Clinical Utilization Reviewer
5 days ago
The Utilization Management Clinical Reviewer plays a critical role in ensuring the delivery of cost-effective and high-quality care to our nation's heroes. As a key member of our team, you will be responsible for reviewing and making decisions about the appropriateness and level of beneficiary care, ensuring that resources are utilized efficiently and effectively.
Key Responsibilities- Conduct prior authorization, continued stay, and referral management activities to ensure timely reviews and notifications.
- Assess medical necessity by screening available information against established criteria, using InterQual Clinical Guidelines Policy Keys and Behavioral Health criteria.
- Interpret information and make decisions whether authorizations align with the TriWest benefit program.
- Ensure compliance with Federal, State, and accreditation organizations' regulations.
- Perform other duties as assigned, including maintaining regular and reliable attendance.
- Active, unrestricted RN license.
- U.S. Citizen.
- Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation.
- 2+ years clinical experience.
- 2+ years UM experience.
- Proficient computer skills, including Microsoft Office Suite (Teams, Word, Excel, and Outlook).
- Demonstrates effective verbal and written communication skills.
- 3+ years Medical/Surgical experience.
- Behavioral Health experience.
- 1 year TriWest or TRICARE experience.
- Managed Care experience.
- Communication/People Skills: Ability to influence or persuade others under positive or negative circumstances; adapt to different styles; listen critically; collaborate.
- Computer Literacy: Ability to function in a multi-system Microsoft environment using Word, Outlook, TriWest Intranet, the Internet, and department software applications.
- Coping/Flexibility: Resiliency in adapting to a variety of situations and individuals while maintaining a sense of purpose and mature problem-solving approach.
- Empathy/Customer Service: Customer-focused behavior; helping approach, including listening skills, patience, respect, and empathy for another's position.
- Independent Thinking/Self-Initiative: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented.
- High Intensity Environment: Ability to function in a fast-paced environment with multiple activities occurring simultaneously while maintaining focus and control of workflow.
- Organizational Skills: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented.
- Team-Building/Team Player: Influence the actions and opinions of others in a positive direction and build group commitment.
- Technical Skills: Knowledge of TRICARE policies and procedures, Utilization Management principles, Managed Care concepts, medical terminology, medical management system, InterQual criteria, working knowledge of medical coding.
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Clinical Utilization Reviewer
3 weeks ago
Phoenix, Arizona, United States Triwest Healthcare Full timeJob SummaryThe Clinical Utilization Reviewer is responsible for reviewing and making decisions about the appropriateness and level of beneficiary care being provided to ensure cost-effective care and proper utilization of resources.Key ResponsibilitiesConducts prior authorization, continued stay, and referral management activities.Assesses medical necessity...
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Clinical Utilization Review Specialist
5 days ago
Phoenix, Arizona, United States Centene Corporation Full timeJob Title: Clinical Utilization Review SpecialistJoin Centene Corporation, a leading healthcare company, as a Clinical Utilization Review Specialist. In this role, you will play a critical part in ensuring the quality and appropriateness of care for our 28 million members.Job Summary:We are seeking a highly skilled Clinical Utilization Review Specialist to...
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Utilization Review Coordinator
4 weeks ago
Phoenix, Arizona, United States NeuroPsychiatric Hospitals Full timeAbout UsNeuroPsychiatric Hospital is a leading healthcare provider with a unique approach to neuropsychiatric and complex medical care. With a strong focus on interdisciplinary collaboration, our facilities offer unrivaled quality care to patients across the United States.Job OverviewWe are seeking a skilled Utilization Review Coordinator to join our team....
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Utilization Review Coordinator
5 days ago
Phoenix, Arizona, United States NeuroPsychiatric Hospitals Full timeAbout Us:Healing the Body and Mind:NeuroPsychiatric Hospital is a leading healthcare provider with a unique approach to neuropsychiatric and complex medical care. Founded 15 years ago, we have established ourselves as the largest hospital system in the nation, serving patients with both neurological and medical needs.Our Mission:We strive to provide...
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Utilization Review Authorization Specialist
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Phoenix, Arizona, United States Sanctuary Recovery Centers Full timeJob Title: Utilization Review Authorization SpecialistThe Utilization Review Authorization Specialist is a critical role at Sanctuary Recovery Centers, responsible for ensuring timely and appropriate care for our patients. This position requires strong communication and organizational skills, as well as a deep understanding of healthcare regulations and...
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Clinical Utilization Management Consultant
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Phoenix, Arizona, United States CVS Health Full timeJob SummaryCVS Health is seeking a skilled Utilization Management Nurse Consultant to join our team. As a key member of our clinical team, you will play a critical role in ensuring that our patients receive the highest quality care while minimizing unnecessary costs.Key ResponsibilitiesApply critical thinking and clinical expertise to review and authorize...
