Utilization Review Nurse
3 weeks ago
You must reside in one of the following states for this position:
AL, AR, AZ, GA, IA, ID, IL, IN, KS, KY, LA, MI, MO, MS, NY, OH, OK, PA, SC, TN, TX, UT, WI
American Health Plans, a division of Franklin, Tennessee-based American Health Partners Inc. owns and operates Institutional Special Needs Plans (I-SNPs) for seniors who reside in long-term care facilities. In partnership with nursing home operators, these Medicare Advantage plans manage medical risk by improving patient care to reduce emergency room visits and avoidable hospitalizations. This division currently operates in Tennessee, Georgia, Missouri, Kansas, Oklahoma, Utah, Texas, Mississippi, Iowa, Idaho, Louisiana, and Indiana with planned expansion into other states in 2025. For more information, visit AmHealthPlans.com.
If you would like to be part of a collaborative, supportive and caring team, we look forward to receiving your application
Benefits and Perks include:
- Affordable Medical/Dental/Vision insurance options
- Generous paid time-off program and paid holidays for full time staff
- TeleDoc 24/7/365 access to doctors
- Optional short- and long-term disability plans
- Employee Assistance Plan (EAP)
- 401K retirement accounts with company match
- Employee Referral Bonus Program
JOB SUMMARY:
The Utilization Review Nurse is to assess the medical necessity and quality of healthcare services by conducting pre-service, concurrent, and retrospective utilization management reviews. The primary role of the Utilization Management (UM) Nurse is to provide clinical support to the Clinical Services Department and Medical Director to assure that members receive all appropriate medical services in compliance with medical and regulatory guidelines.
ESSENTIAL JOB DUTIES:
To perform this job, an individual must accomplish each essential function satisfactorily, with or without a reasonable accommodation.
•Assess the medical necessity, quality of care, level of care and appropriateness of health care services for plan members
•Identify placement settings that offer the lowest level of restriction and greatest level of autonomy for the members based upon medical necessity
•Conduct outreach to requesting providers which can include specialty physicians, ancillary providers and institutions to gather the appropriate/necessary clinical data
•Apply clinical review criteria, guidelines, and screens in determining the medical necessity of health care services against the clinical data provided
•Certify cases that meet clinical review criteria, guidelines and/or screens
•Consult with physician when reviews do not meet clinical review criteria, guidelines, and screens
•Refer cases to other professionals internally, including case management and medical consultation when indicated
•Adhere to accreditation, contractual and regulatory timeframes in performing all utilization management review processes
•Ensure that the Director of Medical Management or designee is made aware of any potential risk management issues in a timely manner
•Other duties as assigned
JOB REQUIREMENTS:
•Maintain privacy and confidentiality of records, conditions, and other information relating to residents, employees and facility
•Encourage an atmosphere of optimism, warmth and interest in patients' personal and health care needs
•Develop and maintain collaborative relationships with providers and educate on levels of care
•Ensure the integrity and high quality of utilization management services
•Self-motivated
•Ability to work independently and as part of a team
•Able to work congenially with a wide variety of individuals
•Maintain the highest level of confidentiality and professionalism at all times
•Strong oral and written communications skills, including active listening
•Proficient in navigating through multiple computer applications
•Positive, engaging customer service skills
•Critical thinking and decision-making skills
•Successful completion of required training
•Handle multiple priorities effectively
•Independent discretion/decision making
•Make decisions under pressure
REQUIRED QUALIFICATIONS:
•Experience:
o At least 1 year experience in utilization management with a health plan or hospital-based UM department with use of Interqual or MCG
o Prefer clinical experience
o Broad knowledge of Medicare regulations and guidance
o Trained in clinical certification, utilization management, URAC and NCQA principles, policies, and procedures
o Excellent customer service experience
o Strong knowledge of medical terminology and CPT, ICD-10, and HCPCS codes
o Proven ability to problem-solve and make solid decisions
•License/Certification:
o Current Certified Case Manager (CCM) credential is a plus
o Current, active and unrestricted Registered Nurse (RN) license
EQUAL OPPORTUNITY EMPLOYER
This Organization is an equal opportunity employer. We do not discriminate based on race, color, religion, sex, handicap, disability, age, marital status, sexual orientation, national origin, veteran status, or any other characteristic(s) protected by federal, state, and local laws. This Organization will make reasonable accommodations for qualified individuals with disabilities should a request for an accommodation be made. A key part of this policy is to provide equal employment opportunity regarding all terms and conditions of employment and in all aspects of a person's relationship with the Organization including recruitment, hiring, promotions, upgrading positions, conditions of employment, compensation, training, benefits, transfers, discipline, and termination of employment.
