• Utilization Management Review

    AmeriHealth Caritas (Newark, DE)
    …Under the direction of a supervisor, the Clinical Care Reviewer - Utilization Management evaluates medical necessity for inpatient and outpatient services, ... in a fast-paced environment. ;The Clinical Care Reviewer - Utilization Management will also be counted upon...document and assess patient cases. + Strong understanding of utilization review processes, including medical necessity criteria,… more
    AmeriHealth Caritas (07/02/25)
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  • Pediatric Shift Care Utilization

    AmeriHealth Caritas (Philadelphia, PA)
    …pediatric patients in a clinical setting + Minimum of 3 years of Utilization Management experience, preferably within a managed care organization + Experience ... the case is presented to the Medical Director for medical necessity review . Upon approval of services, responsibilities include timely notification and education to… more
    AmeriHealth Caritas (05/22/25)
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  • Registered Nurse (RN), Perioperative…

    Penn Medicine (Lancaster, PA)
    …as defined by the American Nurses Association standards of nursing practice. The Clinical Nurse 2 Colleague is an RN that practices as a full partner on the ... demonstrates safe practice within the organizational professional practice model. The Clinical Nurse 2 Colleague possesses the knowledge, skills and the attitude to… more
    Penn Medicine (07/03/25)
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  • Registered Nurse (RN), Main Operating Room,…

    Penn Medicine (Lancaster, PA)
    …as defined by the American Nurses Association standards of nursing practice. The Clinical Nurse 1 New to Practice/Apprentice is a newly licensed new to practice RN ... safe practice within the organizational professional practice model. The Clinical Nurse 1 New to Practice/Apprentice seeks guidance to integrate concepts, knowledge,… more
    Penn Medicine (05/28/25)
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  • Telephonic Nurse Case Manager

    ICW Group (Philadelphia, PA)
    …regulatory standards. + Interfaces with external agencies in relation to the utilization review process including, Third-Party Payers, Insurance Companies and ... Providers. + May perform Utilization Review activities (or review ...unrestricted Registered Nurse (RN) or Licensed Vocational Nurse (LVN) required. Certification in case management ,… more
    ICW Group (06/18/25)
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  • HEDIS Registered Nurse or LPNs (Field…

    Insight Global (Philadelphia, PA)
    …License or Active LPN License 2-3 years of clinical experience ( Utilization management or utilization review ) Strong computer skills Ability to ... of medical records assigned by a Clinical Quality Lead nurse . Miles will be reimbursed for any travel. Computer...Previous HEDIS review experience or experience with Utilization Review , Quality, Medical Record auditing Bachelors… more
    Insight Global (07/01/25)
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  • Licensed Practical Nurse -Outpatient - MG…

    WellSpan Health (Ephrata, PA)
    …in the management of patient care between visits. + Assists in the management of patient utilization of health care system and provides patient education ... and patient has been notified. Provides related education, counseling, ongoing review , and monitoring regarding diagnostic tests (ie, INR results in Anticoagulation… more
    WellSpan Health (06/06/25)
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  • Registered Office Nurse (RN), General…

    Penn Medicine (Lancaster, PA)
    …physiologic, psychological, and cognitive functions, through patient/provider office visits, nurse visits, and telephone triage. Collaborates with Physician and ... physiologic, psychological, and cognitive functions, through patient/provider office visits, nurse visits, and telephone triage. Collects and manages comprehensive… more
    Penn Medicine (06/25/25)
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  • Licensed Practical Nurse - Family Medicine…

    WellSpan Health (Leola, PA)
    …in the management of patient care between visits. + Assists in the management of patient utilization of health care system and provides patient education ... and patient has been notified. Provides related education, counseling, ongoing review , and monitoring regarding diagnostic tests (ie, INR results in Anticoagulation… more
    WellSpan Health (06/13/25)
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  • Hospice Nurse Manager - Penn Medicine…

    Penn Medicine (Bala Cynwyd, PA)
    …Functions monitored will include, but are not limited to, nursing case management , regulatory compliance, direct clinical care, new product and service development, ... and management of Human Resources related items for RN staff...that all regulatory requirements are met. + Ensures effective utilization of materials, staff, and financial resources. + Sponsors… more
    Penn Medicine (05/29/25)
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  • Dialysis Clinical Manager Registered Nurse

