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Utilization Review Manager Jobs

Rn Specialist Utilization Review
By HonorHealth At , Scottsdale, 85258
Determines qualifications for hospital level of care based on set criteria.
Initiates chart reviews, conducts follow-up reviews, and escalates secondary reviews to Physician Advisor as necessary.
Performs other duties as assigned.
Utilization Review Director Jobs
By Coastal Behavioral Health At , Savannah, 31406
Challenging and rewarding work environment
Excellent Medical, Dental, Vision and Prescription Drug Plan
401(K) with company match and discounted stock plan
Career development opportunities within UHS and its 300+ Subsidiaries
Utilization Review Business Support Specialist
By Allegheny Health Network At , Up to $30.93 an hour
Investigates concerns for improper billing/coding practices and recommends corrective action, works collaboratively to understand denial/appeal management process and alert edits/rejections. (10%)
Proficient with department software, analytical tools, basic coding and billing knowledge, and revenue cycle operational policies. (5%)
1 year experience with medical necessity appeals
Implements and organizes downgrades compliantly and per documentation. (10%)
Identifies trends with claim holds and denials and provides communication to all necessary parties. (10%)
Communicates with all parties in a professional manner to alert of specific problem issues. (10%)
Team Coordinator, Behavioral Health Utilization Review
By Sentara Healthcare At , Norfolk, 23502
Provides educational services to the Utilization Management staff
Requires knowledge of managed care contracting, Medical Necessity, CMHRS services, DMAS protocols, clinical protocols and clinical review requirements
Minimum 1 year experience in Managed Care Setting (MCO)
First line supervisor in the Utilization Management Department
Provides a leadership role in ongoing utilization review competency assessment, needs identification and educational offerings
Requires knowledge of contractual, regulatory and compliance requirements for government payers, self funded and commercial payers
Utilization Review Nurse Jobs
By Albany Medical Center At , New Scotland $65,062 - $107,349 a year

Thank you for your interest in Albany Medical Center!

Albany Medical is an equal opportunity employer.

Rn Utilization Review Jobs
By Edward-Elmhurst Health At , Naperville, 60540
KNOWLEDGE, SKILLS AND ABILITIES REQUIRED:
Minimum of two years of utilization review and/or clinical experience
Minimum of two years of utilization review experience
Associate’s Degree or higher in Nursing
Current State of Illinois Registered Nurse licensure
Bachelor’s Degree in Nursing or health care related field
Utilization Review/Performance Improvement Nurse*
By San Bernardino County At , $83,678 - $113,942 a year
An equivalent combination of education and experience may be considered.
Boost Annual Salary Up To: $118,102 When Modified Benefits Option Is Selected
Priority Review Will Begin on Monday, August 14, 2023 For Early Consideration
Receive Paid Holidays, Generous Vacation & Sick Time
Receive A County Pension To Plan For Retirement
For more detailed information, refer to the Utilization Review/Performance Improvement Nurse job description.
Utilization Review Nurse- Prn
By Netsmart Technologies At , Remote
At least 3 years case management, concurrent review or utilization management experience
Case management/concurrent review/utilization management experience within the ED setting
At least 5 years clinical experience in acute care setting in emergency room, critical care and/or medical/surgical nursing
Review electronic medical records of emergency department admissions and screen for medical necessity, using InterQual.
Participate in telephonic discussions with emergency department physicians relative to documentation and admission status.
Enter clinical review information into system for transmission to insurance companies for authorization.
Utilization Review Case Manager
By Lehigh Valley Health Network At , Allentown, 18103
2 years Knowledge of utilization management as it relates to third party payers.
5 years of experience in case management and DC planning experience within the last 5 years.
Knowledge, Skills, and Abilities - Required:
Knowledge, Skills, and Abilities - Preferred:
2 years of previous utilization review experience. and
3 years of experience in acute care and
Senior Therapist - Youth Clinical Utilization Review
By City of Alexandria, VA At , Alexandria $66,460 - $89,027 a year
Implement Independent Assessment Certification & Coordination Team (IACCT) recommendations including locating residential treatment placements and intensive community based services;
Act as Family Assessment and Planning Team (FAPT) Case Manager for high needs youth and their families;
Engage families seeking residential services for their children in the Children’s Services Act (CSA) Parental Agreement process;
Provide consultation, coordination and monitoring when out-of-home behavioral health services are considered, including Parental Agreements;
Participate in multi-disciplinary planning meetings, court hearings, and relevant training, conferences and workshops;
Develop and monitor treatment plans with youth and their families based on their strengths, needs, preferences, and goals;
Utilization Review Specialist Jobs
By Department of Behavioral Healt At , Washington, Dc $87,339 - $111,749 a year
Traffic record check (as applicable);
Consumer credit check (as applicable);
Reasonable suspicion drug and alcohol test; and
Post-accident or incident drug and alcohol test.
RESIDENCY PREFERENCE AMENDMENT ACT OF 1988
Bachelor’s Degree in Nursing preferred.
(F/T) - Utilization Review (Non-Rn) Case Manager - Umhc/Sccc - Miami
By University of Miami At , Miami, Fl
Accurate review of coverage benefits and limitations to determine continued appropriateness of services requested
Maintains knowledge regarding payer reimbursement policies and clinical guidelines.
Minimum of 2 years of relevant experience
Adhere and perform timely reviews for services requiring an authorization for continuation of care
Follows the authorization process using established criteria as set forth by the payer or clinical guidelines
Facilitates interdepartmental communication regarding status of continued authorization in advance of patient’s appointment.
Utilization Review Specialist - Behavioral Health
By Prestige Utilization Management & Billing Solutions At , Remote $35,000 - $40,000 a year
Excellent data entry skills and ability to navigate electronic systems applicable to job functions
Ensure all pre-certifications are completed for inpatient and outpatient services
Work with facilities to ensure documentation requirements are met
Interface with managed care organizations, external reviews, and other payers
2 or more years experience billing UR healthcare industry – in the mental health/addiction field.
Working knowledge of clinical case formulation for substance abuse/mental health treatment.
Outcomes Manager - Utilization Review - Behavioral Health (Remote)
By VIRTUA At , Marlton, 08053, Nj
Appropriate and complete documentation of clinical review and denial management in the case management documentation system and in the billing system.
Position Qualifications Required / Experience Required:
Manages the concurrent denial process by referring to appropriate resource for concurrent and retrospective appeal activity process.
Understands and applies applicable federal and state requirement.
Utilizes Payer specific screening tools as a resource to assist in the determination process regarding level of service and medical necessity.
Consults with Physician Advisor to discuss medical necessity, length of stay, and appropriateness of care issues.
Medicaid Utilization Review Analyst
By State of Idaho Employment At Greater Idaho Falls, United States
An opportunity for student loan forgiveness (https://studentaid.gov/manage-loans/forgiveness-cancellation/public-service)
an opportunity for student loan forgiveness (https://studentaid.gov/manage-loans/forgiveness-cancellation/public-service)
THIS ANNOUNCEMENT WILL BE OPEN UNTIL FILLED. APPLICANTS ARE ENCOURAGED TO APPLY AS SOON AS POSSIBLE TO BE CONSIDERED.
Generous vacation and sick leave accrual beginning as soon as you start
11 paid holidays a year
Multiple savings plans, optional 401K, and optional 457
Utilization Review Specialist(Ft)
By Cornerstone of Recovery At , Louisville, 37777, Tn
Notify supervisor when pre-certification is denied.
Develop collaborate relationships with third party payers and managed care companies
Continue education with new information regarding criteria for various insurance companies.
Track how particular Managed Care Companies approve residential days in keeping with progress notes under our ASAM criteria.
Average to above average computer skills.
Above average verbal and writing skills.
Utilization Review Nurse Jobs
By Ethos At Austin, TX, United States
Certified Case Manager (CCM), Health Care Quality & Management (HCQM) or equivalent certification preferred.
1-year experience with workers' compensation/utilization management preferred.
Assists in promoting and furthering the objectives of the Quality Management Program.
Active, unrestricted professional license or certification to practice as a health professional in a state or territory of the United States:
2 years of clinical nursing experience (direct patient care, administrative or combination post licensure).
Knowledge of workers' compensation laws and regulations (preferred).
Utilization Review Nurse - Remote | Wfh
By Get It Recruit - Healthcare At Atlanta, GA, United States

