utilization review nurse

Deaconess Health System

<div>Incentives:

Eligible for evening/night, weekend shift incentive based on company policies and applicable job codes. Additional details will be provided during the interview process. 


Bonus:

Potential for a performance-based bonus, subject to eligibility criteria and achievement of defined metrics. Details regarding bonus eligibility and performance goals will be provided during the interview process or upon hire. 


Benefits:

We pride ourselves in retaining our top talent by offering work environments that support professional development and personal success. In addition to our robust healthcare and retirement plans, we offer:
<ul>
<li>Flexible work schedules &ndash; Full time/part time/supplemental &ndash; Day/Eve/Night</li>
<li>Onsite children&rsquo;s care centers (Infant through Pre-K)</li>
<li>Tuition reimbursement</li>
<li>Payactiv-earned wage benefit-work today, get paid tomorrow</li>
<li>Free access to fitness centers</li>
<li>Career advancement opportunities</li></ul> 


Explore All Benefits:

https://www.deaconess.com/For-You/Employees/Employee-Benefit-Resources/Documents 


Job Overview:

This position is responsible for working assigned denials (such as no authorization, medical necessity, and readmission) from assigned work queues according to policy and established productivity standard. This position will work with third party payors to obtain payment on accounts according to legal and proper collection techniques as well as maintain accounts receivable goals developed by the department. The Coordinator will prepare appeals, reports of denial activity and identify trends for the Denial Analysis Team to make appropriate changes to prevent future denials. 

Required: Certifications/Licenses/Experience:
<ul>
<li>Active Registered Nurse (RN) in Indiana or other compact licensure state</li></ul> 


Preferred Certification/License/Experience:
<ul>
<li>BSN</li>
<li>Three (3) to five (5) years of clinical experience as a Registered Nurse in an acute care or specialty hospital</li>
<li>Minimum of two (2) years performing utilization review, charge audit, case management or similar functions in an acute care or specialty hospital</li></ul> 


Other Key Words: Registered Nurse // HRS // Healthcare Resources // UM // Utilization Management // Case Management

Department: HRS

Hours: Full-time, 40 hours/week
Equal Opportunity Employer 
This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.</div>

Clinical Denial Analyst (RN)

Incredible Health

<div>
 Hospitals on Incredible Health are actively hiring and accepting applications in the Washington, DC area for the following position: Nurse Case Manager (RN). Nurses with experience in any of the following areas are strongly encouraged to apply: Clinical pathway, Navigator, or Utilization Review.
 
 
 <ul>
 <li>
 Shift(s) available: day shift, night shift, and mid shift
 </li>
 <li>
 Job types available: full time, part time, and per diem
 </li>
 <li>
 Employer features: 401(K), 401(K), Academic medical center, Adoption Assistance, Best Places to Work recognition, Child Care Benefits, Community hospital, Cross training, Cross training, Cross training, Cross training, Disability Insurance, EAP, FSA, FSA, FSA, Healthgrades Specialty Excellence Award recipient, Health Insurance, Level 1 trauma center, Level 1 trauma center, Level 2 trauma center, Level 2 trauma center, Life Insurance, Life Insurance, Magnet recognized, Magnet recognized, Magnet recognized, Magnet recognized, Medical, Medical, Nurse self-care program , Offers sign on bonus, Offers sign on bonus, Paid Parental Leave, PTO, PTO, PTO, Retirement Plan, Retirement Plan, Retirement Plan, Teaching Hospital, Tuition Assistance, Tuition Assistance, Union facility, U.S. News best hospital, U.S. News best hospital, U.S. News best hospital, U.S. News best hospital
 
 
 </li>
 </ul>
 
 Qualifications
 
 
 
 <ul>
 <li>
 Bachelor of Science in Nursing (BSN) or higher educational attainment from an accredited program
 </li>
 <li>
 Active and unencumbered Registered Nurse license
 </li>
 <li>
 1+ years experience in case management, preferably within a healthcare or hospital setting
 </li>
 <li>
 Exceptional interpersonal and communication skills, both written and verbal, to effectively collaborate with medical professionals, patients, and family members
 </li>
 <li>
 Proficiency in electronic health records (EHR) software
 
 
 </li>
 </ul>
 
 Responsibilities
 
 
 
