarity with federal and state regulations governing hospital and home care, as well as understanding of the financial structure of health plan and delivery system is preferred.
 
Pay Range ($50.84 - $73.72)
 
Our Commitment
 
Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.

RN Health Plan Case Manager

Granite Hills Hospital

<div>Responsibilities:
<div>
Granite Hills Hospital offers high-quality, patient centered behavioral health care for the greater Milwaukee community. Our 120-bed facility will feature evidence-based treatment for adolescents, adults, and older adults.</div><div></div><div> 
We are seeking a Utilization Management Assistant for the Utilization Management Department. If you're passionate about working in the behavioral health setting and have the desire to join a team of healthcare professionals dedicated to serving our patients, we want to hear from you!</div><div> 
The Utilization Management Assistant (UMA) provides administrative support to the Utilization Management (UM), departments. The UMA performs clerical duties including but not limited to: Notification of Admission of hospitalizations, distribution of incoming authorization requests, maintaining the electronic filing system, monitoring, conducting fax, email, online payer databases, voicemail coverage, discharge notifications, determinations, etc in the UM department following established standards and practices, adhering to UM polices and standards.</div><div></div><div> 
Granite Hills Hospital offers comprehensive benefits such as:</div><div></div><div> 
Competitive Compensation</div><div>
Excellent Medical, Dental, Vision, and Prescription Drug Plan</div><div>
Generous Paid Time Off</div><div>
401(K) with company match and discounted stock plan</div><div>
Career development opportunities within UHS and its Subsidiaries</div><div>
Education Assistance</div><div>
Challenging and rewarding work environment</div><div></div><div> 
Interested applicants may apply directly through our website https://granitehillshospital.com/ and apply through the Careers tab.</div><div></div><div> 
One of the nation&rsquo;s largest and most respected hospital companies, Universal Health Services, Inc. (UHS) has built an impressive record of achievement and performance. Steadily growing from a startup to an esteemed Fortune 500 corporation, UHS today has annual revenue nearing $10 billion. UHS is recognized as one of the World&rsquo;s Most Admired Companies by Fortune; ranked #276 on the Fortune 500, and listed #275 in Forbes inaugural ranking of America&rsquo;s Top 500 Public Companies.</div>
Qualifications:

Education: High school diploma or GED required AA/ BA preferred.<div> 
Experience: One (1) years of medical office or health insurance experience required OR Two (2) years&rsquo; experience working in mental health setting and previous secretarial experience preferred. Solid verbal, written and interpersonal communication skills required. Demonstrated customer service skills required. Excellent organization skills, with attention to detail and follow through. Ability to meet and/or exceed all established performance standards on a consistent basis (i.e., regulatory timeframes, accuracy, and quality).</div><div></div><div> 
Knowledge: MS Office including Word, Excel, and Outlook in a Windows based environment and an ability to quickly learn new systems.</div><div></div><div> 
Additional Requirements: Successful completion of CPI training including de-escalation and appropriate use of seclusion and restraint, within the first 30 days of employment and required prior to assisting in the procedures. Obtain CPI instructor certification within 6 months of hire.</div><div></div><div> 
ESSENTIAL FUNCTIONS
</div><ul><li>Extracts necessary admission and discharge records from the hospital medical record and other electronic applications and accurately enters records/data communicating as a bridge between insurance payers and the hospital UM department with a goal of supporting the procurement of hospitalization authorizations.</li><li>
PDF&rsquo;s and places in electronic file re-authorization requests with supporting documentation and insurance verification, assigns patient files to the appropriate utilization review clinicians.</li><li>
Faxes completed re-authorization forms to the appropriate agencies, obtains fax confirmation and files both with supporting documentation in the patient charts.</li><li>
Sorts additional information received from the staffing department, pulls patient charts and delivers all to the appropriate UM Coordinator.</li><li>
Ensures smooth UM department functioning while working in tandem with the UM team, Health Information Management and Physicians. Responsibilities include but are not limited to working with payer-based web systems (Acentra Health aka Kepro), answering phones/voicemails, communicating effectively and professionally through both written and verbal means, demonstrating proficiency with use of various electronic applications (Midas, MS4), providing appropriate &amp; accurate documentation related to hospitalization authorization and running daily reports.</li><li>
Accurately processes and documents incoming and outgoing communication in all forms in the hospital EMR or payer-specific web-based systems. Communicates time-sensitive information to UM Team and Business Office counterparts. Escalates challenges to leadership as needed. Involves payer-based supervisory staff when warranted.</li><li>
Communicates and documents all conversations with internal and external key stakeholders according to departmental policy and procedure.</li></ul></div>