-
Healthcare Utilization Management Professional
4 weeks ago
Franklin, Tennessee, United States XSOLIS Full timeAbout UsXsolis is a forward-thinking AI-driven technology company that streamlines collaboration between healthcare providers and payers through real-time transparency and data-driven insights. Our innovative approach fosters efficient medical necessity decisions and better patient outcomes.Our flagship platform, Dragonfly, utilizes predictive analytics to...
-
Diagnostic Imaging Specialist
4 weeks ago
Franklin, Wisconsin, United States Travel Nurse Across America Full timeAbout the OpportunityTravel Nurse Across America is seeking a skilled Diagnostic Imaging Specialist for a 13-week assignment in Franklin, WI.Job SummaryThis role involves utilizing computed tomography equipment to capture diagnostic images of patients' internal organs and tissues. The ideal candidate will have 1 year of experience and be certified as an ARRT...
-
Nurse Care Specialist
4 weeks ago
Franklin, Wisconsin, United States Jackson Nurse Professionals Full timeJob SummaryJackson Nurse Professionals is seeking a travel nurse RN for a 13 week contract assignment at a reputable area hospital in Franklin, Wisconsin.We're offering a rewarding position for a Registered Nurse with experience caring for patients that are transitioning between intensive care and regular units. As a member of our team, you'll experience an...
-
Appeals Nurse
2 months ago
Franklin, United States Aspirion Health Resources Full timeWhat is Aspirion? For over two decades, Aspirion has delivered market-leading revenue cycle services. We specialize in collecting challenging payments from third-party payers, focusing on complex denials, aged accounts receivables, motor vehicle accident, workers’ compensation, Veterans Affairs, and out-of-state Medicaid. At the core of our success is our...
-
Clinical Denials and Appeals Nurse
4 weeks ago
Franklin, Tennessee, United States Aspirion Health Resources Full timeAbout UsAt Aspirion Health Resources, we have been delivering market-leading revenue cycle services for over two decades. Our team of specialists focuses on collecting challenging payments from third-party payers, specializing in complex denials, aged accounts receivables, motor vehicle accident, workers' compensation, Veterans Affairs, and out-of-state...
-
Registered Nurse
3 weeks ago
Franklin, United States SimplyApply Full timePosition OverviewThe Hospice Registered Nurse is responsible for pain management, symptom control in the delivery of care to hospice patients, as established by the plan of care, the interdisciplinary team, attending physician and Hospice Medical Director. Territory: Franklin/BrentwoodEssential Job Functions:Ensures the timely and adequate delivery of...
-
Registered Nurse
4 weeks ago
Franklin, United States Aveanna Healthcare Full timePosition OverviewThe Hospice Registered Nurse is responsible for pain management, symptom control in the delivery of care to hospice patients, as established by the plan of care, the interdisciplinary team, attending physician and Hospice Medical Director. Territory: Franklin/BrentwoodEssential Job Functions:Ensures the timely and adequate delivery of...
-
Hospice Registered Nurse
4 weeks ago
Franklin, United States Aveanna Healthcare Full timePosition OverviewThe Hospice Registered Nurse is responsible for pain management, symptom control in the delivery of care to hospice patients, as established by the plan of care, the interdisciplinary team, attending physician and Hospice Medical Director. Territory: Franklin/BrentwoodEssential Job Functions:Ensures the timely and adequate delivery of...
-
Hospice Registered Nurse RN Full Time
5 months ago
Franklin, United States Aveanna Healthcare Full timePosition Overview The Hospice Registered Nurse is responsible for pain management, symptom control in the delivery of care to hospice patients, as established by the plan of care, the interdisciplinary team, attending physician and Hospice Medical Director. Essential Job Functions: Ensures the timely and adequate delivery of hospice services to...
-
Hospice Registered Nurse RN Full Time
4 weeks ago
Franklin, United States Aveanna Healthcare LLC Full timePosition Overview The Hospice Registered Nurse is responsible for pain management, symptom control in the delivery of care to hospice patients, as established by the plan of care, the interdisciplinary team, attending physician and Hospice Medical Director. Territory: Franklin/BrentwoodEssential Job Functions: Ensures the timely and adequate delivery of...