 <ul>
 <li>
 Conduct comprehensive assessments of patients, including their medical history, medication, treatment plans, and psychosocial needs
 </li>
 <li>
 Collaborate closely with healthcare providers, patients, and families to develop and implement individualized care plans
 </li>
 <li>
 Monitor and evaluate patient progress, adjusting care plans as needed and communicating any changes to the healthcare team
 </li>
 <li>
 Serve as the main point of contact between the patient and healthcare providers, ensuring seamless communication and care coordination
 </li>
 <li>
 Maintain up-to-date records and case notes, adhering to all confidentiality and compliance standards
 
 
 </li>
 </ul>
 
 Benefits
 
 
 
 <ul>
 <li>
 Healthcare coverage: Medical, Dental, Vision
 </li>
 <li>
 401K
 </li>
 <li>
 Paid Time Off
 </li>
 <li>
 Tuition Assistance
 
 
 </li>
 </ul>
 Salary: $61,000 to $130,000 /year
</div>

Nurse Case Manager (RN)

Interim HealthCare

<div>Description 
 
Our Registered Nurse Case Managers (RNCM) have been called to care when they're needed most. At Interim HealthCare, you'll support a full range of patient services to bring comfort and dignity to our clients.
What we offer our Registered Nurse Case Managers (RNCM):
<ul><li>Competitive pay, benefits, and incentives.</li><li>
Truly flexible scheduling - a dedication to work/life balance - Full-time/ Part-time / PRN / Weekends</li><li>
Daily Pay option available
</li><li>No Overtime Required
</li><li>1:1 patient care
</li></ul>Working at Interim HealthCare means a career unlike any other. With integrity at the center of all we do, we know that when we support you and your community, you'll change lives every day.
As a Registered Nurse Case Manager (RNCM), you will:<ul><li>
Conduct In Person patient interviews and comprehensive physical assessments.</li><li>
Oversee the implementation and ongoing assessment of the patient's plan of care through the management of home health aides, LPNs, RNs, and other caregivers.</li><li>
Communicate patient conditions and collaborate with appropriate providers to deliver care when patient needs evolve.</li><li>
Provide education to patients and families on proper home health care procedures. Ie. Wound care, IV administration, medication management.</li><li>
Work to decrease readmissions by promoting preventative care and ensuring continuity of care.</li></ul>
To qualify as a Registered Nurse Case Manager (RNCM) with us, you will need:
<ul><li>Licensure: Current unrestricted license to practice as a Registered Nurse (RN) in the state associated with this position
</li><li>Current CPR/AED/BLS/First Aid certification
</li><li>Reliable transportation to/from care sites and/or work locations.</li><li>
One (1) year of professional experience practicing as a Registered Nurse (RN) in home health or similar setting; previous case management/utilization review experience preferred.</li><li>
OASIS experience preferred.</li><li>
Practical trach and/or ventilator experience preferred, not required.</li></ul>
At Interim HealthCare, we know that being our best is non-negotiable - that's why we treat your family like our own. We take a patient-centric approach to address each individual's mind, body, and spirit, our caregivers work tirelessly to help their patients and families find peace. From our unmatched referral response times to our focus on quality improvement, the most beautifully complicated time of your life is our life's work.
We're an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran, or disability status.
#Akron1</div>

