Top 8493 Rn Utilization Management Jobs

RN Claims Review and Utilization Management (CR/UM)
MedHealth —Oklahoma City, OK
- Full-time
- Nursing
- RN License
- Mid-level
Quick Apply
23h
Utilization Review RN
Memorial Health —Springfield, IL
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- Full-time
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- RN License
Utilization Review Nurse (RN)
Lighthouse Care Center of Augusta —Augusta, GA
- Full-time
- Nursing
- Psychiatry
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- Health insurance
- Dental insurance
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Utilization Management Outpatient Authorization Nurse
Champion Health Plan is a Medicare Advantage Prescription Drug HMO C-SNP serving Medicare beneficiaries with End-Stage Renal Disease. —Long Beach, CA
- From $67,000 a year
- Full-time
- Nursing
- LVN
- HIPAA
- Health insurance
- Dental insurance
Quick Apply
Utilization Specialist
RiverWoods Behavioral Health —Riverdale, GA
- Part-time
- CPR Certification
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- RN License
Utilization Management Nurse
TEXAS INDEPENDENCE HEALTH PLAN INC —Austin, TX
- Weekends as needed
- Hybrid work
- Nursing
- Microsoft Excel
- Microsoft Outlook
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Utilization Management Nurse
Blue Eagle Consulting —Remote
- RN License
- Mid-level
- Nursing
Quick Apply
Medical Management - Utilization Management RN 145-2026
CommunityCare —Remote
- Full-time
- Remote
- Background check
- Nursing
- RN License
Quick Apply
16h
Denials & Appeals Administrator (RN)
Boston Medical Center —Remote
- $43.03 - $62.50 an hour
- Full-time
- Remote
- Nursing
- RN License
- 5 years
- Health insurance
- Dental insurance
Utilization Management Registered Nurse
West Coast Consulting —Remote
- $30 - $34 an hour
- Contract
- Remote
- RN License
- Mid-level
- Nursing
- 401(k)
Quick Apply
17h
Health Nurse - Utilization Management
Alterwood Health —Remote
- $75,000 - $95,000 a year
- Full-time
- Microsoft Word
- Background check
- Nursing
- Health savings account
- Disability insurance
Quick Apply
2d
Utilization Management Nurse Consultant
CVS Health —New Jersey
- $32.01 - $68.55 an hour
- Weekends as needed
- Remote
- RN License
- Computer literacy
- Mid-level
- Health insurance
- Dental insurance
10d
Claims - Care Manager, RN, Claims
Wellcove —Remote
- Full-time
- Remote
- RN License
- Mid-level
- Geriatrics
Quick Apply
Concurrent Utilization Review Nurse, RN
NeueHealth —Los Angeles, CA
- $74,286.15 - $111,429.23 a year
- Remote
- Nursing
- RN License
- Mid-level
- Paid holidays
- Health insurance
Quick Apply
Utilization Management RN
Centurion Health —Springfield, IL
- $90,000 a year
- Weekends as needed
- Remote
- CPR Certification
- RN License
- BLS Certification
- Paid holidays
- Disability insurance
Quick Apply
Utilization Review Nurse
Cobalt Benefits Group LLC —Dallas, TX
- $90,000 - $98,000 a year
- Full-time
- Remote
- Nursing
- Microsoft Excel
- Microsoft Outlook
- Health savings account
- AD&D insurance
Quick Apply
Clinical Medical Review Nurse (Remote)
CareFirst BlueCross BlueShield —Baltimore, MD
- $67,320 - $133,705 a year
- Full-time
- Remote
- Nursing
- Microsoft Excel
- RN License
- 401(k)
Quick Apply
9d
Clinical Review & Correspondence RN
Cohere Health —Remote
- $31 - $35 an hour
- Full-time
- Remote
- Nursing
- RN License
- Mid-level
- Paid parental leave
- Health savings account
Quick Apply
Utilization Management RN (Hybrid)
TEXASCONNECT INC —Dallas, TX
- Weekends as needed
- Hybrid work
- Nursing
- Microsoft Outlook
- RN License
- Relocation assistance
Utilization Review Specialist
We Level Up —Pompano Beach, FL
- $50,000 - $90,000 a year
- Full-time
- Remote
- 18 years or older
- CPR Certification
- HIPAA
Quick Apply