-
Burn ICU Nurse
7 months ago
Franklin, United States TriStar Skyline Medical Center Full timeDescription IntroductionDo you have the career opportunities as a(an) Burn ICU Nurse you want in your current role? We invest in what matters most to nurses like you – at home, at work, and at every stage in your career. We have an exciting opportunity for you to join TriStar Skyline Medical Center which is a part of the nation’s leading provider of...
-
Hospice Registered Nurse RN Full Time
2 months ago
Franklin, United States Aveanna Healthcare Full timePosition OverviewThe Hospice Registered Nurse is responsible for pain management, symptom control in the delivery of care to hospice patients, as established by the plan of care, the interdisciplinary team, attending physician and Hospice Medical Director. Territory: Franklin/BrentwoodEssential Job Functions:Ensures the timely and adequate delivery of...
-
Hospice Registered Nurse RN Full Time
3 months ago
Franklin, United States Aveanna Healthcare Full timePosition OverviewThe Hospice Registered Nurse is responsible for pain management, symptom control in the delivery of care to hospice patients, as established by the plan of care, the interdisciplinary team, attending physician and Hospice Medical Director. Territory: Franklin/BrentwoodEssential Job Functions:Ensures the timely and adequate delivery of...
-
Hospice Registered Nurse RN Full Time
3 months ago
Franklin, United States Aveanna Healthcare Full timePosition OverviewThe Hospice Registered Nurse is responsible for pain management, symptom control in the delivery of care to hospice patients, as established by the plan of care, the interdisciplinary team, attending physician and Hospice Medical Director. Territory: Franklin/BrentwoodEssential Job Functions:Ensures the timely and adequate delivery of...
-
Hospice Registered Nurse RN Full Time
3 months ago
Franklin, United States Aveanna Healthcare Full timePosition OverviewThe Hospice Registered Nurse is responsible for pain management, symptom control in the delivery of care to hospice patients, as established by the plan of care, the interdisciplinary team, attending physician and Hospice Medical Director. Territory: Franklin/BrentwoodEssential Job Functions:Ensures the timely and adequate delivery of...
-
Hospice Registered Nurse RN Full Time
3 months ago
Franklin, United States Aveanna Healthcare Full timeJob DescriptionJob DescriptionPosition OverviewThe Hospice Registered Nurse is responsible for pain management, symptom control in the delivery of care to hospice patients, as established by the plan of care, the interdisciplinary team, attending physician and Hospice Medical Director. Territory: Franklin/BrentwoodEssential Job Functions:Ensures the timely...
-
Hospice Registered Nurse RN Full Time
5 months ago
Franklin, United States Aveanna Healthcare Full timePosition OverviewThe Hospice Registered Nurse is responsible for pain management, symptom control in the delivery of care to hospice patients, as established by the plan of care, the interdisciplinary team, attending physician and Hospice Medical Director. Essential Job Functions:Ensures the timely and adequate delivery of hospice services to the terminally...
-
Hospice Registered Nurse RN Full Time
3 months ago
Franklin, United States Aveanna Healthcare Full timePosition Overview The Hospice Registered Nurse is responsible for pain management, symptom control in the delivery of care to hospice patients, as established by the plan of care, the interdisciplinary team, attending physician and Hospice Medical Director. Essential Job Functions: Ensures the timely and adequate delivery of hospice services to the...
-
Hospice Registered Nurse RN Full Time
3 months ago
Franklin, United States Aveanna Healthcare Full timeJob DescriptionJob DescriptionPosition OverviewThe Hospice Registered Nurse is responsible for pain management, symptom control in the delivery of care to hospice patients, as established by the plan of care, the interdisciplinary team, attending physician and Hospice Medical Director. Essential Job Functions:Ensures the timely and adequate delivery of...
-
Hospice Registered Nurse RN Full Time
2 months ago
Franklin, United States Aveanna Healthcare Full timePosition OverviewThe Hospice Registered Nurse is responsible for pain management, symptom control in the delivery of care to hospice patients, as established by the plan of care, the interdisciplinary team, attending physician and Hospice Medical Director. Territory: Franklin/BrentwoodEssential Job Functions:Ensures the timely and adequate delivery of...