RN Case Manager

<div>Description
Our Registered Nurse Case Managers (RNCM) have been called to care when they&rsquo;re needed most. At Interim HealthCare, you&rsquo;ll support a full range of patient services to bring comfort and dignity to our clients. 
What we offer our Registered Nurse Case Managers (RNCM):
<ul><li>Competitive pay, benefits, and incentives.
</li><li>Truly flexible scheduling &ndash; a dedication to work/life balance &ndash; Full-time/ Part-time / PRN / Weekends
</li><li>Daily Pay option available
</li><li>No Overtime Required
</li><li>1:1 patient care</li></ul> 
Excited to hear more? 
Working at Interim HealthCare means a career unlike any other. With integrity at the center of all we do, we know that when we support you and your community, you&rsquo;ll change lives every day. 
As a Registered Nurse Case Manager (RNCM), you will:
<ul><li>Conduct In Person patient interviews and comprehensive physical assessments.</li><li>Oversee the implementation and ongoing assessment of the patient&rsquo;s plan of care through the management of home health aides, LPNs, RNs, and other caregivers.</li><li>Communicate patient conditions and collaborate with appropriate providers to deliver care when patient needs evolve.</li><li>Provide education to patients and families on proper home health care procedures. Ie. Wound care, IV administration, medication management.</li><li>Work to decrease readmissions by promoting preventative care and ensuring continuity of care.</li></ul> 
To qualify as a Registered Nurse Case Manager (RNCM) with us, you will need:
<ul><li>Licensure: Current unrestricted license to practice as a Registered Nurse (RN) in the state associated with this position
</li><li>Current CPR/AED/BLS/First Aid certification
</li><li>Reliable transportation to/from care sites and/or work locations.</li><li>One (1) year of professional experience practicing as a Registered Nurse (RN) in home health or similar setting; previous case management/utilization review experience preferred.</li><li>OASIS experience preferred.</li><li>Practical trach and/or ventilator experience preferred, not required.</li></ul> 
At Interim HealthCare, we know that being our best is non-negotiable &ndash; that&rsquo;s why we treat your family like our own. We take a patient-centric approach to address each individual&rsquo;s mind, body, and spirit, our caregivers work tirelessly to help their patients and families find peace. From our unmatched referral response times to our focus on quality improvement, the most beautifully complicated time of your life is our life&rsquo;s work. 
We're an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran, or disability status.
 #Kentucky1</div>

CVS Health

<div>At CVS Health, we&rsquo;re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.
As the nation&rsquo;s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues &ndash; caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.
Position Summary
CVS Health Aetna has an opportunity for a full-time Utilization Management (UM) Nurse Consultant. As a Utilization Management Nurse Consultant, you will utilize clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. You would be responsible for ensuring the member is receiving the appropriate care at the appropriate time and at the appropriate location, while adhering to federal and state regulated turn-around times. This includes reviewing written clinical records.
Key Responsibilities of the UM Nurse Consultant (Includes but is not limited to)<ul><li>
Reviews services to assure medical necessity, applies clinical expertise to assure appropriate benefit utilization, facilitates safe and efficient discharge planning and works closely with facilities and providers to meet the complex needs of the member.</li><li>
Facilitate the delivery of appropriate benefits and/or healthcare information which determines eligibility for benefits while promoting wellness activities.</li><li>
Develops, implements and supports Health Strategies, tactics, policies and programs that ensure the delivery of benefits and to establish overall member wellness and successful and timely return to work.</li><li>
Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members.</li><li>
Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members.</li><li>
Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure, and clinical judgment to render coverage determination/recommendation along the continuum of care.</li><li>
Communicates with providers and other parties to facilitate care/treatment.</li><li>
Identifies members for referral opportunities to integrate with other products, services and/or programs.</li><li>
Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization.</li></ul>
Required Qualifications<ul><li>
Registered Nurse (RN) with current unrestricted US licensure required.</li><li>
2+ years clinical practice experience as an RN required.</li><li>
2+ Years Utilization Management experience.</li><li>
Must be willing to travel to the local office as needed if living within approximately 45 minutes/miles.</li></ul>
Preferred Qualifications<ul><li>
Bilingual proficiency preferred.</li><li>
1+ year(s) experience utilizing multiple computer systems and applications including Microsoft Word, Excel, Outlook, and web-based applications.</li></ul>
Education<ul><li>
Associate&rsquo;s degree in Nursing.</li><li>
BSN preferred.</li></ul>
Anticipated Weekly Hours
40
Time Type
Full time
Pay Range
The typical pay range for this role is:
$26.01 - $74.78
This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. 
Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.
Great benefits for great people
We take pride in our comprehensive and competitive mix of pay and benefits &ndash; investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:<ul><li>
Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.</li><li>
No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.</li><li>
Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.</li></ul>
For more information, visit https://jobs.cvshealth.com/us/en/benefits
We anticipate the application window for this opening will close on: 11/07/2025
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.</div>

Utilization Management Nurse Consultant

RN - Home Visits

State of Arizona

<div><div>AHCCCS
Arizona Health Care Cost Containment System 
Accountability, Community, Innovation, Leadership, Passion, Quality, Respect, Courage, Teamwork 
 
The Arizona Health Care Cost Containment System (AHCCCS), Arizona&rsquo;s Medicaid agency, is driven by its mission to deliver comprehensive, cost-effective health care to Arizonans in need. AHCCCS is a nationally acclaimed model among Medicaid programs and a recipient of multiple awards for excellence in workplace effectiveness and flexibility. 
 
