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Utilization Review Nurse Jobs

Medical Review Nurse (Mrac)
By Provider Resources, Inc. At , Columbia, 29203
Engage clients in appropriate communication that manages client expectations and builds a collaborative relationship with the client
Make clinical judgments based on clinical experience when applicable
Understand and represent PRI?s mission, vision, and values to all internal and external customers
Perform medical record and claims review in accordance with all State and Federal mandated regulations
Maintain compliance with all regulation changes as they impact medical and utilization review practices
Analyze patient records and participate in interdisciplinary collaboration with PRI staff and all recognized teaming partners and/or subcontractors
Utilization Review Jobs
By CodeMax Medical Billing At Los Angeles, CA, United States

The Utilization Review Specialist will perform utilization review of pre-certification and concurrent clinical utilization reviews with insurance companies in accordance with certification ...

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.
Medicaid Utilization Review Analyst
By State of Idaho At , Coeur D'alene $26 an hour
(PERSI) that offers a lifetime benefit.
Excellent medical, dental and vision insurance- (full-time) employee only coverage for PPO $65/month for medical and vision & $11.00/month for dental
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
An opportunity for student loan forgiveness
Medical Review Nurse (Mrac)
By Provider Resources, Inc. At ,
Engage clients in appropriate communication that manages client expectations and builds a collaborative relationship with the client
Make clinical judgments based on clinical experience when applicable
Understand and represent PRI’s mission, vision, and values to all internal and external customers
Perform medical record and claims review in accordance with all State and Federal mandated regulations
Maintain compliance with all regulation changes as they impact medical and utilization review practices
Analyze patient records and participate in interdisciplinary collaboration with PRI staff and all recognized teaming partners and/or subcontractors
Utilization Review Representative Jobs
By Ethos At Dallas, TX, United States
Receives, screens and manages mail, faxes and calls.
Collection and data entry of structured clinical data (including diagnosis, diagnosis codes, procedures, procedure codes).
Reviews service request for completeness of information.
Assigns reviews to Utilization Review Nurse
Assists with written determination letter communications via fax, e-mail or written mail under.
Maintains confidentiality and security in all aspects of performance.
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
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
Medical Review Nurse (Mrac)
By Provider Resources, Inc. At , Baltimore, 21244
Engage clients in appropriate communication that manages client expectations and builds a collaborative relationship with the client
Make clinical judgments based on clinical experience when applicable
Understand and represent PRI?s mission, vision, and values to all internal and external customers
Perform medical record and claims review in accordance with all State and Federal mandated regulations
Maintain compliance with all regulation changes as they impact medical and utilization review practices
Analyze patient records and participate in interdisciplinary collaboration with PRI staff and all recognized teaming partners and/or subcontractors
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 ...

Medical Claims Review Nurse
By Healthcare Management Administrators Inc At ,
Retrospective utilization management case review
Knowledge, Experience, and Key Attributes needed for Success:
2+ years of clinical nursing experience
Knowledge of Utilization Review processes
Knowledge of the medical plan appeal process (preferred)
Strong experience in clinical practice with diverse diagnoses
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
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.

Are you looking for a challenging and rewarding career as a Utilization Review Nurse? Join our team and help us make a difference in the lives of our patients! We offer competitive salaries, excellent benefits, and a supportive team environment. Come join us and make a positive impact on the healthcare industry!

Overview:

Utilization Review Nurses are responsible for ensuring that healthcare services are provided in a cost-effective and efficient manner. They review patient records to determine the appropriateness of care and services, and to ensure that they are in compliance with the standards of care. Utilization Review Nurses also provide education and support to healthcare providers and patients on the utilization of healthcare services.

Detailed Job Description:

Utilization Review Nurses are responsible for reviewing patient records to ensure that healthcare services are provided in a cost-effective and efficient manner. They analyze patient records to determine the appropriateness of care and services, and to ensure that they are in compliance with the standards of care. Utilization Review Nurses also provide education and support to healthcare providers and patients on the utilization of healthcare services. They may also be responsible for developing utilization review plans, monitoring utilization trends, and providing recommendations for improvement.

What is Utilization Review Nurse Job Skills Required?

• Knowledge of healthcare regulations and standards of care
• Ability to analyze patient records
• Excellent communication and interpersonal skills
• Ability to work independently and as part of a team
• Proficiency in computer applications
• Ability to work with a variety of healthcare providers

What is Utilization Review Nurse Job Qualifications?

• Bachelor’s degree in Nursing or related field
• Current Registered Nurse (RN) license
• Experience in utilization review or related field
• Knowledge of healthcare regulations and standards of care

What is Utilization Review Nurse Job Knowledge?

• Knowledge of healthcare regulations and standards of care
• Knowledge of medical terminology
• Knowledge of healthcare reimbursement systems
• Knowledge of healthcare quality improvement processes

What is Utilization Review Nurse Job Experience?

• Previous experience in utilization review or related field
• Previous experience in healthcare reimbursement
• Previous experience in healthcare quality improvement

What is Utilization Review Nurse Job Responsibilities?

• Review patient records to determine the appropriateness of care and services
• Monitor utilization trends and provide recommendations for improvement
• Develop utilization review plans
• Educate healthcare providers and patients on the utilization of healthcare services
• Ensure compliance with healthcare regulations and standards of care
• Maintain accurate and up-to-date records