Utilization Management Nurse

2 weeks ago


Valley City OH United States Akron Children's Hospital Full time

Full-Time 40 hours/week Remote Summary: The Utilization Management Nurse is responsible for conducting medical necessity review to assure appropriate use of hospital resources, and serving as a resource to the hospital staff on utilization management practices. Responsibilities: Provides clinical review to health plans as required by the health plan and/or the Utilization Review plan and ensures all days are approved and authorized. Notifies physician advisor when patients do not meet admission or continued stay criteria. Validates patient registration status with physician order against medical necessity screening criteria and applies evidence based medical necessity screening criteria as defined by the Utilization Review plan. Proactively confers with attending physician to provide coaching on accurate level of care determination at point-of-hospital entry. Ensures that all extended recovery and observation patients are screened at least daily for appropriate level of care. Assists with denial management, peer review, and quality/safety work to identify opportunities to improve department/hospital processes. Identifies compliance and ethical issues and reports appropriately. Actively participates in daily huddles, multidisciplinary rounds, and patient care conferences as needed to maintain knowledge about intensity of service, delays in service, barriers to discharge, and progression of care. Identifies and records episodes of avoidable days. Clearly documents outcomes of all actions taken in Midas and Epic as appropriate. Serves as a resource to the health care team on issues related to admission qualifications, resource utilization, and documentation improvement opportunities. Other duties as required. Other information: Technical Expertise 1. Experience in inpatient clinical is required. 2. Experience in pediatrics is preferred. 3. Experience working with all levels within an organization is required. 4. Experience in healthcare is required. 5. Proficiency in MS Office [Outlook, Excel, Word] or similar software is required. Education and Experience 1. Education: Bachelors in Nursing [BSN] is required. For employees hired after July 1, 2013, BSN is required or must be obtained within 5 years from date of hire. 2. Certification: Registered Nurse licensure is required. 3. Years of relevant experience: 3 to 5 years is preferred. 4. Years of experience supervising: None. Full Time FTE: 1.000000 Status: Remote



  • , VT, United States Central Vermont Medical Center Full time

    Building Name: HHH - In-State Hybrid/RemoteRegularDepartment: CVMC - Care ManagementFull TimeStandard Hours: 40Biweekly Scheduled Hours:Shift: DayPrimary Shift: 7:30 AM - 4:00 AMWeekend Needs: NoneRecruiter: Kate DaviesPOSITION SUMMARYThe Utilization Review Nurse is responsible for ensuring the medical necessity and appropriate level of care of all hospital...


  • , OH, United States UC Health Full time

    At UC Health, we're proud to have the best and brightest teams and clinicians collaborating toward our common purpose: to advance healing and reduce suffering.As the region's adult academic health system, we strive for innovation and provide world-class care for not only our community, but patients from all over the world. Join our team and you'll be able to...


  • Milford, MA, United States Milford Regional Medical Center Full time

    Per diem, 8a-4;30P as needed weekends + occ/ holidays About Us Milford Regional Medical Center is a full-service, community and regional teaching hospital located in Milford, Mass. and serves patients from more than 20 towns in Central Massachusetts. The 149-bed medical center is a nonprofit, acute-care facility, where more than 300 primary care and...


  • Meadowbrook, PA, United States Holy Redeemer Hospital and Medical Center Full time

    Utilization Review NursePer Diem 1648 Huntingdon Pike Nursing RN/LPN Day SUMMARY OF JOB: To review each admission for appropriate assignment of level of care based upon clinical guidelines as well as to review documentation for continued stays daily and provide clinical information including assessments and outcomes for all payers and all levels of care...


  • Porterville, CA, United States Sierra View Medical Center Full time

    Senior Utilization Management Nurse Coordinator*Shift: 8:00a – 4:30p, exempt positionPOSITION SUMMARY:Under the direction of the Administrative Director of Revenue Cycle, the Senior Utilization Management Nurse Coordinator will monitor adherence to the hospital's utilization review plan to ensure the effective and efficient use of hospital services and...

  • Utilization Review Nurse

    10 minutes ago


    Burlington, VT, United States Central Vermont Medical Center Full time

    Building Name: HHH - In-State Hybrid/Remote Regular Department: CVMC - Care Management Full Time Standard Hours: 40 Biweekly Scheduled Hours: Shift: Day Primary Shift: 7:30 AM - 4:00 AM Weekend Needs: None Recruiter: Kate Davies POSITION SUMMARY The Utilization Review Nurse is responsible for ensuring the medical necessity and appropriate level of...


  • Norwood, OH, United States TriHealth, Inc. Full time

    Job Overview: This position may perform utilization management functions on a prospective, concurrent or retrospective basis in order to maximize revenue for TriHealth. This includes analysis of clinical information presented with comparison to established national clinical criteria to determine appropriate place of service such as...


