RN, Utilization Management Job at University of Rochester (Rochester)

Embedded Transitional Care Manager RN

Oak Street Health takes a team-based approach to providing outstanding patient c...

Location

United States , Rockford

Salary:

66575.00 - 142576.00 USD / Year

CVS Health

Expiration Date

Until further notice

Requirements

An active RN license within the state of practice in good standing
Willingness to obtain cross-state licensure, as needed
Certified Case Manager (CCM) or equivalent case management certification required, or willingness to obtain within 12 months of hire
2+ years’ experience in transitional nursing, discharge planning, nursing case management, or home health
Experience in utilization management preferred
Knowledge of Medicare/Medicaid and NCQA regulatory transitions of care criteria
Exceptional communication skills and customer service orientation
Innovative and independent problem solving skills
Ability to monitor and evaluate opportunities for cost-effective care options with high-quality outcomes
Spanish-speaking preferred but not required

Job Responsibility

Manage patients through transitions of care
Advocate for the patient throughout the care continuum
Identify opportunities for improved program workflows
Maintain real-time and accurate records of patient status
Adhere to CMS, state specific and NCQA compliance criteria
Evaluate patient status post-ED visit or observation stay
Triage to determine appropriate follow up care
Engage directly with inpatient physicians, case managers, medical directors, and hospitalists
Coordinate with the Utilization Management team
Conduct structured clinical assessment to identify post-discharge needs

What we offer

Paid vacation, sick time, and investment/retirement 401K match options
Health insurance, vision, and dental benefits
Affordable medical plan options
No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching
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

Fulltime

Embedded Transitional Care Manager

The Embedded Transitional Care Manager - RN (TCM-RN) plays a critical role in en...

Location

United States , Indianapolis

Salary:

54095.00 - 116760.00 USD / Year

CVS Health

Expiration Date

Until further notice

Requirements

An active RN license within the state of practice in good standing
willingness to obtain cross-state licensure, as needed
Certified Case Manager (CCM) or equivalent case management certification required, or willingness to obtain within 12 months of hire
2+ years’ experience in transitional nursing, discharge planning, nursing case management, or home health
experience in utilization management preferred
knowledge of Medicare/Medicaid and NCQA regulatory transitions of care criteria
exceptional communication skills and customer service orientation
innovative and independent problem-solving skills
ability to monitor and evaluate opportunities for cost-effective care options with high-quality outcomes
Spanish-speaking preferred but not required

Job Responsibility

Manage patients through transitions of care, either face to face in the facility or telephonically
advocate for the patient throughout the care continuum
identify opportunities for workflow improvements and partnerships
maintain real-time records of patient transitions
engage with physicians, case managers, and hospitalists
coordinate follow-up care, medication reconciliation, and discharge planning
collaborate with internal stakeholders and regional leaders on transitions initiatives
participate in training, documentation, tracking, and quality assurance

What we offer

Mission-focused career
paid vacation and sick time
investment/retirement 401K match options
health insurance, vision, and dental benefits
affordable medical plan options
no-cost programs for health and wellness
tuition assistance
flexible schedules
family leave
dependent care resources

Fulltime

Medical Appeals/Grievance Specialist II - Registered Nurse

Responsible for utilizing clinical acumen and managed care expertise related to ...

Location

United States , Phoenix

Salary:

Not provided

Blue Cross Blue Shield of Arizona

Expiration Date

Until further notice

Requirements

1 year experience in clinical and health insurance or other healthcare related field
3 years experience in clinical and health insurance or other healthcare related field AND 1 year Managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
5 years experience in clinical and health insurance or other healthcare related field AND 2 years Managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
8 years experience in clinical and health insurance or other healthcare related field AND 3 years above satisfactory job performance in the managed care environment with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
Associate’s Degree in a healthcare field of study or Nursing Diploma
Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) or a compact state as a Registered Nurse (RN), a Physical Therapist (PT) or a Licensed Master Social Worker LMSW.
Intermediate PC proficiency
Intermediate skill using office equipment, including copiers, fax machines, scanner and telephones
Maintain confidentiality and privacy
Advanced clinical knowledge

