• UHS (Bethlehem, PA)
    …for seniors, adults and adolescents. Hanover is seeking an experienced Director of Utilization Management and Review. This is a fantastic opportunity to join a ... team while working in a state-of-the-art facility, including EPIC. The Utilization Review Director is responsible for overseeing the utilization … more
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  • Kaiser Permanente (Los Angeles, CA)
    …the interdisciplinary approach to providing continuity of care, including Utilization management, Transfer coordination, Discharge planning, and obtaining all ... outside services for patients/families. Conducts daily clinical reviews for utilization /quality management activities based on guidelines/standards for patients in a… more
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  • Surgery Partners (Bryan, TX)
    Job Summary: We are seeking a Part-Time Utilization Review Nurse to join our dedicated healthcare team. In this role, you will play a critical part in ensuring that ... Current Registered Nurse (RN) license in the state of practice Experience in utilization review, acute hospital case management, or quality assurance is required 2+… more
    Upward (07/18/25)
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  • Valley Health System (Paramus, NJ)
    POSITION SUMMARY: Performs concurrent utilization review activities on all patients within the assigned caseload. Collaborates and educates the medical staff on ... appropriate utilization review guidelines and documentation in accordance with CMS...Commercial payors guidelines. Monitors and intervenes on LOS, resource utilization and denial management/ prevention within the assigned caseload.… more
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  • Kaiser Permanente (Sacramento, CA)
    Job Summary: Coordinates quality, utilization and risk management activities for the Home Care Agency; provides technical, educational, consultative, and ... Essential Responsibilities: Assists in the coordination of the quality management/ utilization management department activities. Acts as a consultant for appropriate… more
    Upward (07/20/25)
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  • AmeriHealth Caritas Health Plan (Philadelphia, PA)
    …services. Discover more about us at www.amerihealthcaritas.com. Join a mission-driven Utilization Management team where your clinical expertise helps shape better ... and meaningful collaboration. Lead with Clinical Insight. Whether you're an experienced utilization review nurse, a sharp case manager, or a behavioral health… more
    Upward (07/24/25)
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  • EvergreenHealth (Kirkland, WA)
    …for equipment, and arrange for additional services in the community. Utilization Management/Case Management Nurses provide clinical information to our payers and ... hospital admissions for status per defined criteria and reviews for appropriate utilization of resources. Ensures continuity and coordination of care for patients… more
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  • Curative HR LLC (Austin, TX)
    …This pivotal role will be responsible for overseeing and performing utilization reviews, prior authorizations, and making crucial medical necessity determinations. ... serve as a key clinical expert, ensuring appropriate resource utilization , promoting evidence-based care, and fostering positive relationships with practitioners… more
    Upward (07/12/25)
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  • Boston Childrens Hospital (Boston, MA)
    …of payer denials. They identify and implement initiatives to manage utilization trends, collaborating with the hospital's discharge planning case managers, ... preferred. Experience as a Case Manager (Discharge Planning and or Utilization Management) preferred. Licensure/ Certifications: Current Massachusetts license as a… more
    Upward (07/19/25)
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  • Alameda Health System (Oakland, CA)
    SUMMARY: The System Utilization Management [SUM] Utilization Review RN is responsible for ensuring the appropriate use of healthcare resources while maintaining ... feedback and education to clinicians regarding best practices in resource utilization . 15. Maintain continued professional growth and education to meet continuing… more
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  • American Traveler (Salem, MA)
    …through AHA required, *ACLS certification through AHA required, *Case Management, Utilization Management, and Discharge Planning skill set required, *Certified Case ... patients, *Collaboration with multidisciplinary teams to coordinate care and resource utilization , *Parking may not be validated and public parking may incur… more
    Upward (07/21/25)
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  • Pharmacy Careers (Tampa, FL)
    Formulary Strategy & Utilization Review Pharmacist Shape the drug benefit landscape-analyze and optimize medication use. Key Responsibilities: Review prescribing ... trends and propose cost-saving alternatives. Maintain evidence-based formularies across multiple payers. Conduct retrospective DUR and prepare stakeholder reports. Qualifications: PharmD with managed care, DUR, or pharmacy benefit experience. Strong Excel/data… more
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  • HEALTH FIRST CAREERS (Melbourne, FL)
    Job Requirements POSITION SUMMARY The Utilization Review (UR) nurse performs medical necessity reviews on all payer admissions to determine appropriate admission ... care including the appropriate length of stay, patient status management, resource utilization and discharge planning for all hospital admissions. The UR Nurse… more
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  • Sheppard Pratt (Gaithersburg, MD)
    …assist individuals who receive mental health services in supporting utilization & authorization activities for Gaithersburg Residential Rehabilitation Programs. You ... will track authorizations and plan due dates , maintain spreadsheets, send out clinical requests for new authorizations, maintain and send monthly reports to other staff members, and track and review the progress of clients. Additional responsibilities will… more
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  • Freeman Health System (Joplin, MO)
    …healthcare solutions. Schedule: Part-Time 30 hours per week What You'll Do The Utilization Review Coordinator provides utilization review to assure patients are ... admitted to the hospital in the correct status according to applied criteria. They work closely with payers to assure correct authorization for admissions are given and if needed to appeal payer decisions. They also assure the system is meeting regulatory… more
    Upward (07/25/25)
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  • Medical Solutions (Omaha, NE)
    …CA is seeking its next amazing RN (Registered Nurse) to work in Case Management ( Utilization Review). Read on if this sounds like your perfect fit! Nurses and allied ... healthcare professionals are in high demand nationwide, and our team of industry-leading, traveler-favorite recruiters can get you where you want to go - personally and professionally. Wherever you may roam, travel healthcare helps you hone your skills and… more
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  • Sanford Health (Bemidji, MN)
    …years of clinical practice. Knowledge and experience in case management, utilization management and/or Coding highly preferred. Currently holds an unencumbered RN ... license with the State Board of Nursing where the practice of nursing is occurring and/or possess multistate licensure if in a Nurse Licensure Compact (NLC) state. Obtains and subsequently maintains required department specific competencies and certifications.… more
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  • Mad River Community Hospital (Arcata, CA)
    …Profession RN Specialty Case Manager RN Job ID 16149898 Job Title RN - Utilization Review RN Weekly Pay $2205.3 Shift Details Shift Days 3x12 Scheduled Hours 36 ... Job Order Details Start Date 03/05/2025 End Date 06/04/2025 Duration 13 Week(s) Client Details City Arcata State CA Zip Code 95518 more
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  • WellSpan Health (York, PA)
    …weekend requirement General Summary Performs a variety of duties and applies utilization and case management techniques to determine the most efficient use of ... patient discharge needs. Provides leadership in the integration of utilization and case management principles. Responsibilities Essential Functions: Reviews assigned… more
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  • Fort Duncan Regional Medical Center (Eagle Pass, TX)
    …review, and transitions to prevent readmissions. Liaise with medical staff, utilization review, social services, payors, and community providers. Track and report ... on KPIs: utilization metrics, discharge planning efficiency, and compliance. Ensure adherence to TJC, CMS, and state regulatory standards. Participate in… more
    Upward (07/13/25)
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