utilization review rn

University of Maryland Medical System

<div><b>Job Requirements<br>
</b><br>
<p><b>Job Summary
</b></p><p>Utilization Review coordinates the care and service of selected patient populations across the continuum. He/ she works collaboratively with physicians and other members of the health care team to achieve the highest quality clinical outcomes with the most cost-effective use of available resources. Utilization Review assumes responsibility for an interdisciplinary process which assesses, plans, implements, monitors and measures the effectiveness of interventions to meet patients&rsquo; treatment and transitional needs.</p><p><b><br>
COLLABORATION: </b>Collaborates with the physician and other healthcare professionals to promote appropriate use of medical center resources. Participates as a team member to facilitate communication among all disciplines, identify barriers to meeting treatment goals, and determines ways to achieve best outcomes. Participates in the hospital Ethics Committee, as well as facilitates the hospital UR committee.</p><p><b>
DOCUMENTATION AND MEASUREMENT: </b>Uses established criteria to determine appropriateness of admissions, transfer and continued stays. Documents actions in medical record according to departmental guidelines and oversees process of exchange of information with other facilities/ agencies adhering to legal mandates regarding confidentiality. Measures effectiveness of interventions through direct communication with patients and caregivers and data collection of defined indicates (e.g. overall length of stay, readmission rates, feedback from referral services, etc.).</p><p><b>
PATIENT CARE: </b>Uses severity of illness/ intensity of services indexes to determine appropriateness of admissions, transfers and continued stays. Provides physicians and ancillary departments with data on treatment outcomes and avoidable delays in order to promote highest quality care. Identifies potential areas of compliance vulnerability and risk; develops and implements corrective action plans for resolution of problematic issues; and provides general guidance on how to avoid or deal with similar situations in the future. Measures effectiveness of interventions through direct communication with patients and caregivers and data collection of defined indicators (e.g. overall length of stay, readmission rates, feedback from referral sources, etc.). Plays and active leadership role in the ongoing management of inpatient length of stay and utilization review across the organization.</p><p><b>
PROBLEM SOLVING: </b>Identifies problems or gaps in community resources that impact outcome and takes leadership role in efforts to effect changes. Takes a leadership role in identifying opportunities to reduce risks, both financial and clinical, through analysis of resource consumption outcomes.</p><b><br>
Work Experience<br>
</b><br>
<p><b>Education
</b></p><ul><li>4 year/ Bachelor's degree in Nursing (Required)</li></ul><p>
Combination of relevant education and experience may be considered in lieu of degree.</p><p>
Master's Degree in Nursing (Preferred)</p><p><b><br>
Certification / Licensure / Registration</b></p><p>
Case Management Certification (Preferred)</p><p><b><br>
Experience and Skills Required Skills:
</b></p><p>Strong Verbal Communications Skills, Strong Written Communications Skills, Excel - Intermediate Level, PowerPoint - Intermediate Level, MS Word - Intermediate Level, Excellent Organizational Skills</p></div>