Job Responsibility

Perform in-depth analysis, clinical review and resolution of provider appeals/inquiries, corrected claims and subscriber reconsiderations, member appeals, corrected claims and provider grievances for all lines of business
Identify, research, process, resolve and respond to customer inquiries primarily through written / verbal communication.
Respond to a diverse and high volume of health insurance appeal related correspondence on a daily basis.
Analyze medical records and apply medical necessity criteria and benefit plan requirements to determine the appropriateness of appeal, grievance and reconsideration requests.
Maintain complete and accurate records per department policy.
Meet quality, quantity and timeliness standards to achieve individual and department performance goals as defined within the department guidelines and required by State, Federal and other accrediting organizations.
Demonstrate ability to apply plan policies and procedures effectively.
Consult and coordinate with various internal departments, external plans, providers, businesses, and government agencies to obtain information and ensure resolution of customer inquiries.
Attend staff and interdepartmental meetings.
Participate in continuing education and current developments in the fields of medicine and managed care.

Fulltime

Director, RN Case Management

The Director, RN Case Management provides strategic and operational leadership f...

Location

United States , Denver, Colorado

Salary:

115700.00 - 150500.00 USD / Year

InnovAge

Expiration Date

Until further notice

Requirements

Bachelor’s degree in Nursing (BSN)
Current state-issued Registered Nurse (RN) license
5+ years of experience in acute care coordination, case management, or discharge planning
2+ years of leadership or supervisory experience in a clinical setting
Demonstrated success in performance management, operational execution, and cross-functional collaboration
Experience in quality improvement, compliance adherence, or care coordination oversight

Job Responsibility

Leads, develops, and supports RN Case Managers, including recruitment, onboarding, coaching, and performance management
Establishes division-wide workflows, standards, and best practices for acute and post-acute care coordination
Partners with the VP of Nursing Operations and clinical leadership to implement staffing strategies, workload balancing, and coverage expectations for case management services
Oversees daily operational execution of case management functions, ensuring timely coordination, documentation, and communication across care teams
Ensures RNs receive training and ongoing development to maintain clinical competency in transitional care and utilization management
Oversees the experience of participants during hospitalization and post-acute stays, ensuring high-quality transitions and strong communication
Responds to escalated participant concerns in coordination with Center Directors, providers, and Quality teams
Ensures RN Case Managers collaborate effectively with participants, families, caregivers, and IDT members to support person-centered care plans
Monitors service KPIs and drives improvements in communication, responsiveness, and participant satisfaction during transitional care periods
Ensures division performance aligns with quality metrics related to readmissions, skilled days, length of stay, and transition-of-care outcomes

What we offer

medical/dental/vision insurance
short and long-term disability
life insurance and AD&D
supplemental life insurance
flexible spending accounts
401(k) savings
paid time off
company-paid holidays

Fulltime

Utilization Management Nurse RN

Signature HealthCARE is a family-based healthcare company offering integrated se...

Location

United States , Louisville

Salary:

75000.00 - 89000.00 USD / Year

Signature HealthCARE, LLC

Expiration Date

Until further notice

Requirements

Registered Nurse (RN) in good standing with required current state license
Associates degree required, but Bachelor’s degree preferred
Basic knowledge of medical necessity criteria such as Milliman Care Guidelines or Interqual
Minimum of three (3) years related case management experience
Minimum of three (3) years of hospital, SNF or Acute Rehab clinical experience
Certified in Case Management through ACMA, CCMC or other credentialed agencies, preferred or willing to obtain after one year of employment
Knowledge of Medicare payment methodology and the MDS RUG system
Previous experience with MDS and assessment preferred

Job Responsibility

Collaborate regularly and maintain open communication with leadership, patients, families, internal care givers, and external Utilization Management Nurses
Coordinate internal and external health care team activities related to resident care, transitions and discharge planning with agencies, and other healthcare organizations
Conduct initial baseline assessment of resident care needs and communicate that effectively to the Managed Care Organization (MCO) ensuring all aspects of care services are communicated accurately
Verify all care needs and the authorization for services and outliers
Communicate/collaborate with the Managed Care Organization (MCO) at required intervals as determined by the MCO
Negotiate appropriate levels based on services provided and contractual arrangements with the facility and the MCO
Document all authorizations and continued stay activity in Case Management software to ensure appropriate reporting and billing
Prepare all Managed Care documentation to facility accurate billing

What we offer

Medical, Dental and Vision – Voluntary Life/Disability
Free Telemedicine with Medical Plan
401(K) and Roth 401(K)
Tuition Forgiveness/Education Reimbursement
A variety of additional specialized Insurances
Pay Advance and Next Day Pay
Paid Time Off (PTO)
Partner Perks and Discounts
Reward & Recognition Program (HEART)

Fulltime

Clinical Nurse

Humata Health Inc. is seeking a Clinical Nurse to join our team and work at the ...

