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

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 Consultant

We're building a world of health around every individual — shaping a more connec...

Location

United States , Work At Home, Columbus, Ohio

Salary:

29.10 - 62.32 USD / Hour

CVS Health

Expiration Date

Until further notice

Requirements

Active unrestricted state Registered Nurse licensure in state of residence required
Minimum 5 years of relevant experience in Nursing
At least 1 year of Utilization Management experience in concurrent review or prior authorization
Strong decision-making skills and clinical judgment in independent scenarios
Proficient with phone systems, clinical documentation tools, and navigating multiple digital platforms
Commitment to attend a mandatory 3-week training (Monday–Friday, 8:30am–5:00pm EST) with 100% participation

Job Responsibility

Apply critical thinking and evidence-based clinical criteria to evaluate outpatient and inpatient services requiring precertification and concurrent review
Conduct clinical reviews via phone and electronic documentation, collaborating with healthcare providers to gather necessary information
Use established guidelines to authorize services or escalate to Medical Directors as needed
Navigate multiple computer systems efficiently while maintaining accurate documentation
Thrive in a fast-paced, high-volume environment with strong organizational, multitasking, and prioritization skills
Perform sedentary work that primarily involves extended periods of sitting, as well as frequent talking, listening, and use of a computer
Flexibility to provide coverage for other Utilization Management (UM) Nurses across various UM specialty teams as needed, ensuring continuity of care and operational support
Participate in occasional on-call rotations, including some weekends and holidays, per URAC and client requirements

What we offer

Medical, dental, and vision coverage
Paid time off
Retirement savings options
Wellness programs

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
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 based on the referral determination status
Generates approval, modification and denial communications, to include member and provider notification of referral determination
Actively monitors for admissions in any inpatient setting
Performs telephonic and/or onsite admission and concurrent review, and collaborates with onsite staff, physicians, providers, member/family interaction to develop and implement a successful discharge plan
Works with the UM Manager and Physician Advisor on case reviews for pre-service, concurrent, post-service and retrospective claims medical review
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, researches to identify timely and accurate resolution steps
Follows up with caller to provide response or resolution steps

What we offer

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

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
Must be computer literate, with expertise in Outlook, Word, Excel, PowerPoint
Excellent time management and priority-setting skills
Strong verbal and written communication skills
Registered Nurse (RN) - Active, current and unrestricted California License

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

Registered Nurse, Capacity Management, Part Time, 7A-7P Specialty/Non-Procedural

The Direct Patient Care Registered Nurse- DPC RN is a licensed professional able...

Location

United States , Miami

Salary:

Not provided

Baptist Health

Expiration Date

Until further notice

Requirements

Active Florida RN license required
7 months of RN experience in Medical Surgical Unit
associate degree in nursing or Bachelor’s degree in Nursing, BSN preferred
RNs hired prior to 2/2012 are not required to have a BSN to continue in their non-leadership role as an RN
RNs hired after 2/2012 with an Associate degree will have 3 years from their date of hire to complete the BSN degree
BLS and ACLS required
Certification in area of practice preferred

Job Responsibility

Delivers patient-family centered care in a culturally competent manner utilizing and promoting evidence based practice standards of quality, safety and service
Demonstrates proficiency in core competencies: assessment, technical skills, communication, critical thinking, interpersonal skills, planning, intervention, evaluation, flexibility, organizational skills, professional accountability, leadership and service

What we offer

Sign-On Bonus: Available with Experience
extensive training programs
tuition assistance
comprehensive benefits

Parttime

Registered Nurse, Wound Management

Location

United States , North Wilkesboro

Salary:

35.50 - 53.25 USD / Hour

Advocate Aurora Health

Expiration Date

Until further notice

Requirements

Graduate of a Board of Nursing approved nursing education program
Basic Life Support (BLS)
Active, unrestricted registered nurse (RN) multi-state compact and/or single-state license with privileges to practice in the state(s) where the RN is providing client nursing services
Typically requires 2 years of experience in clinical nursing
Strong clinical judgment and critical thinking
Time management, prioritization and problem-solving skills
Excellent communication and interpersonal skills
Ability to work in a fast-paced, dynamic environment
Proficiency in operating computer functions (e.g., E-mail, electronic records, digital platforms etc.)
Must be able to sit, stand, walk, lift, squat, bend, reach above shoulders, and twist frequently throughout the workday