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RN Claims Review and Utilization Management (CR/UM)

MedHealth -
Oklahoma City, OK

Quick Apply

Job Details

Full-time
23 hours ago

Qualifications

Utilization review
Electronic health records (EHR) management
RN License
Case management
Utilization management
Corrections facility medical clinic experience
Resource utilization in healthcare
Claims documentation review
Medical terminology

Full Job Description

A CR/UM nurse monitors and manages current inpatient care to ensure medically necessary care is provided and then evaluates healthcare claims submitted by providers to ensure medical necessity, accuracy, and compliance with MedHealth policies. The CR/UM nurse also reaches out to hospitals and specialty providers to negotiate aggressive rates. This is done in coordination with our corporate legal, who will memorialize the approved negotiated rates. Key responsibilities include daily contact with hospitals when a MedHealth patient is an inpatient, review medical records and clinical data, coordinating with healthcare providers, and communicating with providers to reprice claims as negotiated approve or deny services. This role is crucial for controlling costs and ensuring patients receive appropriate evidence-based care. The CR/UM nurse must have a current nursing license, minimal 1 year experience in CR/UM, and thorough knowledge of medical terminology, strong knowledge of CR/UM standards, working knowledge of claims coding to ensure we aren't overbilled, and a willingness to negotiate favorable rates with community providers/hospitals. knowledge of medical coding standards. Familiarity with claims processing, electronic medical record (EMR) systems, and utilization review platforms like InterQual or MCG is required. Strong analytical thinking, attention to detail, and effective written and verbal communication skills make someone stand out in this role. These capabilities ensure accurate and efficient patient care and subsequent claim assessments, minimizing errors and supporting fair reimbursement within regulatory and negotiated guidelines.

Monitor Inpatient Care: Monitor care when a MedHealth patient is hospitalized to ensure proper care is provided and the patient is returned to the MedHealth facility as soon as medically appropriate.
Review claims and medical records: Assess claims for accuracy in coding and determine if services align with established clinical guidelines and industry/MedHealth policies.
Ensure medical necessity: Verify that proposed treatments and procedures are medically necessary and appropriate for the patient's condition.
Determine coverage: In coordination with our Chief Medical Officer, make coverage decisions for specific procedures or treatments based on their review.
Communicate with stakeholders: Collaborate with physicians and other healthcare professionals to discuss care plans and resolve issues.
Manage appeals and denials: Investigate and respond to claim denial appeals, when necessary, which will involve negotiating with providers.
Ensure compliance: Stay up to date with federal, state, and local regulations to ensure compliance.
Monitor quality and efficiency: Track the utilization of healthcare services to identify trends and areas for improvement while maintaining quality of care.
Negotiate Rates: Reach out to community providers and hospitals and negotiate the most favorable payment rates.
Other tasks as assigned and in line with the skills and licensure.

Work is 8am to 5pm M-F in our Oklahoma Office. Includes a 60-minute lunch break.

Skills & Qualifications

Active registered nurse (RN) license.
Experience in acute care nursing or case management.
Strong knowledge of clinical guidelines, correctional healthcare, and healthcare delivery systems in general.
Excellent analytical, documentation, and critical thinking skills.
Effective communication and interpersonal skills.
Proficiency with electronic health records and computer skills.
Knowledge of or willingness to learn insurance coding is a plus

Job Type: Full-time

Work Location: In person

Quick Apply

Refine Your Search

Rn Utilization Management jobs

RN Claims Review and Utilization Management (CR/UM)

Utilization Review RN

Utilization Review Nurse (RN)

Utilization Management Outpatient Authorization Nurse

Utilization Specialist

Utilization Management Nurse

Utilization Management Nurse

Medical Management - Utilization Management RN 145-2026

Denials & Appeals Administrator (RN)

Utilization Management Registered Nurse

Health Nurse - Utilization Management

Utilization Management Nurse Consultant

Claims - Care Manager, RN, Claims

Concurrent Utilization Review Nurse, RN

Utilization Management RN

Utilization Review Nurse

Clinical Medical Review Nurse (Remote)

Clinical Review & Correspondence RN

Utilization Management RN (Hybrid)

Utilization Review Specialist

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