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Registered Nurse Utilization Review Jobs in Bexar, Texas

Remote Registered Nurse - Medical Review Specialist
By Avosys Technology, Inc. At San Antonio, TX, United States
Years of experience in supporting, administering, managing content management platform such as Sharepoint
years of experience in supporting, administering, managing content management platform such as Sharepoint
Maximize family time with no weekend, Holiday, or on-call requirements
Take advantage of our competitive, comprehensive benefits package including medical, dental, vision, life, short-term disability, long-term disability & 401(k)
Ensure that all documentation includes a valid signature consistent with the signature requirements
Complete one-on-one provider education (i.e., webinar, conference call, etc.) within 30 days of sending out review results letter
Registered Nurse - Utilization Management
By US Veterans Health Administration At , San Antonio, 78229, Tx $77,286 - $161,761 a year
Interprets federal regulations, VHA guidelines, medical review criteria, utilization management processes, clinical documentation requirements, current standards of care, and compliance guidelines.
If you are relying on your education to meet qualification requirements:
Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).
3-5 years recent Clinical Experience
2-5 years recent Interqual Experience
2-3 years experience managing teams and/or programs
Utilization Review Registered Nurse (Rn), Care Coordination, Full Time, Days
By MarinHealth Medical Center At , Greenbrae $66.03 - $99.04 an hour
Basic knowledge of government and private insurance benefits (e.g. Medi-Cal, Medicare, DRGs, and managed care), including reimbursement requirements is needed.
Experience in applying evidence based criteria related to utilization management.
Experience using case management software
National certification in Case Management preferred
Complies with all reporting requirements for mandated, risk management, and other medical/legal situations consistent with confidentiality policies and department standards.
Must be assertive and creative in problem solving, system planning and management.
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 Full Time – Care Management
By Montefiore Nyack Hospital At , Nyack, Ny

Description Comprehensively plans with the health care team to ensure patient needs are met and care delivery is coordinated across the continuum. Identifies and works to eliminate/minimize ...

Registered Nurse Utilization Review Prn
By UT Southwestern At , Dallas, 75390, Tx

Registered Nurse Utilization Review PRN Days Remote Monday-Friday shifts Why UT Southwestern? With over 75 years of excellence in Dallas-Fort Worth, Texas, UT Southwestern is committed to excellence, ...

Utilization Review Nurse Jobs
By Methodist McKinney Hospital At , Mckinney, 75070, Tx
Uses knowledge of the nursing process and pathophysiology to interpret the needs or requirements of patients
Identifies, documents and communicates potential quality assurance or risk management issues as appropriate.
Uses knowledge of nursing process and pathophysiology to anticipate discharge needs.
Licensure as a registered nurse required.
Performs initial, concurrent, discharge and retrospective reviews.
Uses evidence-based medical guidelines to determine the medical appropriateness of inpatient and outpatient services
Concurrent Review Nurse Jobs
By University HealthCare Alliance At , Newark, 94560, Ca $49.59 - $65.71 an hour
Excellent communication, organizational and time management skills with the ability to meet tight timeframes.
Refer members to various other departments (i.e., Case Management, Disease Management, TPL, COB) for follow-up as appropriate.
Properly request letters, including applying the appropriate legal and regulatory requirements for ICE and health plan specific letter Templates.
All other duties as assigned including department-specific functions and responsibilities:
Three (3) years of Medical/Surgical clinical nursing experience.
Proficient in Microsoft Office applications and other computer skills.
Education Coordinator (Registered Nurse) - Utilization Management
By Texas Children's Hospital At , Houston, 77001, Tx
Utilization management experience highly preferred
Designs, implements, coordinates and evaluates educational programs for clinical and non-clinical staff
Manages special projects and performance improvement initiatives for the department
BLS certification from the American Heart Association required
2 years clinical nursing experience required
Instructs 4 CPR/BLS programs annually by collaborating with the department of clinical training and development
Utilization Review Specialist Jobs
By Lexington Medical Center At , West Columbia, 29169, Sc
Communicates with case management triad regarding reimbursement issues.
We are committed to offering quality, cost-effective benefits choices for our employees and their families:
Manages inpatient Medicare discharge expedited appeals process through the QIO.
Indentifies abnormal patterns of utilization and refers to Manager/Director.
Day ONE medical, dental and life insurance benefits
Exhibits commitment and pride through personal example by positively speaking about LMC, the department, employees and guests.
Utilization Review Nurse Jobs
By INTEGRANET HEALTH At , Houston, Tx
Preferred knowledge in case management principles, utilization management procedures and practices
Prior experience with Utilization Management
Provides telephonic case management, referral of resources, education and other clinically based activities to plan member.
QUALIFICATIONS, SKILLS, ABILITIES AND PROFESSIONAL COMPETENCIES:
Experience with Health Plans and Managed Care
Previous training and demonstrated competence in negotiations, quality assurance and case management outcomes
Utilization Review Specialist Jobs
By Memorial Hermann Health System At , Houston, 77024, Tx
Experience / Knowledge / Skills
Refers cases and issues to Care Management Medical Director in compliance with Department procedures and follows up as indicated.
Effective oral and written communication skills.
Utilizes conflict resolution skills as necessary to ensure timely resolution of issues.
Uses appropriate criteria sets for admission reviews, continuing stay reviews, outlier reviews and clinical appropriateness recommendation.
Takes appropriate follow-up action when established criteria for utilization of services are not met.
Medical Review Nurse Jobs
By Vital Signs At , Concord, 94519, Ca

