Utilization Management Nurse Job at Valley Children's Healthcare (Madera)

Nurse Manager- Weekend Operations

The Nurse Manager is responsible for day-to-day patient flow and operations in a...

Location

United States , Boston

Salary:

170000.00 - 182500.00 USD / Year

Dana-Farber Cancer Institute

Expiration Date

Until further notice

Requirements

Licensed as a Registered Nurse in the Commonwealth of Massachusetts
Baccalaureate degree required
Baccalaureate degree in nursing preferred
Master’s degree required or intent to enroll into program within 6 months of hire
Certification in Oncology Nursing, OCN, ACON, or CPON strongly preferred
3 years of oncology experience required
leadership or charge nurse experience preferred
Critical thinking, collaboration and excellent communication skills
Clinical resource regarding the administration of chemotherapy and blood products
Demonstrates understanding of special needs and behaviors of age groups of the population served: young adult to geriatric

Job Responsibility

Responsible for day-to-day patient flow and operations in a specific clinical unit
Coordination and supervision of assigned nursing and clinical assistant staff
Oversees direct patient care, including patient and family education
Delegates triage of unexpected patients to the charge nurse
Modifies nursing assignments, as needed, to meet the needs of patients
Provides clinical leadership and management and promotes professional growth for self and staff
Demonstrates systems thinking, response to diversity, collaboration, clinical judgment, clinical inquiry, facilitation of learning and advocacy for patients and staff
Collaborates with the Clinical Specialist to provide clinical expertise for the unit
Serves as a mentor for clinical staff
Develops daily staffing assignments for all clinic staff in collaboration with practice manager

Fulltime

Case Manager, Registered Nurse

Remote case manager position working intensely as a telephonic case manager with...

Location

United States , Remote

Salary:

54095.00 - 155538.00 USD / Year

CVS Health

Expiration Date

Until further notice

Requirements

5+ years’ experience as a Registered Nurse
1+ year of experience in a hospital setting
Active, unrestricted RN license in state of residence
Willingness to receive multi-state/compact privileges
1+ years' experience documenting electronically using a keyboard
1+ years' current or previous experience in Oncology, Transplant, Specialty Pharmacy, Pediatrics, Medical/Surgical, Behavioral Health/Substance Abuse or Maternity/Obstetrics experience

Job Responsibility

Work as a telephonic case manager with patients and their care team
Application and/or interpretation of applicable criteria and clinical guidelines
Assess benefits and/or member's needs to ensure appropriate administration of benefits
Incorporate strategies designed to reduce risk factors and barriers
Address complex health and social indicators which impact care planning
Consult with supervisor and others in overcoming barriers
Utilize case management processes in compliance with regulatory requirements
Utilize motivational interviewing skills for member engagement
Identify and escalate member's needs appropriately
Actively reach out to members to collaborate/guide their care

What we offer

Affordable medical plan options
401(k) plan with matching company contributions
Employee stock purchase plan
Wellness screenings
Tobacco cessation programs
Weight management programs
Confidential counseling
Financial coaching
Paid time off
Flexible work schedules

Fulltime

Assistant Nurse Manager

Our nurse leaders maintain a strong commitment to the highest standards of profe...

Location

United States , Oakland

Salary:

156000.00 - 179850.00 USD / Year

Kaiser Permanente

Expiration Date

Until further notice

Requirements

Minimum two (2) years of experience in patient care delivery
Associates degree in a Business, Nursing, Health Care, or directly related field AND minimum two (2) years of experience in business operations, clinical health care, or a directly related field OR minimum three (3) years of experience in business operations, clinical health care, or a directly related field
Minimum one (1) year of experience in a leadership role with or without direct reports
Registered Nurse License (California) required at hire
Basic Life Support required at hire

