• Commonwealth Care Alliance (Boston, MA)
    …clinical and service authorization review for medical necessity and decision-making. The Nurse Utilization Management Reviewer has a key role in ensuring CCA ... Utilization Mgmt **Position Summary:** Reporting to the Manager Utilization Management, the Nurse Utilization ...+ Conducts timely clinical decision review for services requiring prior authorization in a variety of clinical… more
    DirectEmployers Association (10/02/25)
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  • Commonwealth Care Alliance (Boston, MA)
    …Required Knowledge, Skills & Abilities (must have): - Expertise in managing utilization review processes including prior authorization , concurrent and ... for overseeing and managing the daily operation of the Utilization Management Review Nurse and Specialist staff...Management - Oversees clinical decision review for services requiring prior authorization in a variety of clinical… more
    DirectEmployers Association (10/02/25)
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  • Luke Staffing (Yigo, GU)
    ** NURSE - REFERRAL MANAGEMENT** **SITE OF SERVICE:** +...+ Ensures Line of Duty paperwork is on file prior to authorization . + Verify eligibility of ... Base, Guam + Full Time **POSITION QUALIFICATION/REQUIREMENTS:** + **Education:** Vocational Nurse Program OR Baccalaureate of Science in Nursing Program from an… more
    DirectEmployers Association (08/04/25)
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  • Stony Brook University (Stony Brook, NY)
    …with the transferring hospital, Patient Access and physicians and payers for authorization prior to transfer from other hospitals. + Consistent documentation ... the following but are not limited to:** + Completes Utilization review screen for inpatient and observation cases. Activity...of care from initial assess point. Follows cases for authorization for in patient stay. + Staff review short… more
    DirectEmployers Association (09/26/25)
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  • Prior Authorization , RN - Hybrid…

    Fallon Health (Worcester, MA)
    …Registered Nurse in a clinical setting required. + 2 years' experience as a Utilization Management/ Prior Authorization nurse in a managed care payer ... on Facebook, Twitter and LinkedIn. **Brief summary of purpose:** The PA Nurse uses a multidisciplinary approach to review service requests ( prior more
    Fallon Health (10/02/25)
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  • Clinical Review Nurse - Prior

    Centene Corporation (New York, NY)
    …**Must have a New York State nursing license.** **Position Purpose:** Analyzes all prior authorization requests to determine medical necessity of service and ... interdepartmental teams, to assess medical necessity of care of member + Escalates prior authorization requests to Medical Directors as appropriate to determine… more
    Centene Corporation (10/05/25)
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  • UM Prior Authorization Review…

    UCLA Health (Los Angeles, CA)
    …This position is responsible for reviewing and evaluating clinical documentation related to prior authorization requests for medical services. The UM Review ... Description At UCLA Health, the Utilization Management (UM) Review Nurse plays...of resources. Key Responsibilities: + Conducts clinical reviews of prior authorization requests to evaluate medical necessity… more
    UCLA Health (10/03/25)
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  • Behavioral Health Utilization Review…

    Actalent (Fort Lauderdale, FL)
    …the team on utilization review-related issues. Responsibilities + Review prior authorization requests for medical necessity and appropriateness using ... Actalent is Hiring a Behavioral Health Utilization Review Nurse Job Description We...physicians, and office staff to resolve prior authorization questions. + Evaluate and monitor appropriate utilization more
    Actalent (10/15/25)
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  • Behavioral Health Utilization Review…

    Actalent (Sunrise, FL)
    …care, maintaining high provider and patient satisfaction. Responsibilities + Review prior authorization requests for medical necessity and appropriateness, using ... as a liaison between Medical Director, physicians, and office staff to resolve prior authorization issues. + Communicate denial determinations to providers when… more
    Actalent (10/10/25)
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  • Utilization Review Nurse

    US Tech Solutions (Chicago, IL)
    …as an RN + Registered Nurse in state of residence + Must have prior authorization utilization experience + Experience with Medcompass **Skills:** + MUST ... + Do you have experience with Prior Authorization ? + Do you have experience with Utilization... Review? + Do you have an Active Registered Nurse License? **About US Tech Solutions:** US Tech Solutions… more
    US Tech Solutions (07/18/25)
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  • Utilization Management Nurse