AHCCCS employees are passionate about their work, committed to high performance, and dedicated to serving the citizens of Arizona. Among government agencies, AHCCCS is recognized for high employee engagement and satisfaction, supportive leadership, and flexible work environments, including remote work opportunities. With career paths for seasoned professionals in a variety of fields, entry-level positions, and internship opportunities, AHCCCS offers meaningful career opportunities in a competitive industry.
 
 
Come join our dynamic and dedicated team.
</div>Public Health Nursing Consultant - Prior Authorization and Utilization Review
Division of Fee for Service Management
Job Location:
<div>Address: 150 North 18th Avenue Phoenix, Arizona 85007
All AHCCCS Employees must reside within the state of Arizona.
This position has the potential to work from a Virtual Office (VO) setting or may Telecommute based on the needs of the unit and at the discretion of leadership.
</div>Posting Details:
<div>Salary: $71,032
FLSA Status: Exempt 
Grade: 22 
Closing Date: Open until filled
</div>Job Summary:
<div>The position is responsible for monitoring, evaluating and approving or denying payment of medical and/or behavioral healthcare services through prospective, concurrent, and retrospective review for the Fee for Service population. The position determines medical necessity based on standards of care, rules, regulations, policies and procedures governing the provision of covered services. This position will primarily work from home with some in-office meetings and on-site duties being required.
The State of Arizona strives for a work culture that affords employees flexibility, autonomy, and trust. Across our many agencies, boards, and commissions, many State employees participate in the State&rsquo;s Remote Work Program and are able to work remotely in their homes, in offices, and in hoteling spaces. All work, including remote work, should be performed within Arizona unless an exception is properly authorized in advance.</div> 

<div>
<div>Major duties and responsibilities include but are not limited to: 
<ul><li>Collaborates with providers, Tribal and AHCCCS staff regarding care coordination, utilization review, prior authorization, coverage criteria, policies and procedures, workflow, member needs, and other issues</li><li>Evaluates, recommends action, negotiates rates, and provides ongoing monitoring for program policy compliance and reporting of data related to specialty services such as Specialty DME, Exception NF Rates, and Over Institutional Cost services.</li><li>Confers with Utilization Review Coordinators from the Peer Review Organization regarding concurrent review of length of stay and appropriateness of services.</li><li>Provides education and technical assistance to FFS Providers and Tribal staff as needed, including identification, research and resolution of member specific and provider issues, to improve compliance with AHCCCS requirements, policies, and procedures.</li><li>Tracks and/or performs focused reviews for compliance related to utilization management processes and Federal and State Rules and Regulations related to the AHCCCS FFS populations. Maintain documentation files.</li><li>Devises and submits system generated reports, extracts, and analyses for unit and division and management.</li><li>Participates in process improvement and other special projects, work groups, and committees to improve the efficiency of care coordination, utilization management, and other functions in the Clinical Administration unit.</li></ul></div>
</div>
Knowledge, Skills &amp; Abilities (KSAs):
<div><div>Knowledge: 
<ul><li>Understanding of health care delivery systems and mechanisms necessary for coordination and delivery of services
</li><li>Principles of medical and/or behavioral management and assessment
</li><li>Current standards of medical/behavioral practice and delivery of acute/non-acute medical/behavioral care
</li><li>Current costs, appropriateness and utilization of medical supplies and equipment
</li><li>Principles of utilization review
</li><li>Alternative levels of care.
</li><li>ICD-9/10 Diagnosis Coding; DSM-IV/V; CPT procedure coding
</li><li>Medical technology computer data retrieval and input
</li><li>AHCCCS, ALTCS, Medicaid and Medicare Federal Regulations. State Statute and Rule and policies applicable to AHCCCS programs, policies and procedures
</li><li>Code of Federal Regulation (42 CFR)
</li><li>Medical and psycho- social needs of ALTCS members, cultural, environmental, and community influences on behavior of ALTCS members
</li><li>AHCCCS and ALTCS program design and implementation, including case management functions and responsibilities, provider network, and funding source
</li><li>Familiarity with American Indian Tribes/ programs and policy relative to IGA's and other related policies</li></ul> 