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Clinical Utilization Management Specialist
3 days ago
Phoenix, Arizona, United States CVS Health Full timeJob SummaryCVS Health is seeking a skilled Utilization Management Nurse Consultant to join our team. As a key member of our utilization management team, you will play a critical role in ensuring that our patients receive the highest quality care while minimizing unnecessary costs.Key ResponsibilitiesApply critical thinking and clinical expertise to review...
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Clinical Utilization Management Consultant
4 days ago
Phoenix, Arizona, United States CVS Health Full timeJob SummaryCVS Health is seeking a skilled Clinical Utilization Management Consultant to join our team. As a key member of our healthcare team, you will play a critical role in ensuring the delivery of high-quality, patient-centered care.Key ResponsibilitiesApply critical thinking and clinical expertise to review and authorize medical services and...
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Clinical Utilization Manager
2 weeks ago
Phoenix, Arizona, United States CVS Health Full timeJob Title: Clinical Utilization ManagerCVS Health is seeking a highly skilled Clinical Utilization Manager to join our team. As a key member of our Behavioral Health department, you will play a critical role in coordinating, documenting, and communicating all aspects of the utilization/benefit management program for preauthorization of mental health...
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Clinical Research Nurse
5 days ago
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Clinical Research Nurse
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Clinical Reviewer
3 weeks ago
Phoenix, Arizona, United States TriWest Healthcare Alliance Full timeJob SummaryWe are seeking a highly skilled Clinical Reviewer to join our team at TriWest Healthcare Alliance. As a Clinical Reviewer, you will play a critical role in ensuring the medical necessity of procedures and services for our members.Key ResponsibilitiesConduct medical necessity reviews using InterQual Clinical Guidelines and Clinical Decision Support...
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Pharmacy Utilization Manager
4 days ago
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Medical Record Review Specialist
4 weeks ago
Phoenix, Arizona, United States Optum Full timeOptum Clinical Document Improvement SpecialistAt Optum, we're dedicated to delivering care that improves health outcomes for millions of people around the world. As a Clinical Document Improvement Specialist, you'll play a critical role in ensuring that our clients' patients receive accurate and comprehensive documentation that reflects their clinical...
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Pharmacy Utilization Management Specialist
5 days ago
Phoenix, Arizona, United States Medix™ Full timeJob Title: Certified Pharmacy TechnicianWe're a fully licensed health insurer, Medix™, and we're changing how health insurance works by creating a healthcare experience that's intuitive and puts people, not cost or workflows, first.In this role, you will play an essential part in building our pharmacy utilization management function. The Clinical Review...
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Registered Nurse
5 days ago
Phoenix, Arizona, United States Veterans Affairs, Veterans Health Administration Full timeJob SummaryWe are seeking a highly skilled Registered Nurse to join our Utilization Management team at the Phoenix VA Healthcare System. As a key member of our team, you will play a pivotal role in ensuring optimal patient care through admission and continued stay reviews for inpatients.ResponsibilitiesConduct thorough medical record reviews to identify the...
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Registered Nurse
8 hours ago
Phoenix, Arizona, United States Veterans Affairs, Veterans Health Administration Full timeJob SummaryThis position is located within the GEC Utilization Management, Nursing Service at the Phoenix VA Healthcare System in Phoenix, AZ.Key ResponsibilitiesEnsure optimal patient care through admission and continued stay reviews for inpatients.Utilize National Utilization Management Integration software package in conjunction with VHA and local...
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Document Review Specialist
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Phoenix, Arizona, United States KLDiscovery Full timeJob Title: Document ReviewerWe are seeking a skilled Document Reviewer to join our team at KLDiscovery. As a Document Reviewer, you will play a critical role in supporting our clients' litigation needs by reviewing and coding documents for relevancy, confidentiality, and privilege.Key Responsibilities:Review and code documents using electronic review...
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Phoenix, Arizona, United States CVS Health Full timeJob SummaryCVS Health is seeking a highly skilled Oncology and Transplant Utilization Management Nurse Consultant to join our team. As a key member of our clinical team, you will work in a clinical telephone queue, collaborating with providers to secure additional information for prior authorization reviews. Your clinical expertise will be utilized to...
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Utilization Management Nurse Consultant
5 days ago
Phoenix, Arizona, United States CVS Health Full timeJob SummaryCVS Health is seeking a highly skilled Utilization Management Nurse Consultant to join our team. As a key member of our clinical team, you will work closely with providers to secure additional information for prior authorization reviews, utilizing your clinical expertise to coordinate, document, and communicate all aspects of the...