  • Moscow, ID, United States Gritman Medical Center Full time

    Job Summary: At Gritman, we pride ourselves on being the premier healthcare employer on the Palouse. We bring exceptional care that's close to home for the members of our community. We are seeking a Staff RN to join our Utilization Review/Case Management team. The Utilization Review Nurse (UR) has skills in areas of Utilization Management (UM), medical...


  • Cincinnati, OH, United States TriHealth Full time

    Job DescriptionJob Overview:This position may perform utilization management functions on a prospective, concurrent or retrospective basis in order to maximize revenue for TriHealth. This includes analysis of clinical information presented with comparison to established national clinical criteria to determine appropriate place of service such as...

  • Nurse Manager

    2 weeks ago


    Valley City, United States CommonSpirit Health Full time

    Overview As our Nurse Manager of Med/Surg at CHI Mercy Health , you'll oversee a department of frontline nurses and act as the conduit between these caregivers and leadership teams. You will communicate the organization's goals to the nursing staff as we constantly seek to improve patient experiences, reach out to our community, and deliver quality care. At...

  • Nurse Manager

    3 weeks ago


    Valley City, United States Catholic Health Initiatives Full time

    **Overview**As our Nurse Manager of Med/Surg at CHI Mercy Health, you’ll oversee a department of frontline nurses and act as the conduit between these caregivers and leadership teams. You will communicate the organization’s goals to the nursing staff as we constantly seek to improve patient experiences, reach out to our community, and deliver quality...


  • Meadowbrook, PA, United States Holy Redeemer Health System Full time

    Per Diem 1648 Huntingdon Pike Nursing RN/LPN Day SUMMARY OF JOB: To review each admission for appropriate assignment of level of care based upon clinical guidelines as well as to review documentation for continued stays daily and provide clinical information including assessments and outcomes for all payers and all levels of care as required by the...

  • Utilization Review Nurse

    39 minutes ago


    Portland, ME, United States Martin's Point Health Care Full time

    Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an...


  • Berlin, VT, United States The University of Vermont Health Network Full time

    This position is hybrid, allowing for remote work at times and requiring an onsite presence at Central Vermont Medical Center in Berlin, VT.POSITION SUMMARYThe Utilization Review Nurse is responsible for ensuring the medical necessity and appropriate level of care of all hospital admissions and extended hospital stays, including psychiatry; affirming...


  • Berlin, VT, United States The University of Vermont Health Network Full time

    This position is hybrid, allowing for remote work at times and requiring an onsite presence at Central Vermont Medical Center in Berlin, VT.POSITION SUMMARYThe Utilization Review Nurse is responsible for ensuring the medical necessity and appropriate level of care of all hospital admissions and extended hospital stays, including psychiatry; affirming...


  • Jacksonville, IL, United States Taylorville Memorial Hospital Full time

    Overview As a Utilization Review Nurse, you will work under the direct supervision of the Supervisor, Utilization Review and Clinical Documentation Improvement, this role will be responsible for providing clinically based concurrent and retrospective review of inpatient medical records to evaluate the documentation and utilization of acute care services....

  • Utilization Review Nurse

    54 minutes ago


    Huntsville, TX, United States Huntsville Memorial Hospital Full time

    Under general supervision of the Director of Case Management, the Utilization Review Nurse provides a clinical review of cases using medical necessity criteria to determine the medical appropriateness of inpatient and outpatient services. Provides feedback and assistance to other members of the healthcare team regarding the appropriate use of resources and...


  • Bellaire, TX, United States Texas Children's Hospital Full time

    Job Summary We are searching for a Utilization Management Clinical RN -- someone who works well in a fast-paced setting. In this position, you will provide precertification of inpatient hospitalizations and all outpatient procedures and services requiring authorization. This role performs telephonic and/or concurrent review of inpatient hospitalizations and...

  • Registered Nurse

    5 days ago


    Cincinnati, OH, United States Professional Case Management Full time

    Make a Difference on Your Own Schedule and Terms!Hiring Case Managers in Ohio   Come join our growing team! A few of our perks:Create your own schedule!$38/hr. (including 100% of Hourly Wage Paid for All Drive) Our RN-Case Managers conduct in-home nursing visits for our clients. All our clients are former Nuclear Weapon's Workers with chronic/terminal...


  • Bellaire, TX, United States Texas Children's Hospital Full time

    Utilization Management Clinical Registered Nurse (RN)Job Summary We are searching for a Utilization Management Clinical RN -- someone who works well in a fast-paced setting. In this position, you will provide precertification of inpatient hospitalizations and all outpatient procedures and services requiring authorization. This role performs telephonic...