utilization review nurse

JOL Healthcare

<div>The Utilization Review Nurse (RN) is responsible for evaluating the medical necessity, appropriateness, and efficient use of hospice services through detailed clinical chart review, utilization monitoring, and workflow oversight. This role ensures that hospice care delivery aligns with Medicare Hospice Conditions of Participation (42 CFR Part 418), Texas regulations, and agency policy. The Utilization Review Nurse places strong emphasis on accurate, timely, and compliant documentation within the Homecare Homebase (HCHB) EMR system and collaborates closely with interdisciplinary team (IDG) members to support high-quality, compliant hospice care.
Essential Functions:
Utilization Review &amp; Clinical Oversight:
<ul><li>Conduct a comprehensive review of hospice admission documentation, ongoing clinical assessments, visit notes, plans of care (POCs), physician orders, certifications of terminal illness (CTIs), and related records to confirm hospice eligibility, medical necessity, and regulatory compliance.
</li><li>Ensure documentation supports terminal illness prognosis, hospice eligibility criteria, and continued appropriateness of services in accordance with Medicare hospice regulations.
</li><li>Review interdisciplinary group (IDG) documentation to ensure plans of care reflect patient needs, goals, and hospice levels of care.
</li><li>Collaborate with clinical staff to clarify, educate, and correct documentation discrepancies on time.
</li><li>Evaluate visit utilization patterns, levels of care, and service frequency to promote efficient care delivery while supporting compliance and reimbursement integrity.
</li><li>Participate in the assigned Administrator-on-Duty (AOD) on-call rotation, providing administrative and clinical support after hours under the direction of the Hospice Administrator and Director of Nursing. This role does not serve as the licensed Hospice Administrator.
</li></ul>HCHB Workflow Monitoring:
<ul><li>Monitor and manage clinical workflow within the HCHB system to ensure timely completion of documentation, orders, and visit notes.
</li><li>Track pending tasks, outstanding physician orders, certifications, and incomplete documentation using HCHB dashboards and reports.
</li><li>Identify workflow delays or compliance risks and proactively communicate with appropriate team members to facilitate resolution.
</li></ul>Quality &amp; Compliance Support:
<ul><li>Participate in internal audits and mock surveys to support readiness for CMS, Texas Health and Human Services, and accrediting organization reviews.
</li><li>Assist with performance improvement initiatives related to hospice utilization, documentation accuracy, and quality outcomes.
</li><li>Support compliance with federal and state hospice regulations, payer requirements, and agency policies and procedures.
</li></ul>Staff Support &amp; Education:
<ul><li>Provide ongoing feedback and education to clinicians related to hospice documentation standards, utilization expectations, and regulatory requirements.
</li><li>Assist with onboarding and training of new clinical staff related to HCHB workflows, hospice documentation protocols, and utilization review processes.
</li></ul>Education:
Graduate of an accredited School of Nursing; BSN preferred.
License/Certification:
<ul><li>Current RN license in the state of Texas.
</li><li>Current BLS certification.
</li></ul>Experience:
<ul><li>Minimum 2 years of clinical hospice experience.
</li><li>Strong knowledge of Medicare hospice Conditions of Participation (42 CFR Part 418), hospice eligibility criteria, and interdisciplinary team processes.
</li><li>Experience with Homecare Homebase (HCHB) is strongly preferred.
</li></ul>Skills:
<ul><li>Proficient with electronic medical record systems and Microsoft Office applications.
 
Strong organizational, analytical, and communication skills.
</li><li>Ability to manage multiple priorities while meeting regulatory and operational deadlines.
</li><li>Working knowledge of Medicare and Medicaid hospice regulations.
</li></ul>Environmental and Working Conditions:
<ul><li>Primarily office-based with potential for remote/hybrid work (based on agency policy).
</li><li>May require minimal travel for field support or in-person training.
</li><li>Frequent use of computer systems and prolonged screen time.
</li></ul>Physical and Mental Effort:
<ul><li>Prolonged sitting and computer use are required.
</li><li>Ability to manage stressful situations calmly and courteously.
</li><li>Requires working under some stressful conditions to meet deadlines and patient needs.</li></ul></div>

Hospice Utilization Review Nurse

Palm Medical Centers

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

Utilization Management Nurse

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

Gainwell Technologies

<div>
 It takes great medical minds to create powerful solutions that solve some of healthcare&rsquo;s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you&rsquo;ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you&rsquo;ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You&rsquo;ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development.
 
 
 
 Summary
 
 
 
 We are seeking a talented individual for the Nurse Reviewer, Associate position. In this role, you will perform clinical reviews to determine whether medical record documentation supports the need for a service, based on clinical criteria, coverage policies, and utilization and practice guidelines as defined by the review methodologies specific to the contract. This involves accessing proprietary systems to audit medical records, accurately documenting findings, and providing policy and regulatory support for determinations.
 