    Fresenius Medical Center (Upper Darby, PA)
    …and acts as the liaison for patient care as per the disease management agreement, including initial and ongoing validation of member eligibility. Facilitate timely ... workup of patients for access management , dialysis services, patient education, hospitalizations, and kidney transplantation as appropriate, and ensures coordination… more
    Fresenius Medical Center (06/14/25)
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  • Dialysis Clinical Manager Registered Nurse

    Fresenius Medical Center (Wilmington, DE)
    …auditing activities. + Accountable for completion of the Annual Standing Order Review and Internal Classification of Disease (ICD) coding. + Manages clinic ... financials including efficient utilization of supplies or equipment and regular profits and...of supplies or equipment and regular profits and loss review . + Responsible for all required network reporting and… more
    Fresenius Medical Center (06/28/25)
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  • RN Pre Certification Case Manager

    Penn Medicine (Philadelphia, PA)
    …+ 5yrs prior experience as a Nurse Case Manager with knowledge of utilization review and 3rd Party Payors (Required) + Pennsylvania State Licensed Nurse ... And 5+ years Prior experience as a nurse case manager with knowledge of utilization review and third-party payors. We believe that the best care for our… more
    Penn Medicine (06/05/25)
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  • Acute Care Manager (RN)

    ChenMed (Philadelphia, PA)
    …years' clinical work experience required + A minimum of one (1) year of utilization review and/or case management , home health, hospital discharge planning ... through external providers and healthcare systems. The Acute Care Nurse is an important member of the Complex Care...patients' progress and adjust and plan accordingly + Understanding utilization review and how to leverage with… more
    ChenMed (06/24/25)
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  • PRN Clin Resource Coordinator WEEKDAYS

    Penn Medicine (Philadelphia, PA)
    …skills and being a strong patient advocate. The case manager conducts utilization management activities, communication with insurers, team, and physician ... fearful you will miss patient contact? If so, our nurse case manager role at Penn Medicine is the...community resources, transportation, and quality data collection and risk management referral. + Responsibilities: Utilization management more
    Penn Medicine (06/04/25)
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  • RN Clinical Manager

    CenterWell (Lancaster, PA)
    review of clinical documentation in addition to feedback and recommendations by Utilization Review staff. Upon completion of the assessment, creates and ... requirements. + Responsible for the QA/PI activities. Works with Utilization Review staff relative to data tracking...and reliable transportation. + Two years as a Registered Nurse with at least one-year of management more
    CenterWell (06/17/25)
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  • Discharge Planning RN Case Manager (FT) - Penn…

    Penn Medicine (Philadelphia, PA)
    …hospice, community resources, transportation, and quality data collection and risk management referral. Responsibilities: + Utilization management ... community resourcesParticipates and drives accountability in daily interdisciplinary meetings Utilization Management :Adheres to guidelines to satisfy 3rd party… more
    Penn Medicine (06/17/25)
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  • Inpatient Case Manager RN, BSW or MSW (Full…

    Penn Medicine (Lancaster, PA)
    …of Nursing. + Bachelor's degree in Nursing BSN . + Knowledge of utilization review or managed care. + Care management experience in a managed care setting. ... Coordinates care across the continuum inpatient outpatient community to assure appropriate utilization of clinical and community resources. + Oversees and guides the… more
    Penn Medicine (05/24/25)
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  • RN Clinical Administrator - Per Diem

    Trinity Health (Wilmington, DE)
    …complex problems in the areas of census verification, bed assignment and utilization review . + Ensures compliance with hospital departmental policies and ... about the hospital's bed availability + Ensure proper bed utilization and management throughout the hospital. +...acute care setting required + Previous Supervisor or Charge Nurse experience required + Must possess sound computer literacy.… more
    Trinity Health (05/23/25)
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  • Insurance Pre-Cert Coord at Infusion Services…

    Penn Medicine (Philadelphia, PA)
    …optimal reimbursement for the hospital for services provided. Responsibilities: + Review chemo schedule in advance and determines patients insurance requirements for ... to patient arrival. Assess information for appropriateness of setting and utilization of resources to optimize patient outcomes and cost effectiveness. Maintain… more
    Penn Medicine (06/11/25)
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