- BroadPath Healthcare Solutions (Tucson, AZ)
- …** UM RN Appeals Coordinator.** This role collaborates with clinical review staff, medical directors/physician reviewers, network physicians, and network ... facilities to ensure consistent clinical evaluation and processing of medical necessity appeals. Accurate...most appropriate course of action + Provides education to nurse and therapist reviewers regarding appeal updates and process… more
- Commonwealth Care Alliance (Boston, MA)
- …Reporting to the Manager Utilization Management, the Nurse Utilization Management ( UM ) Reviewer is responsible for day-to-day timely clinical and service ... authorization review for medical necessity and decision-making. The Nurse Utilization Management Reviewer has a key role in...with Standard Operating Procedures + Ensures accurate documentation of clinical decisions and works with UM Manager… more
- ERP International (Tinker AFB, OK)
- **Overview** ERP International, LLC is seeking a **Registered Nurse - Case Manager** for a full-time position supporting **SHG Clinic** in support of **Tinker AFB, ... such as those used for patient identification and patient assessment, clinical practice guidelines, algorithms, CM software, and databases for community resources.… more
- Premera Blue Cross (Mountlake Terrace, WA)
- …four (4) years' work experience (REQUIRED) + Current State Licensure as a registered nurse (REQUIRED) + Three (3) years of clinical experience (REQUIRED) + ... our Healthsource blog: https://healthsource.premera.com/ . The **Care Coordinator** - ** Clinical Appeals** performs prospective review (benefit advisory/ prior authorization)… more
- Premera Blue Cross (Mountlake Terrace, WA)
- …hospitalizations, skilled nursing, and inpatient rehabilitation by applying their clinical knowledge and critical thinking skills, along with established criteria ... and protocols, to determine the medical appropriateness of the clinical requests from providers and facilities. The incumbent partners with Medical Directors and… more
- Stony Brook University (Stony Brook, NY)
- …Case Manager** is a valuable member of our team, who provides clinical services to our patient population. Qualified candidates will demonstrate superior patient ... required. **Qualifications** **Required** : A Bachelor's degree or a nurse working on their degree with an RN license...their work and follow up with cases. **Preferred:** CM, UM , Quality, Coding, Risk or MCG Certification Working knowledge… more
- CenterWell (Atlanta, GA)
- …our caring community and help us put health first** The Utilization Management Nurse 2 uses clinical knowledge, communication skills, and independent critical ... **Required Qualifications** + Must be a licensed Registered Compact Nurse license (RN) with no disciplinary action and ability...Lung or Critical Care Nursing experience required + Prior clinical experience preferably in an acute care, skilled or… more
- Molina Healthcare (Salt Lake City, UT)
- **JOB DESCRIPTION** **Job Summary** The Clinical Appeals Nurse (RN) provides support for internal appeals clinical processes - ensuring that appeals requests ... regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Assesses appropriateness of services, length of stay and… more
- UCLA Health (Los Angeles, CA)
- …clinical documentation related to prior authorization requests for medical services. The UM Review Nurse applies clinical judgment, regulatory standards, ... Description At UCLA Health, the Utilization Management ( UM ) Review Nurse plays a vital...contributes to performance improvement projects. + Remains current with clinical best practices and UM regulatory changes.… more
- Humana (Charleston, WV)
- …community and help us put health first** The Utilization Management Behavioral Health Nurse 2 utilizes clinical nursing skills to support the coordination, ... from medical records sent from Behavioral Health Facilities to obtain sufficient clinical information. The Utilization Management Behavioral Health Nurse 2 work… more
- Centers Plan for Healthy Living (Margate, FL)
- …For Healthy Living is currently accepting applications for Full Time Registered Nurse without experience. The Utilization Management Clinical Reviewer works ... in their home to improve their quality of life. Utilization Management Clinical Reviewer will assess and process all authorization requests to determine medical… more
- UPMC (Pittsburgh, PA)
- …is hiring a full-time Behavioral Health UM Care Manager to support our UM Clinical Operations team. This role will primarily work Monday - Friday standard ... required.Licensure, Certifications, and Clearances: + Case management certification or approved clinical certification preferred + Registered Nurse (RN) *Current… more
- Molina Healthcare (Syracuse, NY)
- …**Job Summary** The RN Care Review Clinician provides support for clinical member services review assessment processes. Responsible for verifying that services ... are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members...intensive care unit, or in a telemetry type setting. UM medical review experience highly preferred. Work Hours: Monday… more
- Penn State Health (Hershey, PA)
- … Nurse or Specialist, the Utilization Management Coordinator supports the UM process by obtaining authorizations, reviewing clinical documentation in the ... of health plan insurance criteria. Additionally, the coordinator must have clinical knowledge to assess diagnoses, current conditions, and previous treatments… more
- CVS Health (Harrisburg, PA)
- …Fully Remote- WFH **Position Summary** UM Nurse Consultant Position Summary: UM Nurse Consultant Utilizes clinical experience and skills in a ... options to facilitate appropriate healthcare services/benefits for members. Gathers clinical information and applies the appropriate clinical criteria/guideline,… more
- Brighton Health Plan Solutions, LLC (Chapel Hill, NC)
- …) services to its clients, ensuring high-quality, clinically sound decision-making. The Clinical Appeal and Grievance Nurse is responsible for conducting daily ... in a quality-focused, production-driven environment. The position reports directly to the Clinical Appeal Manager. Note: This job description is not intended to be… more
- Veterans Affairs, Veterans Health Administration (Miami, FL)
- …for the UM microsystem that impacts operations or resources. The proficient UM nurse demonstrates critical thinking with efficiency and accuracy in assessing ... point of care. Practice is enhanced through development of collegial relationships. The UM /Float Nurse demonstrates collaboration by using the group process to… more
- University of Miami (Miami, FL)
- … Educator - Medical Simulation and Education Lab to work in Miami, FL. The Nurse Educator provides clinical education to nursing and patient care staff and ... community clinical partners, to ensure high quality clinical outcomes. The Simulation Nurse Educator is...per year. Training programs include curricula developed by the UM Gordon Center, and other organizations, such as the… more
- CVS Health (Phoenix, AZ)
- …healthcare for members. **Position Summary** We are seeking a dedicated Utilization Management ( UM ) Nurse to join our remote team. In this role, you'll ... be at the forefront of clinical decision-making, applying your expertise in Behavioral Health to...+ Flexibility to provide coverage for other Utilization Management ( UM ) Nurses across various UM specialty teams… more
- Veterans Affairs, Veterans Health Administration (Seattle, WA)
- Summary The VA Puget Sound Healthcare System is recruiting for a Nurse Manager to perform supervisory duties with the Patient Access Center and Patient Flow services ... at the VA hospital in Seattle, Washington. The Nurse Manager directly supervises the RN Utilization Management/Discharge Planners, AMSA Discharge Coordinators,… more