Utilization Review RN

JOL Healthcare

<div><p>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.
</p><p><b>Essential Functions:</b>
</p><p><b>Utilization Review &amp; Clinical Oversight:
</b></p><ul><li><p>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.
</p></li><li><p>Ensure documentation supports terminal illness prognosis, hospice eligibility criteria, and continued appropriateness of services in accordance with Medicare hospice regulations.
</p></li><li><p>Review interdisciplinary group (IDG) documentation to ensure plans of care reflect patient needs, goals, and hospice levels of care.
</p></li><li><p>Collaborate with clinical staff to clarify, educate, and correct documentation discrepancies on time.
</p></li><li><p>Evaluate visit utilization patterns, levels of care, and service frequency to promote efficient care delivery while supporting compliance and reimbursement integrity.
</p></li><li><p>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.
</p></li></ul><p><b>HCHB Workflow Monitoring:
</b></p><ul><li><p>Monitor and manage clinical workflow within the HCHB system to ensure timely completion of documentation, orders, and visit notes.
</p></li><li><p>Track pending tasks, outstanding physician orders, certifications, and incomplete documentation using HCHB dashboards and reports.
</p></li><li><p>Identify workflow delays or compliance risks and proactively communicate with appropriate team members to facilitate resolution.
</p></li></ul><p><b>Quality &amp; Compliance Support:
</b></p><ul><li><p>Participate in internal audits and mock surveys to support readiness for CMS, Texas Health and Human Services, and accrediting organization reviews.
</p></li><li><p>Assist with performance improvement initiatives related to hospice utilization, documentation accuracy, and quality outcomes.
</p></li><li><p>Support compliance with federal and state hospice regulations, payer requirements, and agency policies and procedures.
</p></li></ul><p><b>Staff Support &amp; Education:
</b></p><ul><li><p>Provide ongoing feedback and education to clinicians related to hospice documentation standards, utilization expectations, and regulatory requirements.
</p></li><li><p>Assist with onboarding and training of new clinical staff related to HCHB workflows, hospice documentation protocols, and utilization review processes.
</p></li></ul><p><b>Education:
</b></p><p>Graduate of an accredited School of Nursing; BSN preferred.
</p><p><b>License/Certification:</b>
</p><ul><li><p>Current RN license in the state of Texas.
</p></li><li><p>Current BLS certification.
</p></li></ul><p><b>Experience:
</b></p><ul><li><p>Minimum 2 years of clinical hospice experience.
</p></li><li><p>Strong knowledge of Medicare hospice Conditions of Participation (42 CFR Part 418), hospice eligibility criteria, and interdisciplinary team processes.
</p></li><li><p>Experience with Homecare Homebase (HCHB) is strongly preferred.
</p></li></ul><p><b>Skills:
</b></p><ul><li><p>Proficient with electronic medical record systems and Microsoft Office applications.
<br>
Strong organizational, analytical, and communication skills.
</p></li><li><p>Ability to manage multiple priorities while meeting regulatory and operational deadlines.
</p></li><li><p>Working knowledge of Medicare and Medicaid hospice regulations.
</p></li></ul><p><b>Environmental and Working Conditions:
</b></p><ul><li><p>Primarily office-based with potential for remote/hybrid work (based on agency policy).
</p></li><li><p>May require minimal travel for field support or in-person training.
</p></li><li><p>Frequent use of computer systems and prolonged screen time.
</p></li></ul><p><b>Physical and Mental Effort:
</b></p><ul><li><p>Prolonged sitting and computer use are required.
</p></li><li><p>Ability to manage stressful situations calmly and courteously.
</p></li><li><p>Requires working under some stressful conditions to meet deadlines and patient needs.</p></li></ul></div>

Hospice Utilization Review Nurse

WPS—A health solutions company

<div>
 Our
 <strong>
  Utilization Management RN (Registered Nurse)
 </strong>
 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
 <strong>
  Utilization Management RN
 </strong>
 will be responsible for referring questionable cases to medical directors to prevent unnecessary procedures, treatments, or prolonged hospital stays.
 <br/>
 <br/>
 <strong>
  Salary Range
  <br/>
  <br/>
 </strong>
 <strong>
  $75,000 ~ $100,000
  <br/>
  <br/>
 </strong>
 <em>
  The base pay offered for this position may vary within the posted range based on your job-related knowledge, skills, and experience.
  <br/>
  <br/>
 </em>
 <strong>
  Work Location
  <br/>
  <br/>
 </strong>
 <strong>
  We are open to remote work in the following approved states:
  <br/>
  <br/>
 </strong>
 Colorado, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, New Jersey, North Carolina, Ohio, South Carolina, Texas, Virginia, Wisconsin
 <br/>
 <br/>
 <strong>
  How do I know this opportunity is right for me? If you:
  <br/>
  <br/>
 </strong>
 <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.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Minimum Qualifications
 </strong>
 <br/>
 <br/>
 <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.
    <br/>
   </li>
  </ul>
 </ul>
 <strong>
  Preferred Qualifications
  <br/>
  <br/>
 </strong>
 <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.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Remote Work Requirements
  <br/>
  <br/>
 </strong>
 <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
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Benefits
  <br/>
  <br/>
 </strong>
 <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/)
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Who We Are
  <br/>
  <br/>
 </strong>
 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.
 <br/>
 <br/>
 <strong>
  Culture Drives Our Success
  <br/>
  <br/>
 </strong>
 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.
 <br/>
 <br/>
 We are proud of the recognition we have received from local and national organization regarding our culture and workplace: WPS Newsroom - Awards and Recognition.
 <br/>
 <br/>
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  Sign up for
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  FOLLOW US!
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 </strong>
 <strong>
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 </strong>
</div>