100% Remote, Work-From-Home position anywhere in the US. MUST HAVE A CALIFORNIA LICENSE. Registered nurse will be auditing medical claim reviews that physicians have completed. Previous medical ...

Utilization Review Nurse-Weekends Jobs
By Sentara Healthcare At , Virginia Beach, 23462
Must possess 2-3 years of acute care clinical experience.
Previous Utilization Review experience a plus.
InterQual or Milliman experience preferred.
This position is Remote, Weekend Days.
Bachelor’s Degree in Nursing preferred
Basic Life Support (BLS) - Other/National
Utilization Review Nurse - Outpatient
By Johns Hopkins University At , Baltimore, 21218

Requisition #: 627353 Location: Johns Hopkins Health Plans, Hanover, MD 21076 Category: Nursing Schedule: Day Shift Who you are: As a Utilization Review Registered Nurse for Johns ...

Utilization Review Nurse Jobs
By Samaritan Health Services At , Corvallis $40.88 - $60.03 an hour
Acute care utilization review, discharge planning or case management experience preferred.
Utilization Review or Case Management Certification preferred.
Experience and/or training in insurance benefits or covered services including Medicare and Medicaid required.
Three (3) years RN experience required.
Experience and/or training in computer applications required. Typing speed of 35 wpm preferred.
Three (3) years hospital nursing experience preferred.
Registered Nurse - Utilization Review Case Manage - Peds/Adults - 8 Hour Days
By CEDARS-SINAI At , Los Angeles $52.47 - $83.95 an hour

lifting, standing, walking, sitting, typing, reaching, repetitive motions

Utilization Review Nurse Jobs
By Mercy At , Springfield, 65804
Education: Graduate of an accredited school of nursing.
Experience: 2-3 years acute care hospital setting.
Tuition Reimbursement up to $2,000 for continuing education
Licensure: Current license in the state of residence and/or employment.
Health/Dental/Vision available after day one
Annual contribution of $100 per month to eligible co-workers enrolled in the Dependent Care FSA
Manager, Utilization Management, Registered Nurse, Rn
By Humana At ,
Minimum 1 year Utilization Management Experience
Intermediate to advanced computer skills and experience with Microsoft Suite, Word, Excel, Outlook.
Requires cross departmental collaboration, and conducts briefings and area meetings; maintains frequent contact with other managers across the department.
Manager will travel twice a year to South Florida to attend meetings (See Additional Information below)
Minimum 1 year experience with any of the following Team Leadership, Project Leadership, or Subject Matter Expert, SME
Minimum 1-year progressive clinical experience preferably in an acute care clinical setting
Utilization Review Nurse - Outpatient
By Johns Hopkins Health Plans At , Hanover
Excellent verbal/written communication skills to effectively interact and work collectively with enrollees, physicians, facility staff and management staff
Understanding of managed care delivery systems and utilization management
1+ years’ experience in Managed Care/Utilization Review is required
Knowledge and expertise in utilizing various criteria sets (i.e. InterQual)
3+ years’ experience as an acute care RN
This position is eligible for remote work.
Utilization Review Nurse Selecthealth
By Intermountain Healthcare At , Murray $38.83 - $57.46 an hour

The hourly range for this position is listed below. Actual hourly rate dependent upon experience.