Are you ready to make a significant impact on healthcare quality, cost efficiency, and patient well-being? Join our dynamic team as a Utilization Management Nurse and play a pivotal role in ensuring ...

Utilization Review Nurse Hospital Compliance, Hybrid
By University of Maryland Medical System At , Linthicum, Md
Drafts written reports that detail audit findings and recommendations to senior UMMS leadership, Department management/personnel, and/or other related business partners.
Provides input to CCBEG management and operational leaders to assist in the creation of management action plans to resolve identified deficiencies.
In collaboration with CCBEG management, performs activities specified in the Auditing and Monitoring Plan.
This position requires experience with utilization review in a hospital setting.
Conducts analysis of findings to identify trends/problems in billing and documentation.
Develops and administers coding and billing compliance training related to audit findings.
Utilization Review Business Support Specialist
By Allegheny Health Network At , , Pa
Investigates concerns for improper billing/coding practices and recommends corrective action, works collaboratively to understand denial/appeal management process and alert edits/rejections. (10%)
Proficient with department software, analytical tools, basic coding and billing knowledge, and revenue cycle operational policies. (5%)
1 year experience with medical necessity appeals
Implements and organizes downgrades compliantly and per documentation. (10%)
Identifies trends with claim holds and denials and provides communication to all necessary parties. (10%)
Communicates with all parties in a professional manner to alert of specific problem issues. (10%)

Are you looking for a challenging and rewarding role in healthcare? We are seeking an experienced Utilization Review Manager to join our team! You will be responsible for managing the utilization review process, ensuring that all services are medically necessary and appropriate. You will also be responsible for developing and implementing policies and procedures to ensure compliance with applicable regulations. If you have a passion for healthcare and are looking for an opportunity to make a difference, this is the job for you!

A Utilization Review Manager is responsible for overseeing the utilization review process for a healthcare organization. This includes ensuring that all utilization review activities are conducted in accordance with applicable laws and regulations, as well as the organization’s policies and procedures.

What is Utilization Review Manager Skills Required?

• Knowledge of utilization review processes and procedures
• Knowledge of healthcare regulations and laws
• Excellent communication and interpersonal skills
• Ability to analyze data and make decisions
• Ability to work independently and as part of a team
• Ability to manage multiple projects and prioritize tasks
• Proficiency in Microsoft Office Suite

What is Utilization Review Manager Qualifications?

• Bachelor’s degree in healthcare administration, business administration, or related field
• At least 5 years of experience in utilization review
• Certification in utilization review (preferred)

What is Utilization Review Manager Knowledge?

• Knowledge of healthcare reimbursement and coding
• Knowledge of medical terminology
• Knowledge of healthcare quality assurance and improvement
• Knowledge of healthcare data analysis

What is Utilization Review Manager Experience?

• Experience in utilization review management
• Experience in healthcare administration
• Experience in healthcare quality assurance and improvement

What is Utilization Review Manager Responsibilities?

• Develop and implement utilization review policies and procedures
• Monitor utilization review activities to ensure compliance with applicable laws and regulations
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