Utilization Management Assistant (Full-time)

Hill Physicians Medical Group

<div>We&rsquo;re delighted you&rsquo;re considering joining us!
At Hill Physicians Medical Group, we&rsquo;re shaping the healthcare of the future: actively managed care that prevents disease, supports those with chronic conditions and anticipates the needs of our members.
Join Our Team!
Hill Physicians has much to offer prospective employees. We&rsquo;re regularly recognized as one of the &ldquo;Best Places to Work in the Bay Area&rdquo; and have been recognized as one of the &ldquo;Healthiest Places to Work in the Bay Area.&rdquo; When you join our team, you&rsquo;re making a great choice for your professional career and your personal satisfaction.
DE&amp;I Statement:
At PriMed, your uniqueness is valued, celebrated, encouraged, supported, and embraced. Whatever your relationship with Hill Physicians, we welcome ALL that you are.
We value and respect your race, ethnicity, gender identity, sexual orientation, age, religion, disabilities, experiences, perspectives, and other attributes. Our celebration of diversity and foundation of inclusion allows us to leverage our differences and capitalize on our similarities to better serve our communities. We do it because it's right!
Job Description:
Responsible for carrying out case management activities for IPA members referred to the case management program across all levels of care. Case management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates options and services required to meet the client&rsquo;s health and human service needs. It is characterized by advocacy, communication and resource management and promotes quality and cost-effective interventions and outcomes. Case management activities are based on nationally recognized case management standards and concepts and principles. All contacts are telephonic with an option for on-site case conferences as needed.
Job Responsibilities<ul><li>
Identification of members appropriate for case management, based on identification of health-related problems.</li><li>
Assessing members&rsquo; physical and psychosocial needs/barriers.</li><li>
Developing the case management care plan.</li><li>
Developing and implementing the interventions needed to resolve barriers and coordinate care, allowing members to accomplish their goals with physician guidance and supervision.</li><li>
Documenting assessments, care plans, interventions, and all other activity related to coordinating the care of case-managed members.</li></ul>
Additional Responsibilities<ul><li>
Maintain client privacy, safety, confidentiality, and advocacy while adhering to ethical, legal, regulatory and accreditation standards.</li><li>
Maintain department procedure/policy standards with regard to turnaround time, etc.</li><li>
Support the interdisciplinary team approach to ensure effective resource utilization, as well as quality and cost-effective outcomes.</li><li>
Coordinate internal and external resources for the individual member.</li><li>
Maintain and update a community resource database.</li><li>
Document all case management activities in the HPMG case management online system.</li><li>
Utilize existing reports and systems to identify and monitor utilization resource patterns and facilitate needed care coordination in order to support Quality Improvement.</li><li>
Refer to various departments for supportive interventions, i.e., Health Education, Quality Management, Contracting, Provider Services, Client Data Management, TPL, COB, etc.</li><li>
Issue letters of explanation in accordance with department policy.</li><li>
Support Medical Management Team, Authorization Review, Clinical Initiatives, and Provider Education.</li><li>
Attend and participate in in service programs and conferences that support practice of case management.</li><li>
Perform other duties as assigned.</li></ul>
Required Experience<ul><li>
Minimum 3 &ndash; 5 years of experience required</li><li>
Minimum three years clinical nursing experience in an area such as medical surgical, critical care, home health or skilled nursing, and;</li><li>
Two years of experience in case management, utilization management, discharge planning and or quality improvement in a managed care setting</li><li>
Experience with managed care delivery including IPA networks and Medicare.</li><li>
Optimum organizational skills with ability to meet both expected and unexpected time frames.</li><li>
Excellent verbal and written communication skills.</li><li>
Ability to coordinate effectively with a variety of customers including members, providers, office staff, health plans, internal department, community resources, and peers.</li><li>
Ability to work independently with self-initiative and discipline.</li><li>
Knowledge of ICD-10 and or CPT coding.</li><li>
Working knowledge of personal computers.</li></ul>
Required Education<ul><li>
A.S. degree</li><li>
Unrestricted California Registered Nurse licensure; certification in case management preferred.</li></ul>
Additional Information
Salary: $100,000 - $123,000 Annual
Hill Physicians is an Equal Opportunity Employer</div>

Case Manager - 26-44

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