Utilization Management RN

American Traveler

<div><h3 class="jobSectionHeader"><b>Assignment Overview</b></h3><ul><li>
Shift: Days, 3x12hrs</li><li>
Hours: 36 hrs/wk</li><li>
Start Date: May 11, 2026</li><li>
Length: 13 weeks</li><li>
Openings: 1</li></ul><p>
American Traveler has an immediate opening for a Travel RN Case Management/Utilization Review Case Management job in Chicago, Illinois. RN travelers who work with us receive a highly competitive pay and benefits package. You'll enjoy the personalized client service that has earned us high ratings from travelers nationwide - and the security that comes from working with an established, Joint Commission-certified agency.</p>
<p>More about traveling in Illinois: Illinois travel assignments can take you to quaint towns or big cities - Chicago for one. This America's Heartland state is known for winning sports franchises, agricultural production and friendly residents.</p>
<p>Job ID: P-695376</p><h3 class="jobSectionHeader"><b>
Requirements</b></h3><ul><li>
1+ year of recent experience in this specialty and setting</li><li>
Valid nursing license as required by this state</li><li>
Valid Basic Life Support (BLS) certification from the American Heart Association (AHA)</li><li>
Valid Advanced Cardiac Life Support (ACLS) certification through AHA recommended and may be required</li><li>
Specialty-related certifications are preferred and may be required</li><li>
Professional References</li><li>
Additional job specific requirements will be provided by your Recruiter</li></ul><h3 class="jobSectionHeader"><b>
Benefits</b></h3><ul><li>
High Pay and Bonuses</li><li>
Medical, Dental and Vision Insurance with Day 1 Options</li><li>
401(k) Plan</li><li>
Weekly Payroll Deposit</li><li>
Free Online CEUs</li><li>
Generous Housing Allowance</li><li>
Travel and Licensure Reimbursements</li><li>
Non-taxed Per Diem and Subsidy</li><li>
Traveler Rewards and Discounts</li></ul></div>

Travel RN - Case Management/Utilization Review - Case Management

PrairieCare

<div>About Us:
<div><b>
Join PrairieCare: Transform Lives Through Meaningful Work!</b></div><div></div><div><br>
Are you ready to embark on a rewarding career in psychiatric healthcare? At PrairieCare, we are passionate about delivering exceptional mental health services to individuals in need. Our comprehensive approach covers the entire spectrum of care, creating a wealth of diverse roles for those who aspire to make a real impact.</div><div>
We believe in nurturing talent and fostering professional growth in a supportive environment. Here, you won&rsquo;t just find a job&mdash;you&rsquo;ll discover a fulfilling career path in the mental health field.</div><div>
If you're eager to contribute to a mission-driven organization and help change lives for the better, we invite you to join our dedicated team at PrairieCare. Together, we can make a profound difference in the lives of those we serve!</div>
Responsibilities:
<div>
 <b>Join Our Dynamic Team as a Utilization Review Specialist</b></div><div></div><div><br>
Are you passionate about making a difference in the lives of those with psychiatric illnesses? Do you thrive in a collaborative environment where your expertise can shine? If so, we have the perfect opportunity for you!</div><div></div><div><b><br>
What You'll Do:</b> As our Behavioral Health Liaison, you will be the vital link between our dedicated clinical treatment team and third-party payers, ensuring that every patient receives the appropriate treatment they deserve. Your role will include:</div><div>
✅ <b>Securing Authorizations:</b> Obtain initial behavioral health authorizations and conduct thorough concurrent reviews to keep our patients on the path to recovery.</div><div>
✅ <b>Collaborative Decision-Making:</b> Work closely with the clinical treatment team to assess the need for denial of stay when patients no longer meet acute care criteria, facilitating timely and appropriate actions.</div><div>
✅ <b>Stay Informed:</b> Maintain an up-to-date understanding of contract requirements for all third-party payor groups, ensuring compliance and optimal patient care.</div><div>
✅ <b>Track Progress:</b> Monitor each patient&rsquo;s treatment journey through inpatient, partial hospitalization, and Intensive Outpatient Programs (IOP), ensuring they receive the best possible support.</div><div>
✅ <b>Cultural Competence:</b> Bring your knowledge of gender, cultural differences, and age-appropriate care to the forefront of Utilization Review, enhancing our approach to diverse patient needs.</div><div><b>
Why Join Us?</b> At our organization, you&rsquo;ll be part of a passionate team committed to improving mental health care. We value your expertise and provide ongoing training and support to help you excel in your role.</div><div>
 <b>Make a Difference Today!</b> If you&rsquo;re ready to take on a rewarding challenge and be a champion for those in need, apply now and help us transform lives through compassionate care!</div><div></div><div><br>
We are excited to hear about your interest in this opportunity! If you have any questions or need assistance with the application process, please feel free to contact me directly at <b>Sydney Spencer</b>, either via email at <b>sydney.spencer@newporthealthcare.com</b> or by phone at <b>615-961-4138</b>. If you need further support, you are also welcome to reach out to our careers and management team at <b>careers@newporthealthcare.com</b><b>.</b>
</div>Qualifications:
<div><b>
What You'll Bring:</b></div><div></div><ul><li><br>
At least two (2) years of work experience in the behavioral health field.
</li><li>Active license or credential in a behavioral health field preferred.
</li><li>Bachelor&rsquo;s or Master&rsquo;s in a behavioral health related specialty preferred.</li></ul><p></p><div><b><br>
Benefit options include:</b></div><ul><li>
Medical/Dental/Vision</li><li>
Company paid life insurance</li><li>
Paid time off including sick time</li><li>
Voluntary Short term and long-term disability</li><li>
401K with company match</li><li>
Flexible spending accounts</li><li>
Tuition Reimbursement</li><li>
Student Loan Repayment</li><li>
Free parking</li><li>
Free 24/7 Fitness Center</li></ul><div><b>
Join Us:</b></div><div>
Join us in our mission to provide outstanding support and make a meaningful difference in the lives of those we assist. Your contributions can help shape the future of our care services&mdash;apply today!</div><div></div><p><br>
PrairieCare Healthcare is an Equal Opportunity Employer.</p><p>
PrairieCare provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, sexual orientation, gender identity, national origin, disability status, protected veteran status, genetic information, or any other characteristic protected by federal, state, or local laws.</p><p>
PrairieCare is committed to ensuring equal employment opportunity, including providing reasonable accommodations to individuals with disabilities. Applicants with a physical or mental disability who require a reasonable accommodation for any part of the application or hiring process are encouraged to email careers@newporthealthcare.com for assistance.</p><p></p><div><br>
#LI-SS1</div></div>