Location

United States

Salary:

Not provided

Humata Health, Inc

Expiration Date

Until further notice

Requirements

Registered Nurse (RN) with an active license
3+ years of experience in utilization management, prior authorization, case management, or related clinical roles
Strong understanding of payer policies, medical necessity criteria, and the prior authorization process
Working knowledge of medical coding systems (ICD-10, CPT, HCPCS)
Comfort working with technology platforms
Demonstrated project management skills — ability to organize complex workflows, manage deliverables, and ensure accountability across teams
Excellent critical thinking and problem-solving skills
Strong communication and collaboration abilities across clinical and technical teams

Job Responsibility

Partner with health plan utilization review nurses to validate and improve AI-driven prior authorization workflows
Review and structure medical policies to enable AI-powered automation of utilization review decisions
Apply clinical judgment to ensure that AI outputs align with evidence-based guidelines, payer standards, and medical coding practices
Participate in product review cycles by providing feedback on usability, accuracy, and workflow alignment
Guide product teams by translating clinical and utilization review needs into actionable product requirements
Collaborate with product and engineering teams to refine how clinical decision points are represented in AI models
Test, validate, and continuously improve AI-enabled review tools for accuracy and fairness
Provide feedback to enhance both policy digitization workflows and AI-driven decision support
Manage small-scale projects, including organizing digitization initiatives, tracking timelines, coordinating stakeholders, and reporting on progress
Stay current on payer requirements, clinical guidelines, regulatory standards, and coding updates relevant to utilization management

What we offer

Competitive base compensation
Equity through our Employee Stock Option Plan
Bonus-eligible roles
Full benefits package including unlimited PTO
401k program with employer match
Growth opportunities
Inclusive culture
Remote flexibility
Access to our new office in Winter Park, FL

Fulltime

Appeals Nurse Consultant

This is a full-time telework position. Hours for this role are Monday-Friday 8a-...

Location

United States

Salary:

Not provided

CVS Health

Expiration Date

Until further notice

Requirements

Must have active and unrestricted RN licensure in state of residence
3+ years clinical experience

Job Responsibility

Responsible for the review and resolution of clinical appeals
Reviews documentation and interprets data obtained from clinical records to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and provider issues
Independently coordinates the clinical resolution with internal/external clinician support as required

Fulltime

Utilization Management Nurse Specialist RN II

The Utilization Management Nurse Specialist RN II facilitates, coordinates, and ...

Location

United States , Los Angeles

Salary:

88854.00 - 142166.00 USD / Year

L.A. Care Health Plan

Expiration Date

Until further notice

Requirements

Associate's Degree in Nursing
At least 5 years of varied RN clinical experience in an acute hospital setting
At least 2 years of Utilization Management/Case Management experience in a hospital or HMO setting
Registered Nurse (RN) - Active, current and unrestricted California License
Must be computer literate, with expertise in Outlook, Word, Excel, PowerPoint
Provision of excellent customer service required
Excellent time management and priority-setting skills
Maintains strict member confidentiality and complies with all HIPAA requirements
Strong verbal and written communication skills

Job Responsibility

Facilitates, coordinates, and approves medically necessary referrals that meet established criteria
Assures timely and accurate determination and notification of referrals and reconsiderations
Generates approval, modification and denial communications
Actively monitors for admissions in any inpatient setting
Performs telephonic and/or onsite admission and concurrent review
Collaborates with onsite staff, physicians, providers, member/family to develop and implement a successful discharge plan
Works with the UM Manager and Physician Advisor on case reviews
Monitors and oversees the collection and transfer of data (medical records) and referral requests by Providers
Acts as a department resource for medical service requests /referral management and processes
Receives incoming calls from providers, professionally handles complex calls

What we offer

Paid Time Off (PTO)
Tuition Reimbursement
Retirement Plans
Medical, Dental and Vision
Wellness Program
Volunteer Time Off (VTO)

Fulltime

RN, Utilization Management

University of Rochester

Location:
United States of America , Rochester

Category:
Nursing

Contract Type:
Not provided

Salary:

Job Description:

Job Responsibility:

Requirements:

Nice to have:

Additional Information:

Job Posted:
March 10, 2026

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