 
 
 Essential Job Functions
 
 
 
 <ul>
 <li>
 Review and interpret medical records, comparing them against criteria to determine the appropriateness and reasonableness of care. Apply critical thinking and decision-making skills to assess whether the documentation supports the need for the service while maintaining production goals and quality standards.
 </li>
 <li>
 Document decisions and rationale to justify review findings or no findings.
 </li>
 <li>
 Determine approvals or initiate referrals to the physician consultant, processing their decisions while ensuring denials are explained in sufficient detail and completed within contractual deadlines.
 </li>
 <li>
 Perform prior authorization, precertification, and retrospective reviews, and prepare decision letters as needed in support of the utilization review contract.
 </li>
 <li>
 Maintain current knowledge of clinical criteria guidelines and complete required CEUs to maintain RN licensure.
 </li>
 <li>
 Attend training and scheduled meetings to enhance skills and working knowledge of clinical policies, procedures, rules, and regulations.
 </li>
 <li>
 Actively cross-train to perform reviews of multiple claim types, providing a flexible workforce to meet client needs.
 
 
 </li>
 </ul>
 
 What We're Looking For
 
 
 
 <ul>
 <li>
 Active, unrestricted RN licensure from the United States and in your state of primary residence; an active compact multistate RN license as defined by the Nurse Licensure Compact (NLC) is also required.
 </li>
 <li>
 3+ years of clinical experience in an inpatient hospital setting.
 </li>
 <li>
 1+ years of experience in utilization review or claims auditing.
 </li>
 <li>
 Experience using Milliman or InterQual criteria is preferred.
 </li>
 <li>
 Demonstrated proficiency in computer skills, including Microsoft Windows, Outlook, Excel, Word, PowerPoint, internet browsers, and typing.
 
 
 </li>
 </ul>
 
 What You Should Expect In This Role
 
 
 
 <ul>
 <li>
 Home-based position; you must have a work location within the continental U.S.
 </li>
 <li>
 Must provide a high-speed internet connection and a work environment free from distractions.
 </li>
 <li>
 Full-time schedule during normal business hours is required, as the role involves frequent interactions with the team and other departments.
 </li>
 <li>
 May be required to work extended hours for special business needs.
 </li>
 <li>
 May be required to travel up to 10% of the time based on business needs.
 
 
 </li>
 </ul>
 This position is for pipeline purposes, and we welcome applications on an ongoing basis.
 
 
 The pay range for this position is $70,000.00 - $80,000.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You&rsquo;ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits, and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities.
 
 
 We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You&rsquo;ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings.
 
 
 
 Gainwell Technologies is an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. Gainwell Technologies defines &ldquo;wages&rdquo; and &ldquo;wage rates&rdquo; to include &ldquo;all forms of pay, including, but not limited to, salary, overtime pay, bonuses, stock, stock options, profit sharing and bonus plans, life insurance, vacation and holiday pay, cleaning or gasoline allowances, hotel accommodations, reimbursement for travel expenses, and benefits.
 