Job Responsibility

Assisting the implementation of best practice models
Assisting the implementation of patient care delivery systems and practice standards in several locations
Supporting investigations into patient/family/member concerns regarding patient care and services
Supporting collaboration with physicians, outside healthcare providers, and other health care team members to achieve optimal and safe patient care across the continuum
Allocating resources in assigned clinical areas to ensure appropriate assignment and utilization
Supervising the use and maintenance of equipment, supplies and medications
Supporting the creation of a safe environment for patients and employees
Maintaining clinical expertise, providing clinical supervision, competency and licensing necessary to fulfill job responsibilities and to direct the provision of care in the unit
Delegating tasks and duties that are aligned to scope of practice
Performing clinical duties as required

What we offer

Medical, Vision & Dental
Retirement Plans
Tuition Reimbursement
Supportive Teams & Resources
Career Growth & Development

Parttime

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

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

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

Director of Nursing

Our client is reputable provider of home care and hospice services in the South....

Location

United States , Baton Rouge

Salary:

Not provided

Above All Talent Solutions

Expiration Date

Until further notice

Requirements

Current Registered Nurse (RN) licensure in the State of Louisiana
Minimum of three years experience as a Registered Nurse, one of these years must be full-time in providing direct patient care in a home health or hospice setting
One year supervisory and administrative experience
Attend annual review and in-services
Actively participate in organization’s performance improvement activities
Maintains regulatory requirements, including all federal, state, local regulations and accrediting organization standards
Comply with all organizational policies regarding ethical business practices
Resolve staff concerns, utilizing the grievance process as required
Must have current, unrestricted license, in state of practice

What we offer

Excellent pay
Company Car Option
Increased Earning Potential
Mileage Reimbursement
Cell Phone Allowance
Complete Benefits Package including Health, Dental, Vision & Life Insurance
Paid Time Off (PTO)
401K
Free CEU online accreditation courses
Remarkable Career Advancement Opportunities

Registered Nurse, Utilization Management

The Utilization Management RN reviews charts assisting to determine correct pati...

Location

United States , Jacksonville

Salary:

Not provided

Baptist Health (Florida)

Expiration Date

Until further notice

Requirements

Associate's Degree - Nursing
3-5 Years Case Management Experience
Licensed Registered Nurse Required

Job Responsibility

Concurrent monitoring of patient record documentation to verify the need for hospitalization
Appropriate utilization of resources and assist with documentation improvement
Ensuring that the UR Plan is carried out in accordance with all QIO/PRO mandates and government regulations
Providing utilization information to commercial carriers per contractual arrangement
Assisting with discharge planning and case management activities

Fulltime

Utilization Management Nurse

Valley Children's Healthcare

Location:
United States , Madera

Category:
Nursing

Contract Type:
Not provided

Salary:

Job Description:

Job Responsibility:

Requirements:

Nice to have:

Additional Information:

Job Posted:
February 17, 2026

Looking for more opportunities? Search for other job offers that match your skills and interests.

Similar Jobs for Utilization Management Nurse

Nurse Manager- Weekend Operations

Case Manager, Registered Nurse

Assistant Nurse Manager

Medical Appeals/Grievance Specialist II - Registered Nurse

Appeals Nurse Consultant

Embedded Transitional Care Manager

Director of Nursing

Registered Nurse, Utilization Management

Utilization Management Nurse

Valley Children's Healthcare

Location:United States , Madera

Category:Nursing

Contract Type:Not provided

Salary:

Job Description:

Job Responsibility:

Requirements:

Nice to have:

Additional Information:

Job Posted:February 17, 2026

Looking for more opportunities? Search for other job offers that match your skills and interests.

Similar Jobs for Utilization Management Nurse

Nurse Manager- Weekend Operations

Case Manager, Registered Nurse

Assistant Nurse Manager

Medical Appeals/Grievance Specialist II - Registered Nurse

Appeals Nurse Consultant

Embedded Transitional Care Manager

Director of Nursing

Registered Nurse, Utilization Management

Location:
United States , Madera

Category:
Nursing

Contract Type:
Not provided

Job Posted:
February 17, 2026