    CVS Health (Austin, TX)
    …and work schedules will include holidays and evening hours **Preferred Qualifications** + Prior Authorization or Utilization Management experience + Managed ... with heart, each and every day. Medicare Clinical Predetermination Nurse **Must be willing and able to work S/S/M/T...(AFTER training M-F for about 4 - 5 months).** ** Utilization Management is a 24/7 operation and work schedules… more
    CVS Health (10/09/25)
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  • Utilization Review Nurse

    CDPHP (Latham, NY)
    …responsible for the clinical review and documentation for services requiring prior authorization . This includes approval determinations and appropriate ... of acute care experience is required as a Registered Nurse . + Minimum of two (2) years Utilization... Nurse . + Minimum of two (2) years Utilization Management experience is preferred. + Knowledge of coding/claims… more
    CDPHP (09/23/25)
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  • Utilization Review Nurse

    US Tech Solutions (May, OK)
    …hospital experience . Registered Nurse in state of residence . Must have prior authorization utilization experience . Able to work in multiple IT ... and Medicare/Medicaid knowledge. . MUST HAVE UM experience, inpatient utilization management review. . MUST HAVE 1 YEAR OF...knowledge of Milliman/MCG. . MUST HAVE 6 months of Prior Authorization . Education: . Active and unrestricted… more
    US Tech Solutions (07/18/25)
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  • Utilization Review Registered Nurse

    Centene Corporation (New York, NY)
    …Provider. + Provides first level RN review for all outpatient and ancillary prior authorization requests for medical appropriateness and medical necessity using ... NY RN Licensure as well as a State Issued NY ID.** **Position Purpose:** The Utilization Review Nurse I provides first level clinical review for all outpatient… more
    Centene Corporation (10/15/25)
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  • Utilization Management Nurse

    CVS Health (Phoenix, AZ)
    …1 year of Utilization Management experience in concurrent review or prior authorization . + Strong decision-making skills and clinical judgment in independent ... for members. **Position Summary** We are seeking a dedicated Utilization Management (UM) Nurse to join our...+ Experience in a high-volume clinical call center or prior remote work environment. **Education** + Associate's degree in… more
    CVS Health (10/04/25)
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  • Utilization Management Nurse

    CVS Health (Springfield, IL)
    …+ Must be willing to work 8-5pm local time. **Preferred Qualifications** + Prior authorization utilization experience preferred + Outpatient Clinical ... opportunities to promote quality effectiveness of Healthcare Services and benefit utilization + Consults and lends expertise to other internal and external… more
    CVS Health (10/15/25)
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  • Utilization Management Nurse

    CVS Health (Phoenix, AZ)
    …1 year of experience in Oncology and Transplant either in UM, concurrent review, or prior authorization + 3+ years of experience in Acute clinical Oncology or ... the lives of patients facing complex medical journeys. As a Utilization Management (UM) Nurse Consultant specializing in Oncology and Transplant, you'll play a… more
    CVS Health (10/01/25)
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  • Pre- Authorization Nurse

    Humana (Columbus, OH)
    **Become a part of our caring community and help us put health first** The Pre- Authorization Nurse 2 reviews prior authorization requests for appropriate ... services or forward requests to the appropriate stakeholder. The Pre- Authorization Nurse 2 work assignments are varied...to Tier III care management as needed. * Perform prior authorization reviews according to established HUMANA… more
    Humana (10/14/25)
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  • Utilization Management Nurse

    Insight Global (Campbell, CA)
    Job Description - Review approximately 60 medical authorization requests per day - Evaluate medical necessity for procedures and care requests - Use internal Access ... medical documentation and applying health plan guidelines - Experience with Utilization Management (UM) - Knowledge of commercial, Medicare, and Medi-Cal HMO… more
    Insight Global (10/16/25)
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  • Care Review Clinician, Prior

    Molina Healthcare (Southaven, MS)
    …benefits and eligibility for requested treatments and/or procedures. + Conducts prior authorization reviews to determine financial responsibility for Molina ... + Processes requests within required timelines. + Refers appropriate prior authorization requests to Medical Directors. +...Any of the following: Completion of an accredited Registered Nurse (RN), Licensed Vocational Nurse (LVN) or… more
    Molina Healthcare (09/06/25)
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