Skills: 
<ul><li>Problem solving-identification; evaluation and initiation of appropriate action; nursing assessment
</li><li>Public relations skills, interacting with statewide providers of healthcare services, public organizations, and social agencies
</li><li>Organizational skills for setting priorities; workload, and record keeping
</li><li>Intermediate computer skills to access and input member information
</li><li>Analytical ability to identify and correlate specific patterns, initiate investigations, submit findings and recommendations
</li><li>Strong Interpersonal skills in working with people of diverse cultures and socioeconomic backgrounds</li></ul> 

Abilities: 
<ul><li>Proficiency in oral and written communication
</li><li>Teach and train
</li><li>Interpret clinical information and assess implications for treatment
</li><li>Negotiate competitive rates to maximize available funding for members' care
</li><li>Read, Interpret, and apply complex rules and regulations
</li><li>Independent decision making
</li></ul></div></div>Selective Preference(s):
<div>Arizona Driver's License 

Minimum: Possession of a current license to practice as a registered nurse in the State of Arizona and three (3) year of relevant experience. 
 
Preferred: Professional experience in the Healthcare Industry - specifically experience in Prior Authorization, Concurrent Review, Retrospective Review, and Utilization Management.
</div>
Pre-Employment Requirements:
<div><ul><li>Successfully pass fingerprint background check, prior employment verifications and reference checks; employment is contingent upon completion of the above-mentioned process and the agency&rsquo;s ability to reasonably accommodate any restrictions.</li><li>Travel may be required for State business. Employees who drive on state business must complete any required driver training (see Arizona Administrative Code R2-10-207.12.)</li></ul>

If this position requires driving or the use of a vehicle as an essential function of the job to conduct State business, then the following requirements apply: Driver&rsquo;s License Requirements. 

All newly hired State employees are subject to and must successfully complete the Electronic Employment Eligibility Verification Program (E-Verify).
</div>
Benefits:
<div><div>Among the many benefits of a career with the State of Arizona, there are: 
<ul><li>10 paid holidays per year</li><li>Paid Vacation and Sick time off (13 and 12 days per year respectively) - start earning it your 1st day (prorated for part-time employees)</li><li>Paid Parental Leave-Up to 12 weeks per year paid leave for newborn or newly-placed foster/adopted child.</li><li>Other Leaves - Bereavement, civic duty, and military.</li><li>A top-ranked retirement program with lifetime pension benefits</li><li>A robust and affordable insurance plan, including medical, dental, life, and disability insurance</li><li>Participation eligibility in the Public Service Loan Forgiveness Program (must meet qualifications)</li><li>RideShare and Public Transit Subsidy</li><li>A variety of learning and career development opportunities</li></ul></div>

By providing the option of a full-time or part-time remote work schedule, employees enjoy improved work/life balance, report higher job satisfaction, and are more productive. Remote work is a management option and not an employee entitlement or right. An agency may terminate a remote work agreement at its discretion. 

</div>
Retirement:
<div><div>Lifetime Pension Benefit Program 
<ul><li>Administered through the Arizona State Retirement System (ASRS)</li><li>Defined benefit plan that provides for life-long income upon retirement.</li><li>Required participation for Long-Term Disability (LTD) and ASRS Retirement plan.</li><li>Pre-taxed payroll contributions begin after a 27-week waiting period (prior contributions may waive the waiting period).</li></ul> 

Deferred Retirement Compensation Program
 
<ul><li>Voluntary participation.</li><li>Program administered through Nationwide.</li><li>Tax-deferred retirement investments through payroll deductions.</li></ul></div>
</div>
Contact Us:
<div>Persons with a disability may request a reasonable accommodation such as a sign language interpreter or an alternative format by emailing careers@azahcccs.gov. 
Requests should be made as early as possible to allow time to arrange the accommodation. The State of Arizona is an Equal Opportunity/Reasonable Accommodation Employer.</div></div>

Public Health Nursing Consultant

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