Anticipated job posting close date:

Utilization Review Nurse Jobs
By MEDSTAR HEALTH At , Washington, 20010
Associate degree in Nursing with five years of bedside nursing experience can be used in lieu of the Bachelor's degree requirement.
Prior experience as a Case Manager required
Knowledge of reimbursement models (commercial, managed care, Medicare) is preferred.
Prior experience in a hospital or office type setting preferred
Prior utilization review experience preferred
Knowledge of MS Office Suite
Utilization Review Nurse (Lpn)
By 1199SEIU Benefit and Pension Funds At , New York
Process prospective, concurrent, retrospective Utilization Management (UM) medical requests and 1st level appeal, adhering to Fund’s established timeframes
Tro ubleshoot and interve ne with difficult vendors/providers and assist with urgent/expedited/complex cases that require management level problem solution.
Work closely with medical advisors and management team for escalated complex UM requests
Perform special projects and assignments as directed by management
Authorize vendor services based on skilled need and or medical necessity applying relevant
Working experience utilizing Milliman Care Guidelines
Registered Nurse-Coordinator-Utilization Management-Full Time-Days-Detroit
By Henry Ford Health At , Detroit, 48202
Previous utilization management or case management experience preferred.
Minimum 3-5 years of clinical experience and strong working knowledge of disease process, required.
Benefits: Full time benefit package
Knowledge of outside regulatory agencies that interface with the institution.
education and training, the health system has trained nearly 40% of physicians currently practicing
in the state and also provides education and training for other health professionals including nurses,
Utilization Review Nurse/ Care Management – Full Time
By Montefiore Nyack Hospital At , Nyack From $110,000 a year

Description Comprehensively plans with the health care team to ensure patient needs are met and care delivery is coordinated across the continuum. Identifies and works to ...

Registered Nurse, Utilization Review, Rn
By BJC HealthCare At , St. Louis, 63144 $68,224 - $104,811 a year
Must have at least one year of Utilization Review experience to be considered!
100% Remote position; however, must live in the St. Louis metro area!
Ideal candidate will have the following experience:
Experience managing an assignment of labor/delivery and mom/baby admissions to obtain authorizations
Knowledge and use of the CMS 2 Midnight process
Uses clinical and analytical skills to review and interpret diagnostic test results to determine appropriateness of patient's level of care.
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.

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.
Behavioral Health Utilization Review Nurse- Hmhi
By University of Utah Health At , Salt Lake City, 84190, Ut
Demonstrated knowledge of payers, payer systems, cost effective utilization management and InterQual criteria.
One year Utilization Review or Case Management experience.
Knowledge / Skills / Abilities
Upload most recent updated resume with work history and experience, please include Month and Year in formatting.
Alerts and discusses with physician/provider and case manager/discharge planner when patient no longer meets medical necessity criteria for the inpatient stay.
Demonstrated team leadership, relationship building, critical analysis, and written and verbal communication skills.
Nurse Case Manager/Utilization Review Nurse I
By State of Vermont At , Burlington, Vt $38.58 - $60.51 an hour
Case management experience/certification, knowledge and experience with working with systems of healthcare, prior work in an Insurance Company setting is ideal.
Case management certification within 2 years is a goal for this position.
Starting rate may be negotiable based on experience and qualifications.
Clinical experience and knowledge, knowledge of community, and community culture are necessary.
Experience working with people with substance abuse/mental health and home visiting experience and knowledge of community is preferred.
Two ways to save for your retirement: A State defined benefit pension plan and a deferred compensation 457(b) plan

Are you a Registered Nurse looking for a rewarding career in Utilization Review? Join our team and help us ensure that our patients receive the best care possible. We offer a competitive salary and benefits package, and the opportunity to make a real difference in the lives of our patients. Apply now and start making a difference today!

A Registered Nurse Utilization Review (RNUR) is responsible for reviewing and evaluating the medical necessity of patient care and services provided by healthcare providers. They are responsible for ensuring that the services provided are medically necessary and meet the standards of quality and cost-effectiveness.

What is Registered Nurse Utilization Review Job Skills Required?

• Knowledge of medical terminology and coding
• Knowledge of healthcare regulations and standards
• Ability to analyze and interpret medical records
• Ability to communicate effectively with healthcare providers
• Ability to work independently and as part of a team
• Knowledge of computer systems and software

What is Registered Nurse Utilization Review Job Qualifications?

• Bachelor’s degree in Nursing or related field
• Current Registered Nurse (RN) license
• Previous experience in utilization review or related field

What is Registered Nurse Utilization Review Job Knowledge?

• Knowledge of medical terminology and coding
• Knowledge of healthcare regulations and standards
• Knowledge of computer systems and software

What is Registered Nurse Utilization Review Job Experience?

• Previous experience in utilization review or related field

What is Registered Nurse Utilization Review Job Responsibilities?

• Review and evaluate medical necessity of patient care and services
• Ensure services provided meet standards of quality and cost-effectiveness
• Monitor utilization of services to ensure compliance with regulations
• Communicate with healthcare providers regarding utilization of services
• Prepare reports and documentation related to utilization review
• Maintain current knowledge of healthcare regulations and standards