Job Responsibility

Engages in unit councils, professional governance, and quality initiatives to improve care processes and apply evidence-based practices
Utilizes the nursing process to assess, plan, diagnose, implement, and evaluate nursing care, engaging patients and families through the continuum of care
Monitors patient conditions, adjusts care plans, mobilizes resources, and collaborates with the care team to influence care outcomes
Upholds and promotes a culture of safety
Continuously evaluates patient, team, and unit outcomes, taking action as needed
May administer medications, treatments, and therapies safely and according to clinical protocols and procedures
Demonstrates effective communication, feedback, and conflict resolution, fostering team collaboration and appropriate delegation
Pursues professional development, completes required education, and maintains certifications
Adhere to the ANA Code of Ethics and practices ethical decision-making, respects interdisciplinary roles, and contributes to integrated, unbiased patient care
Appropriate delegation to other Registered Nurses, Licensed Practical Nurses, and unlicensed assistive personnel

What we offer

Paid Time Off programs
Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
Flexible Spending Accounts for eligible health care and dependent care expenses
Family benefits such as adoption assistance and paid parental leave
Defined contribution retirement plans with employer match and other financial wellness programs
Educational Assistance Program
Premium pay such as shift, on call, and more
Incentive pay for select positions
Opportunity for annual increases based on performance

Fulltime

Registered Nurse - Case Management

Our nurses are a critical part of the UVM Health team. We celebrate their daily ...

Location

United States , Burlington

Salary:

35.78 - 53.67 USD / Hour

The University of Vermont Health Network

Expiration Date

Until further notice

Requirements

Current RN licensure or compact licensure recognized by the State of Vermont required
ADN required, BSN preferred
Appropriate experience in specific clinical area

Job Responsibility

Coordinates the care and services of selected patient populations across the continuum of illness
promotes effective utilization and monitoring of health care resources
assumes a critical role with an interdisciplinary team to achieve optimal patient-centered, clinical, and resource outcomes
proactively identifies and intervenes to address barriers to treatment, health outcomes, and discharge planning, including biopsychosocial and other high-risk factors
serves as an essential link between the patient, the healthcare team, the payer, and the community

What we offer

Health Care (Medical, Dental, Vision)
Flexible Spending Account
Retirement Benefits (403b)
Insurance Benefits (Life, Short-Term, Long-Term)
CTO/PTO: Paid time off
Employee Discounts
Employee & Family Assistance Program
Tuition Reimbursement
Employee Referral Program
Relocation Assistance

Fulltime

Utilization Management Claims Review Nurse Rn Ii

The Utilization Management (UM) Claims Review Nurse RN II is responsible for con...

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 experience in Clinical Nursing
At least 3 years of experience with Medi-Cal and Medicare in a managed care environment
Experience in performing and creating clinical documentation
Experience in regulatory compliance for a health plan
Registered Nurse (RN) - Active, current and unrestricted California License
Knowledge of medical necessity criteria, reimbursement principles, and managed care operation
Working knowledge of clinical policies
Working knowledge of CPT/HCPC Codes, and ICD-10
Proficient in claims processing systems and electronic medical record platforms

Job Responsibility

Perform claims pre-payment review
Conduct comprehensive retrospective reviews
Complete Provider Dispute Review (PDR) clinical evaluations
Apply internal and external clinical policies
Monitor trends related to contested claims and identify potential FWA concerns
Collaborate with internal teams to support payment integrity initiatives
Provide clear, well-documented clinical rationales supporting approval, denial, or adjustment decisions
Maintain productivity and quality standards
Participate in audits, regulatory readiness activities, and quality improvement initiatives
Document review outcomes clearly and accurately

What we offer

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

Fulltime

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Utilization Management Registered Nurse

Job Description

Job Responsibility

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