</div>

Nurse Reviewer Associate- Remote

Emory Healthcare

<div>Overview:
<div>
Be inspired. Be rewarded. Belong. At Emory Healthcare.</div><div></div><div> 
At Emory Healthcare we fuel your professional journey with better benefits, valuable resources, ongoing mentorship and leadership programs for all types of jobs, and a supportive environment that enables you to reach new heights in your career and be what you want to be. We provide:</div><ul><li>
Comprehensive health benefits that start day 1</li><li>
Student Loan Repayment Assistance &amp; Reimbursement Programs</li><li>
Family-focused benefits
</li><li>Wellness incentives</li><li>
Ongoing mentorship, development, leadership programs and... more!</li></ul>
Description:
<div>
Job Summary: The Utilization Review (UR) Specialist is a Registered Nurse responsible for conducting thorough medical necessity reviews to assist with determining appropriate patient class designation. The UR Specialist will perform timely and comprehensive reviews of the patient chart utilizing InterQual Criteria accurately in conjunction with the UR Department workflows/processes, clinical nursing judgement, and when necessary, discussions with the provider team and/or Medical Director of UR. Primary duties and responsibilities: Operational Support: 1. Conducts thorough medical necessity reviews to assist with determining appropriate patient class designation. 2. Performs timely and comprehensive reviews of the patient chart utilizing InterQual Criteria accurately in conjunction with the UR Department workflows/processes, clinical nursing judgement, and when necessary, discussions with the provider team and/or Medical Director of UR. 3. Performs appropriate and accurate initial, admission (episode day one) and concurrent utilization reviews as guided by InterQual Criteria and UR Department workflows on all observation, inpatient, and extended recovery admissions as required based on Emory Healthcare's Utilization Management Plan and the UR Department&Acirc;&iquest;s processes. 4. Ensures that all InterQual reviews are supported with provider team documentation and/or clinical data. 5. When appropriate, the UR Specialist will utilize the UR Department's Severity of Illness/Intensity of Service template to document the medical necessity of the admission or continued stay. 6. While conducting utilization reviews, will identify any Avoidable Delays and accurately document the delay(s) based on the workflow. 7. Follow the UR Department&Acirc;&iquest;s denial workflows as appropriate. 8. Prioritizes work with minimal guidance for optimal reimbursement and to avoid financial risk to both patient and hospital. Compliance: 1. Will identify and complete Medicare Outpatient Observation Notices (MOON), Medicare Change of Status Notice (MCSN), Condition Code 44s and Medicare Hospital Issued Notices of Non-Coverage (HINNs) for Medicare beneficiaries as appropriate. 2. Ensures compliance with all state of Georgia and Federal regulatory requirements as designated in Emory Healthcare's Utilization Management Plan. 3. Maintains all required annual competencies, metrics, and fully participate and engage in department process improvements. Collaboration: 1. Responsible for timely communication to the provider team and interdisciplinary team as it relates to patient class designation and medical necessity of an admission or continued stay on individual patient basis based on UR Department workflows. 2. In a team effort, the UR Specialist will work closely with the UR Department's Case Management Authorization Specialist IP to ensure that authorized days and patient actual LOS are reconciled to ensure appropriate reimbursement for services provided. 3. Responsible for communicating medical necessity denials for in-house patients to the Medical Director of UR, and when designated to the provider team. 4. Serves as a resource to the provider team, Interdisciplinary Care Team, and patient to explain external UR regulations. 5. Provides effective and efficient proactive communication to internal and external customers. 6. Assists in collaborative efforts with the Case Management Department, Revenue Cycle, Physician Advisors, and other required departments. Additional Responsibilities: 1. Ability to multi-task in a fast-paced environment while efficiently handling multiple priorities and ensuring deadlines are met. 2. Performs other duties and tasks as assigned. Travel: Less than 10% of the time may be required. Work Type: This position is a remote position outside traditional office, often from home or another remote setting.
 
 
Minimum Qualifications: Education - Associate degree in nursing. Experience - Minimum of 5 years of recent acute hospital experience or a minimum of two years of previous utilization review experience. Licensure - Must have a valid, active unencumbered Registered Nurse license approved by the Georgia Licensing Board. Skills - Must meet all quality and productivity expectations and successfully complete yearly competencies. Preferred Qualifications: Education - Bachelor's degree in Nursing strongly preferred. Certification - Case Management certification preferred. Skills - InterQual Level of Care Criteria experience. Previous utilization review experience strongly preferred.
 
 
PHYSICAL REQUIREMENTS: Occasional to frequent sitting. Close eye work (computers, typing, reading, writing).
 
 
ENVIRONMENTAL FACTORS: Remote position.</div>
Additional Details:
<div>
Emory is an equal opportunity employer, and qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or other characteristics protected by state or federal law.</div><div></div><div> 
Emory Healthcare is committed to providing reasonable accommodations to qualified individuals with disabilities upon request. Please contact Emory Healthcare&rsquo;s Human Resources at careers@emoryhealthcare.org. Please note that one week's advance notice is preferred.</div></div>

Utilization Review Specialist

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. 
Position Purpose: Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member.<ul><li>
Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care</li>
<li>Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member</li>
<li>Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered</li>
<li>Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines</li>
<li>Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings</li>
<li>Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members</li>
<li>Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines</li>
<li>Reviews member&rsquo;s transfer or discharge plans to ensure a timely discharge between levels of care and facilities</li>
<li>Collaborates with care management on referral of members as appropriate</li><li>
Performs other duties as assigned.</li>
<li>Complies with all policies and standards.</li></ul>
We are seeking a Clinical Review Nurse - Concurrent Review to join our team!
The ideal candidate will bring expertise in:
IL Nursing License
 
Concurrent Review
 
Inpatient Authorizations 
Discharge Planning 
Acute and/or Critical Care
 
Computer Savvy
 
Excellent Customer Service and Communication Skills
Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor&rsquo;s degree in Nursing and 2 &ndash; 4 years of related experience. 2+ years of acute care experience required. 
 
Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred. 
Knowledge of Medicare and Medicaid regulations preferred. 
Knowledge of utilization management processes preferred. 
 
License/Certification:<ul><li>
LPN - Licensed Practical Nurse - State Licensure required</li></ul>
Pay Range: $27.02 - $48.55 per hour
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>

Clinical Review Nurse - Concurrent Review

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