Utilization Review Specialist (or UR Nurse)

<div><h3 class="jobSectionHeader"><b>Assignment Overview</b></h3><ul><li>
Shift: Days, 5x8hrs</li><li>
Hours: 40 hrs/wk</li><li>
Start Date: Apr 20, 2026</li><li>
Length: 13 weeks</li><li>
Openings: 1</li></ul><h3 class="jobSectionHeader"><b>
Description</b></h3><p>
American Traveler is hiring an experienced RN for a community hospice Case Manager position requiring a minimum of 2 years of experience and an active CO or compact RN license.</p><h3 class="jobSectionHeader"><b>
Details</b></h3><ul><li>
Community hospice setting, providing care wherever patients call home &mdash; including private residences, nursing homes, group homes, and assisted living facilities</li><li>
Assigned caseload of patients as a Primary RN, leading an interdisciplinary care team</li><li>
Weekday schedule: Monday&ndash;Friday, 8am&ndash;5pm</li><li>
Occasional weekend backup and on-call responsibilities</li></ul><h3 class="jobSectionHeader"><b>
Requirements</b></h3><ul><li>
Active CO or compact RN license currently in hand</li><li>
Minimum 2 years of RN experience required</li><li>
Hospice nursing experience expected given the specialized nature of the role</li><li>
Strong clinical assessment and critical thinking skills required</li><li>
Ability to function as a generalist across disease types with specialization in symptom management</li></ul><h3 class="jobSectionHeader"><b>
Additional Information</b></h3><ul><li>
Primary RNs lead interdisciplinary teams and serve as the clinical and educational point of contact for patients and their caregivers</li><li>
Responsibilities include helping patients define personal goals of care and empowering caregivers to confidently support their loved ones</li><li>
DOB and SSN may be required for consideration</li></ul></div>

<div><h3 class="jobSectionHeader"><b>Assignment Overview</b></h3><ul><li>
Shift: Days, 4x10hrs</li><li>
Hours: 40 hrs/wk</li><li>
Start Date: Apr 27, 2026</li><li>
Length: 9 weeks</li><li>
Openings: 1</li></ul><h3 class="jobSectionHeader"><b>
Description</b></h3><p>
American Traveler is hiring a travel RN for a Case Management position in Myrtle Beach, SC, requiring at least 2 years of case management experience and an active SC or compact RN license.</p><h3 class="jobSectionHeader"><b>
Details</b></h3><ul><li>
Located in a hospital setting in Myrtle Beach, SC</li><li>
Case Management unit</li><li>
Day shift schedule: 7:00 AM &ndash; 5:30 PM</li><li>
13-week contract</li></ul><h3 class="jobSectionHeader"><b>
Requirements</b></h3><ul><li>
Active SC or compact RN license required</li><li>
Minimum 2 years of recent case management experience required</li><li>
Current BLS certification required (AHA or ARC accepted)</li><li>
US SSN and date of birth required for consideration</li><li>
No gaps in work history of 90 days or more within the past 12 months</li><li>
Certifications must not expire within the first 30 days of the assignment start date</li></ul><h3 class="jobSectionHeader"><b>
Additional Information</b></h3><ul><li>
Candidates must reside more than 50 miles from the facility &mdash; local candidates are not eligible</li><li>
One professional reference required (two required if licensed in Florida or Missouri)</li></ul></div>

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10000 utilization review rn jobs Near Me

Utilization Review RN

Hospice Utilization Review Nurse

Utilization Management RN

Travel RN - Case Management/Utilization Review - Case Management

Utilization Review Specialist (or UR Nurse)

Travel RN - Case Management/Utilization Review - Case Management

Travel RN - Case Management/Utilization Review - Case Management